The Journal of Arthroplasty xxx (2015) xxx–xxx

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Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty Matthew J. Best, BS a, Leonard T. Buller, MD a, Raul G. Gosthe, MD a, Alison K. Klika, MS b, Wael K. Barsoum, MD b a b

Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida Cleveland Clinic Department of Orthopaedic Surgery, Cleveland, Ohio

a r t i c l e

i n f o

Article history: Received 17 December 2014 Accepted 21 February 2015 Available online xxxx Keywords: total knee arthroplasty total hip arthroplasty alcohol misuse alcohol dependence alcohol abuse

a b s t r a c t The influence of alcohol misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. Using the National Hospital Discharge Survey, a cohort representative of 8,372,232 patients (without cirrhosis) who underwent THA or TKA between 1990 and 2007 was identified and divided into two groups: (1) those who misused alcohol (n = 50,861) and (2) those who did not (n = 8,321,371). Differences in discharge status, comorbidities and perioperative complications were analyzed. Compared to patients with no diagnosis of alcohol misuse, alcohol misusers were nine times more likely to leave against medical advice and had longer hospital stays (P b 0.001). Alcohol misuse was independently associated with higher odds of in hospital complications (OR: 1.334, range: 1.307–1.361), surgery related complications (OR: 1.293, range: 1.218–1.373) and general medical complications (OR: 1.300, range: 1.273–1.327). © 2015 Elsevier Inc. All rights reserved.

Alcohol misuse, including abuse and dependence [1], is a maladaptive pattern of drinking associated with an increased risk of postoperative complications including delirium, cognitive decline, pneumonia and death [2–13]. While worse outcomes have been documented among patients with liver cirrhosis undergoing primary total hip (THA) and knee (TKA) arthroplasty [14,15], the influence of alcohol misuse, without cirrhosis, on perioperative outcomes following total joint arthroplasty is poorly understood. One study by Williams-Russo et al [16] evaluated 60 patients undergoing bilateral TKA and found that pre-operative alcohol use was associated with an increased risk of delirium in geriatric patients. The only other study, by Harris et al [17], retrospectively reviewed 185 patients, 32 of whom were alcohol misusers, undergoing THA or TKA at a Veterans Health Administration hospital and found alcohol misuse to be associated with an increased number of postoperative complications. Identifying modifiable risk factors associated with complications following total joint arthroplasty may allow surgeons to intervene preoperatively, potentially decreasing complications and improving outcomes. The purpose of this study was to measure the influence of alcohol misuse on inpatient perioperative outcomes following primary

One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.02.028. Reprint requests: Leonard T. Buller, MD, Department of Orthopaedic, Surgery and Rehabilitation, University of Miami, 1400 NW 12th Avenue, Miami, FL 33136.

THA or TKA using a large national database. The null hypothesis was that there would be no difference in the rate of perioperative complications between patients with and without a history of alcohol misuse.

Materials and Methods Data Source The National Hospital Discharge Survey (NHDS) [18], developed by the National Center for Healthcare Statistics division of the Centers for Disease Control and Prevention (CDC), was used in this study. The NHDS is considered the most comprehensive of all inpatient surgical databases in use today and is the principal database used by the U.S. government for monitoring hospital use [19]. Publicly available, the NHDS provides demographic and medical data for inpatients discharged from non-federal, short stay hospitals in the United States [19]. The survey uses International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) [20] codes to classify up to seven discharge diagnoses and up to four procedures. In addition to medical information, the NHDS collects demographic information (age, gender, race), expected source of payment (insurance status), length of care, hospital size, US region, and inpatient outcomes including discharge destination including: (1) routine/discharge home, (2) left against medical advice, (3) discharged/transferred to short-term facility, (4) discharged/transferred to long-term care institution, (5) alive, disposition not stated, and () dead [21]. The NHDS ensures an unbiased national sampling by using a complex three-stage probability design including: inflation by reciprocals of the probabilities of sample selection,

http://dx.doi.org/10.1016/j.arth.2015.02.028 0883-5403/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Best MJ, et al, Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.02.028

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M.J. Best et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

adjustment for no response and population weighting ratio adjustments [19]. This study did not require approval by the institutional review board because the NHDS is a publically available database with no patient identifying information.

Patient Selection All patients admitted to hospitals in the United States who underwent primary THA or TKA between 1990 and 2007 were identified using ICD-9-CM codes. Due to NCHS budgetary limitations starting in 2008, the number of hospital surveys was halved, decreasing the precision of the survey data and nearly doubling the relative standard error [22]. Consequently, we chose 2007 as the endpoint of our study. Using previously described techniques, all discharges with a procedure code (ICD-9-CM) of THA (81.51) or TKA (81.54) were identified [23]. In order to determine the effect of alcohol misuse on outcomes, patients with a diagnosis of cirrhosis (ICD-9-CM 571.5) were excluded from the study (n = 7258), bringing the total cohort from 8,379,490 to 8,372,232 patients. Patients were divided into two groups: (1) those with a diagnosis of alcohol misuse (alcohol dependence: 303.90– 303.93 or alcohol abuse: 305.00–305.03) and (2) those who did not have a diagnosis of alcohol misuse. Alcohol abuse is defined by the American Psychiatric Association as a maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within a 12-month period: (1) recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household), (2) recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use), (3) recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct), and (4) continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication) and having never met the criteria for alcohol dependence [1]. In contrast, the definition of alcohol dependence is a maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period: (1) need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol, (2) the characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms, (3) drinking in larger amounts or over a longer period than intended, (4) persistent desire or one or more unsuccessful efforts to cut down or control drinking, (5) important social, occupational, or recreational activities given up or reduced because of drinking, (6) a great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking, and (7) continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking [1]. Demographic variables were collected including age, sex and prevalence of comorbidities. Length of stay and discharge destination were also evaluated. The incidence of complications was determined using the complication screening package [24]. The variable “complication” was created based upon the following variables (ICD-9-CM): acute postoperative infection (998.5), other operative complication (998.89), cardiac complication (997.1), acute myocardial infarction (410), acute renal failure (584), pulmonary embolism (415.1), induced mental disorder (293), pneumonia (480–486), pulmonary insufficiency (518.5), deep venous thrombosis (453.4), osteomyelitis (730), gastrointestinal bleeding (578.0), convulsion (780.39), complication of internal joint prosthesis (996.77), intubation (96.xx), and transfusion of blood (99.x).

Statistical Analysis Because of the large sample size, a normal distribution of the data was assumed. Differences between continuous variables were compared using the independent-samples t-test, while the Pearson chi-square test was used to compare differences between categorical variables. To determine whether alcohol misuse was an independent predictor of a negative in-hospital outcome, variables present in at least 2% of the population [25] were included in a multivariable binary logistic regression model. The dichotomous variables were (1) presence of any complication, (2) presence of a surgical complication and (3) presence of a general medical complication. Potential confounders were controlled for using a multivariable regression model, to isolate the effect of alcohol misuse on inpatient outcomes. Covariates accounted for in the regression model included: gender, age, race, length of stay, and preexisting comorbidities (diabetes mellitus, hypertension, congestive heart failure, coronary artery disease, atrial fibrillation, osteoporosis, and rheumatoid arthritis). Odds ratios and confidence intervals were calculated to assess the association between alcohol misuse and inpatient adverse events. Correcting for multiple comparisons, a P-value b 0.001 was used to define statistical significance, as previously described [26]. All data were analyzed using the software-statistical package for social sciences [SPSS] version 20 (Chicago, IL, USA). Source of Funding No external funding source was used for the conduct of this study. Results Overall Cohort A cohort representative of 8,372,232 patients without cirrhosis who underwent primary THA or TKA between 1990 and 2007 was identified (Table 1). Of the total cohort, 50,861 patients had a diagnosis of alcohol misuse, while 8,321,371 patients had no diagnosis of alcohol misuse. The alcohol misuse group was younger (61.2 ± 12.1 years compared to 67.3 ± 11.7 years; P b 0.001), had longer hospital stays (5.2 ± 3.2 days compared to 5.1 ± 4.2 days; P b 0.001), and had a higher rate of patients who left against medical advice (0.40% compared to 0.04%, P b 0.001) when compared with the group of patients with no diagnosis of alcohol misuse (Table 1). The alcohol misuse group had lower rates of diabetes mellitus (8.5% compared to 13.0%), hypertensive disease (45.4% compared to 46.9%), and coronary artery disease (3.9% compared to 4.9%) when compared with the group with no diagnosis of alcohol misuse (P b 0.001 for all; Table 2). Table 1 illustrates the demographics stratified by THA and TKA among patients with a diagnosis of alcohol misuse compared to those with no diagnosis of alcohol misuse undergoing primary THA or TKA, respectively while Table 2 shows comorbidities divided by joint type. Alcohol misusers had a higher rate (P b 0.001) of total complications (33.5% compared to 22.6%), surgery related complications (2.2% compared to 1.7%), and general medical complications (31.6% compared to 21.4%) when compared with the group with no diagnosis of alcohol misuse (Table 3). Notably, alcohol misusers had significantly higher rates (P b 0.001) for all complications evaluated, with the exception of UTI/urinary complication (P = 0.032), pulmonary embolism (P b 0.001), and deep venous thrombosis (P = 0.046) (Table 3). Table 4 depicts odds ratios for complications after THA and TKA for alcohol misusers. Of note, alcohol misuse was a risk factor for acute postoperative infection (OR 15.314 range: 14.662 to 15.966, P b 0.001), thrombocytopenia (OR 10.910 range: 10.502 to 11.334, P b 0.001), convulsion (OR 5.752 range: 5.422 to 6.102, P b 0.001), and pulmonary insufficiency (OR 5.239 range: 4.773 to 5.750, P b 0.001). Patients who misused alcohol had increased odds of leaving against medical advice (OR 9.132 range: 7.923 to 10.525, P b 0.001) (Table 4).

Please cite this article as: Best MJ, et al, Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.02.028

M.J. Best et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx Table 1 Patient Characteristics for Patients Undergoing Primary Total Hip or Knee Arthroplasty With Bivariate Analysis Comparing Those With Alcohol Misuse to Those With No Alcohol Misuse. Parameter Overall cohort Number of patients, N Gender (%) Male Female Comorbidities (%) Discharge disposition (%) Routine/home Left AMA Non-routine Age, years [mean (SD)] Days of care, mean (SD) Payer status (%) Medicare Medicaid Private Insurance Workmens Comp Other Total hip arthroplasty cohort Number of patients, N Gender (%) Male Female Comorbidities (%) Discharge disposition (%) Routine/home Left AMA Non-routine Age, years [mean (SD)] Days of care, mean (SD) Payer status (%) Medicare Medicaid Private Insurance Workmens Comp Other Total knee arthroplasty cohort Number of patients, N Gender (%) Male Female Comorbidities (%) Discharge disposition (%) Routine/home Left AMA Non-routine Age, years [mean (SD)] Days of care, mean (SD) Payer status (%) Medicare Medicaid Private Insurance Workmens Comp Other

Alcohol Misuse

No Alcohol Misuse

50,861

8,321,371

P Value

Table 2 Prevalence of Comorbidities and Bivariate Analysis in Patients Undergoing Primary Total Hip or Knee Arthroplasty Comparing Those With Alcohol Misuse to Those With No Alcohol Misuse. Alcohol Misuse Percentage

No Alcohol Misuse Percentage

P Value

Overall cohort Number of patients, N Diabetes mellitus (250) Hypertensive disease (401–405) Atrial fibrillation (427.31) Coronary artery disease (414.01) Congestive heart failure (428) Rheumatoid arthritis (714.0) Obesity (278.00, 278.01) Hyperlipidemia (272.0–272.4) Osteoporosis (733.0)

50,861 8.5% 45.4% 4.5% 3.9% 2.8% 3.4% 4.4% 9.8% 3.4%

8,321,371 13.0% 46.9% 4.2% 4.9% 2.7% 3.2% 5.8% 14.0% 3.1%

b0.001 b0.001 0.01 b0.001 0.371 0.014 b0.001 b0.001 b0.001

Total hip arthroplasty cohort Number of patients, N Diabetes mellitus (250) Hypertensive disease (401–405) Atrial fibrillation (427.31) Coronary artery disease (414.01) Congestive heart failure (428) Rheumatoid arthritis (714.0) Obesity (278.00, 278.01) Hyperlipidemia (272.0–272.4) Osteoporosis (733.0)

29,234 8.9% 41.8% 2.3% 3.9% 1.7% 3.3% 6.6% 8.2% 5.8%

2,959,185 9.6% 40.6% 4.3% 4.7% 2.8% 2.8% 3.7% 11.8% 3.5%

b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001

Total knee arthroplasty cohort Number of patients, N Diabetes mellitus (250) Hypertensive disease (401–405) Atrial fibrillation (427.31) Coronary artery disease (414.01) Congestive heart failure (428) Rheumatoid arthritis (714.0) Obesity (278.00, 278.01) Hyperlipidemia (272.0–272.4) Osteoporosis (733.0)

21,627 8.1% 50.3% 7.4% 3.9% 4.2% 3.5% 0.7% 11.9% 0.1%

5,364,245 14.9% 50.4% 4.2% 5.0% 2.6% 3.4% 4.4% 15.2% 2.9%

b0.001 0.808 b0.001 b0.001 b0.001 0.32 b0.001 b0.001 b0.001

Comorbidity (ICD-9) b0.001

76.6 38.3 55.4

38.4 61.6 59.7

57.1 0.40 25.3 61.2 (12.1) 5.2 (3.2)

51.9 0.04 30 67.3 (11.7) 5.1 (4.2)

b0.001 b0.001

51.6 8.3 31.1 0.4 8.6

59.6 2.9 32 1 4.5

b0.001 b0.001 b0.001 b0.001 b0.001

29,234

2,959,185

74.4 25.6 53.4

42.3 57.7 53.6

b0.001

59.3 0.53 21.5 57.8 (12.4) 5.4 (3.7)

51.1 0.07 31.1 66.5 (13.4) 5.4 (5.1)

b0.001

b0.001 1

48.1 10.7 32.5 0.1 8.6

57.7 3.1 33.4 0.6 5.2

b0.001 b0.001 b0.001 b0.001 b0.001

21,627

5,364,245

79.5 20.5 58.1

36.1 63.9 63.1

54.2 0.21 30.3 65.7 (10.0) 4.9 (2.4)

52.3 0.03 29.4 67.8 (10.6) 4.9 (3.5)

b0.001 1

56.3 4.9 33.8 0.9 4.1

60.6 2.7 31 1.2 4.5

b0.001 b0.001 b0.001 b0.001 b0.001

b0.001 b0.001

0.495

b0.001 b0.001

3

The World Health Organization estimates the prevalence of alcohol use disorders in the United States to be 5.48% and 1.92% for adult males and females (15 years and above), respectively, in 2004 [27].

b0.001

SD, standard deviation.

Multivariable logistic regression analysis showed that patients who misused alcohol had increased odds of suffering from an in-hospital complication (OR 1.334 range: 1.307–1.361, P b 0.001) (model fit: omnibus test of model coefficients: χ 2 = 72,072, P b 0.001, Nagelkerke R 2 = 0.011; Table 5), as well as any surgery related complication (OR 1.293 range: 1.218 to 1.373, P b 0.001) (omnibus χ 2 = 72,072, P b 0.001, Nagelkerke R 2 = 0.007; Table 6), and any general medical complication (OR 1.300 range: 1.273 to 1.327, P b 0.001) (omnibus χ 2 = 72,072, P b 0.001, Nagelkerke R 2 = 0.012; Table 7) compared with those who did not misuse alcohol. Discussion This study describes the influence of alcohol misuse, without liver cirrhosis, on perioperative outcomes following primary THA or TKA.

Table 3 Prevalence of Adverse Events in Patients Undergoing Primary Total Hip or Knee Arthroplasty With Bivariate Analysis Comparing Those With Alcohol Misuse to Those With No Alcohol Misuse.

Adverse Event (ICD-9) Surgery related complications Acute postoperative infection (998.5) Other operative complication (998.89)

Alcohol Misuse No Alcohol Misuse (N = 50,861) (N = 8,321,371) P Value 3.51% 2.00%

General medical complications Thrombocytopenia (287.4, 287.5) 5.85% UTI/Urinary complication (599.0, 997.5) 3.91% Acute renal failure (584) 0.82% Pulmonary embolism (415.1) 0.00% Induced mental disorder (293) 0.85% Pneumonia (482,486) 0.57% Pulmonary insufficiency (518.5) 0.91% Deep venous thrombosis (453.4) 0.08% GI bleeding (578.0) 0.13% Convulsion (780.39) 2.29% Complications of internal joint 0.30% prosthesis (996.77) Intubation (96.x) 1.12% Transfusion of blood (99.0) 18.99% Surgery related complications 2.17% General medical complications 31.59% Total complications 33.50%

0.49% 1.44%

b0.001 b0.001

0.57% 3.73% 0.36% 0.39% 0.55% 0.46% 0.17% 0.11% 0.06% 0.41% 0.20%

b0.001 0.032 b0.001 b0.001 b0.001 b0.001 b0.001 0.046 b0.001 b0.001 b0.001

0.24% 15.93% 1.69% 21.42% 22.63%

b0.001 b0.001 b0.001 b0.001 b0.001

Please cite this article as: Best MJ, et al, Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.02.028

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M.J. Best et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

Table 4 Odds ratios for Complications After Primary THA or TKA Among Patients With Alcohol Misuse, N = 8,372,232. Complication

OR (95% CI)

P Value

Acute postoperative infection 15.314 (14.662–15.966) b0.001 Thrombocytopenia (287.4, 287.5) 10.910 (10.502–11.334) b0.001 Left AMA 9.132 (7.923–10.525) b0.001 Convulsion (780.39) 5.752 (5.422–6.102) b0.001 Pulmonary insufficiency (518.5) 5.239 (4.773–5.750) b0.001 Intubation (96.x) 4.659 (4.286–5.066) b0.001 Acute renal failure (584) 2.272 (2.063–2.503) b0.001 GI bleeding (578.0) 2.225 (1.745–2.837) b0.001 Induced mental disorder (293) 1.555 (1.414–1.711) b0.001 Complication of internal joint prosthesis (996.77) 1.545 (1.319–1.810) b0.001 Other operative complication (998.89) 1.402 (1.318–1.492) b0.001 Pneumonia (482,486) 1.243 (1.107–1.395) b0.001 Transfusion of blood (99.0) 1.237 (1.210–1.265) b0.001 UTI/Urinary complication (599.0, 997.5) 1.051 (1.005–1.099) b0.001

Table 6 Multivariable Logistic Regression Analysis of Occurrence of a Surgical Complication in Patients Undergoing Primary Total Hip or Knee Arthroplasty, N = 8,372,232. Parameter Congestive heart failure (428) Sex (M) Alcohol misuse Atrial fibrillation (427.31) Osteoporosis (733.0) Days of care Race Age Diabetes mellitus (250) Rheumatoid arthritis (714.0) Coronary artery disease (414.01) Hypertensive disease (401–405)

OR (95% CI)

P Value

1.447 (1.408–1.488) 1.380 (1.365–1.394) 1.293 (1.218–1.373) 1.141 (1.113–1.169) 1.133 (1.101–1.166) 1.025 (1.003–1.048) 1.014 (0.988–1.041) 0.987 (0.978–0.997) 0.847 (0.834–0.862) 0.759 (0.734–0.786) 0.632 (0.614–0.652) 0.619 (0.612–0.626)

b0.001 b0.001 b0.001 b0.001 b0.001 0.024 0.298 0.011 b0.001 b0.001 b0.001 b0.001

OR: odds ratio, CI: confidence interval.

OR: odds ratio, CI: confidence interval. Omnibus χ2 = 72,072, P b 0.001. Nagelkerke R2 = 0.007.

Similarly, according to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the prevalence of alcohol misuse over the last 12 months among adults in the United States is 4.7% [28]. For adults aged 65 years and over, the prevalence of alcohol abuse is estimated at 2.36% and 0.38% for males and females respectively, while the prevalence alcohol dependence is 0.39% and 0.13% for males and females respectively [29]. Despite these high frequencies, few studies have evaluated the effect of alcohol misuse on clinical outcomes in patients undergoing primary TKA and THA [16,17]. This study demonstrated significantly increased odds of surgery related, mechanically related, and general medical complications among patients who misuse alcohol undergoing primary THA or TKA. Previously, Harris et al [17] evaluated 32 alcohol misusers among a cohort of 185 patients undergoing total joint arthroplasty and demonstrated an increased risk of medical complications. Limitations of this study, however, include its use of an all-male, veteran's affairs hospital patient cohort. The veteran's affairs hospital patient population, with its unique set of medical and social comorbidities [30], may not be generalizable to the general population in the United States. Additionally, this study is limited by small sample size as only six patients had a single complication, four patients had two complications, and two patients had three overall complications [17]. In our study, the overall complication rate for patients with a diagnosis of alcohol misuse was 33.5% compared to 22.6% in the group with no diagnosis of alcohol misuse. This large increase was also seen in both the THA and TKA cohorts in subgroup analysis. Many complications

such as convulsions, pulmonary insufficiency, acute renal failure, acute postoperative infection, thrombocytopenia, and increased rate of blood transfusions have never been reported in the literature for this patient population. While epidemiologic studies are unable to identify a causal relationship, the increased rate of adverse events seen in this study may be the result of systemic manifestations of alcohol abuse including immune incompetence, withdrawal, hemostatic dysregulation and cardiac insufficiency [13,31,32]. Interestingly, while the study by Harris et al [17] demonstrated increased rates of pulmonary embolism and deep venous thrombosis with alcohol misuse, this study found decreased odds of thromboembolic events in the alcohol misuse group. This is similar to prior reports regarding alcohol intake and venous thromboembolic events (VTE), which state that moderate alcohol consumption is associated with a reduced risk of cardiovascular disease [33]. For example, one study of over 58,000 patients by Gaborit et al [34] demonstrated a 10%–30% decreased risk of VTE in males who drink moderate amounts of alcohol. This study also demonstrated that patients with a diagnosis of alcohol misuse were nine times more likely to leave against medical advice than patients who did not misuse alcohol. Numerous reports have found drug or alcohol abuse to be associated with the decision to sign out against medical advice [35,36]. Reasons for this behavior have not been determined, but underlying addictive behaviors or the desire for more drugs or alcohol are proposed reasons [37–39]. Overall, the average length of hospital stay was longer in the alcohol misuser group, alluding to increased healthcare utilization and healthcare cost in these patients.

Table 5 Multivariable Logistic Regression Analysis of Occurrence of Any Complication in Patients Undergoing Primary Total Hip or Knee Arthroplasty, N = 8,372,232.

Table 7 Multivariable Logistic Regression Analysis of Occurrence of a General Medical Complication in Patients Undergoing Primary Total Hip or Knee Arthroplasty, N = 8,372,232.

Parameter Congestive heart failure (428) Atrial fibrillation (427.31) Osteoporosis (733.0) Alcohol misuse Rheumatoid arthritis (714.0) Coronary artery disease (414.01) Days of care Age Hypertensive disease (401–405) Race Diabetes mellitus (250) Sex (M) OR: odds ratio, CI: confidence interval. Omnibus χ2 = 72,072, P b 0.001. Nagelkerke R2 = 0.011.

OR (95% CI)

P Value

Parameter

2.135 (2.116–2.154) 1.810 (1.796–1.823) 1.353 (1.341–1.365) 1.334 (1.307–1.361) 1.060 (1.050–1.070) 1.049 (1.041–1.058) 1.036 (1.024–1.047) 1.014 (1.011–1.017) 1.000 (0.997–1.003) 0.993 (0.985–1.002) 0.924 (0.919–0.928) 0.749 (0.747–0.752)

b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 0.927 0.112 b0.001 b0.001

Congestive heart failure (428) Atrial fibrillation (427.31) Osteoporosis (733.0) Alcohol misuse Rheumatoid arthritis (714.0) Coronary artery disease (414.01) Days of care Hypertensive disease (401–405) Age Race Diabetes mellitus (250) Sex (M)

OR (95% CI)

P Value

2.171 (2.152–2.191) 1.847 (1.834–1.861) 1.346 (1.333–1.358) 1.300 (1.273–1.327) 1.074 (1.064–1.085) 1.071 (1.063–1.080) 1.031 (1.020–1.041) 1.028 (1.025–1.032) 1.015 (1.012–1.019) 0.990 (0.982–0.999) 0.926 (0.921–0.931) 0.717 (0.714–0.720)

b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 0.023 b0.001 b0.001

OR: odds ratio, CI: confidence interval. Omnibus χ2 = 72,072, P b 0.001. Nagelkerke R2 = 0.012.

Please cite this article as: Best MJ, et al, Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.02.028

M.J. Best et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

Longer hospital stay and excessive cost have been shown in patients with alcohol use disorders undergoing other surgical procedures, as well [40]. As has been shown in patients undergoing elective colorectal surgery [41], it is possible that abstinence from alcohol prior to surgery may reduce the risk of postoperative complications. While this study reveals increased odds of complications, longer length of stay and higher rates of signing out against medical advice among patients with alcohol dependence undergoing primary THA or TKA, future studies should prospectively evaluate whether alcohol abstinence or decreased consumption reduces postoperative complications following primary THA or TKA. Despite the strengths of using large, national databases for epidemiological research [42], limitations of this study include those inherent in any analysis of data from large administrative databases [43]. The NHDS is subject to coding error or errors in data entry [43]. Additionally, the database only allows for seven diagnosis codes and four procedure codes per entry. As a result, the prevalence of comorbid conditions and adverse events may be underreported [26]. For instance, the percentage of patients who misused alcohol undergoing primary THA or TKA between 1990 and 2007 was estimated at 0.61%, though U.S. prevalence estimates are slightly higher [27,28]. An alternative explanation for this difference is that patients who misuse alcohol have impaired access to orthopaedic care. It is also possible that the low incidence reported for alcohol misuse codes was because only the blatantly uncontrolled alcohol misusers were coded as such. In this scenario, the results of the study may be significantly skewed and less generalizable. Regardless of the reason for the low incidence, it must be noted as a significant limitation in the present study and future research should investigate the influence of alcohol misuse on primary THA or TKA through different study designs. Another limitation is the possibility of misclassification error. Because all cases undergo the same data collection process, potential underreporting and misclassifications should be equally distributed, preventing this from affecting our statistical analysis [44]. Finally, while the majority of life-threatening complications following joint arthroplasty occur within the first days postoperatively [45,46], the NHDS only provides in-hospital data. Consequently, events occurring after discharge are not represented, preventing us from drawing conclusions about late-term adverse events like the risk of dislocation [47]. In conclusion, this is the largest analysis of patients who misuse alcohol undergoing primary THA or TKA and demonstrates an increased risk of multiple perioperative complications. Knowledge of this increased risk has the potential to change treatment strategies, in-hospital monitoring and discharge planning for this patient population. References 1. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 2000[Text Revision]. 2. Neuenschwander AU, Pedersen JH, Krasnik M, et al. Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer. Eur J Cardiothorac Surg 2002;22 [2S1010794002002634 [pii]12142201]. 3. Sonne NM, Tonnesen H. The influence of alcoholism on outcome after evacuation of subdural haematoma. Br J Neurosurg 1992;6 [21590965]. 4. Spies C, Tonnesen H, Andreasson S, et al. Perioperative morbidity and mortality in chronic alcoholic patients. Alcohol Clin Exp Res 2001;25(5 Suppl.) [ISBRA11391067]. 5. Spies CD, Nordmann A, Brummer G, et al. Intensive care unit stay is prolonged in chronic alcoholic men following tumor resection of the upper digestive tract. Acta Anaesthesiol Scand 1996;40 [68836256]. 6. Litaker D, Locala J, Franco K, et al. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry 2001;23 [2S0163–8343(01)00117–7 [pii]11313076]. 7. Marcantonio ER, Goldman L, Orav EJ, et al. The association of intraoperative factors with the development of postoperative delirium. Am J Med 1998;105 [5S0002934398002927 [pii]9831421]. 8. Maxson PM, Schultz KL, Berge KH, et al. Probable alcohol abuse or dependence: a risk factor for intensive-care readmission in patients undergoing elective vascular and thoracic surgical procedures. Mayo Perioperative Outcomes Group. Mayo Clin Proc 1999;74:510319073. 9. Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006;116. http://dx.doi.org/10. 1097/01.MLG.0000194844.87268.ED [[doi]16540903]. 10. Howard MA, Cordeiro PG, Disa J, et al. Free tissue transfer in the elderly: incidence of perioperative complications following microsurgical reconstruction of 197 septuagenarians

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Please cite this article as: Best MJ, et al, Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.02.028

Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty.

The influence of alcohol misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. Using the National Hosp...
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