Increased Mortality and Reoperation Rates After Treatment for Septic Arthritis of the Knee in People Who Inject Drugs: Nationwide Inpatient Sample, 2000-2013
Increased Mortality and Reoperation Rates After Treatment for Septic Arthritis of the Knee in People Who Inject Drugs: Nationwide Inpatient Sample, 2000-2013
复制标题
DOI：
10.1097/01.blo.0000534682.68856.d8
复制
发表时间：
2018-08-01
影响因子：
4.2
通讯作者：
Salzler, Matthew Joseph
中科院分区：
文献类型：
--
作者：
Oh, David Hyung Won;Wurcel, Alysse Gail;Salzler, Matthew Joseph
背景美国阿片类药物流行日益严重，影响了医疗保健的各个方面，包括骨科手术。化脓性膝关节炎是骨科医生经常遇到的与阿片类药物和注射药物使用（IDU）有关的疾病。在迅速发展的阿片类药物流行的背景下，根据IDU状态，IDU相关脓毒性关节炎住院频率的变化和脓毒性关节炎患者结局的差异尚不清楚。问题/目的（1）膝关节脓毒性关节炎患者使用注射药物的比例是多少？(2)有和没有注射毒品的化脓性膝关节炎患者在并发症、再手术、住院时间和违背医嘱离开方面是否有任何差异？(3)2000年至2013年IDU相关脓毒性膝关节炎的年龄和种族趋势是什么？方法使用2000年至2013年的医疗保健成本和利用项目，全国住院患者样本数据库，用于年龄在15至64岁之间的患者，主要出院诊断为小腿的原发性化脓性关节炎，其中绝大多数代表膝关节。Nationwide Inpatient Sample是美国最大的公共医疗数据库，可以显示全国代表性的临床趋势和结果。根据先前发表的使用计费代码的算法，将脓毒性关节炎分类为与IDU相关或不相关。与IDU相关的脓毒性关节炎患者更可能是黑人或西班牙裔，更年轻，并使用医疗保险，医疗补助或自费作为他们的主要支付方式。每年使用注射药物的脓毒性关节炎患者的比例被确定。在多变量回归分析中调整年龄、性别和种族后，比较住院结局，包括住院时间、违背医嘱离开、手术次数和死亡率。在研究期间，比较了各年龄、种族和性别组中IDU相关脓毒性关节炎比例的年度变化。结果IDU相关脓毒性关节炎患者的比例从2000年的5%增加到2013年的11%。在对年龄、性别和种族进行调整后，IDU相关脓毒性关节炎患者在住院期间死亡的可能性更大（调整后的比值比[AOR]，2.86; 95%置信区间[CI]，1.51-5.39; p < 0.001），并接受重复关节镜检查（AOR，1.24; 95% CI，1.06-1.45; p = 0.007）或开放性冲洗和清创术（AOR，1.68; 95% CI，1.28-2.19; p < 0.001）。与与IDU无关的脓毒性关节炎患者相比，与IDU相关的脓毒性关节炎患者更有可能违背医嘱离开（AOR，7.13; 95%CI，5.56-9.15; p < 0.001），平均住院时间也多5天（95%CI，4.1-5.5; p < 0.001）。2000 ~ 2013年，年龄在15 ~ 34岁和55 ~ 64岁的患者中，与IDU相关的脓毒性关节炎患者比例呈上升趋势。结论IDU是脓毒性膝关节入院的原因，与更高的死亡率、再手术率、资源利用率和不遵医嘱离开相关。骨科医生必须对脓毒性关节炎患者进行充分的IDU筛查，并密切监测他们是否有再次手术的可能，以在术后低阈值重新开放膝关节。未来的研究应确定目前使用的多学科方法，包括成瘾专家的潜在好处，以帮助管理越来越多的这些患者。
Background The United States has a growing opioid epidemic impacting all aspects of health care including orthopaedic surgery. Septic arthritis of the knee is a condition commonly encountered by orthopaedic surgeons related to opioid and injection drug use (IDU). Changes in the frequency of hospitalizations for IDU-related septic arthritis and differences in septic arthritis patient outcomes according to IDU status in the setting of the burgeoning opioid epidemic are unknown.Questions/purposes (1) What proportion of patients with septic arthritis of the knee use injection drugs? (2) Are there any differences in complications, reoperations, length of stay, and leaving against medical advice among patients with septic arthritis of the knee with and without IDU? (3) What are the age and racial trends in IDU-related septic arthritis of the knee from 2000 to 2013?Methods The Healthcare Cost and Utilization Project, Nationwide Inpatient Sample database of years 2000 to 2013 was utilized for patients between ages 15 and 64 years with a principal discharge diagnosis of native septic arthritis of the lower leg, the vast majority of which represents the knee. The Nationwide Inpatient Sample is the largest publicly available healthcare database in the United States that can show nationally representative clinical trends and outcomes. Septic arthritis was classified as related or unrelated to IDU based on previously published algorithms using billing codes. Patients with IDU-related septic arthritis were more likely to be black or Hispanic, younger, and use Medicare, Medicaid, or self-payment as their primary payment method. The yearly proportion of patients with septic arthritis who used injection drugs was determined. Hospitalization outcomes including length of stay, leaving against medical advice, number of procedures, and mortality rates were compared after adjusting for age, gender, and race in multivariable regression analyses. The yearly change in proportion of IDU-related septic arthritis in each age, race, and gender group was compared over the study period.Results The proportion of patients with IDU-related septic arthritis increased from 5% in 2000 to 11% in 2013. After adjusting for age, gender, and race, patients with IDU-related septic arthritis were more likely to die during hospitalization (adjusted odds ratio [AOR], 2.86; 95% confidence interval [CI], 1.51-5.39; p < 0.001) and undergo repeat arthroscopic (AOR, 1.24; 95% CI, 1.06-1.45; p = 0.007) or open irrigation and debridement (AOR, 1.68; 95% CI, 1.28-2.19; p < 0.001). Patients with IDU-related septic arthritis were more likely to leave against medical advice (AOR, 7.13; 95% CI, 5.56-9.15; p < 0.001) and also had an additional 5 days in length of stay (95% CI, 4.1-5.5; p < 0.001) on average compared with patients with septic arthritis unrelated to IDU. There was an increasing proportion of patients with IDU-related septic arthritis who were aged 15 to 34 years and 55 to 64 years from 2000 to 2013.Conclusions IDU is increasingly the cause of septic knee admissions and is associated with higher rates of mortality, reoperations, resource utilization, and leaving against medical advice. Orthopaedic surgeons must adequately screen for IDU among patients with septic arthritis and monitor them closely for reoperation with a low threshold to reaspirate a knee in the postoperative period. Future studies should determine the current use and potential benefits of a multidisciplinary approach, including addiction specialists, to aid in the management of the increasing number of these patients.