Obstructive sleep apnea as a risk factor after shoulder arthroplasty

doi:10.1016/j.jse.2013.06.003

Journal of Shoulder and Elbow Surgery

Volume 22, Issue 12, December 2013, Pages e6-e9

https://doi.org/10.1016/j.jse.2013.06.003 Get rights and content

Background

Obstructive sleep apnea (OSA) has been identified as an important risk factor in perioperative orthopaedic surgery outcomes despite limited evidence. Screening systems are being instituted in increasing frequency to prevent morbidity and mortality. Our objective was to determine if patients with OSA have a higher likelihood of postoperative in-hospital complications, length of stay, or increased costs after shoulder arthroplasty.

Methods

We utilized the Nationwide Inpatient Sample (NIS) to analyze 22988 patients undergoing TSA or hemiarthroplasty. Of these patients, 1983 (5.9%) were diagnosed with OSA. Multivariate analysis with logistic regression modeling was used to compare patients with and without OSA for various outcomes.

Results

Patients with obstructive sleep apnea had overall similar in-hospital mortality and complications including PE compared with those without OSA. OSA was not associated with increased postoperative charges ($39,741 in patients with OSA vs $39,334 in those without OSA) and resulted in a shorter length of stay (mean, 2.61 vs 2.91 days; P < .0001).

Conclusion

This study does not support OSA as a significant risk factor for in-hospital morbidity and mortality following shoulder arthroplasty. Our results suggest that a diagnosis of OSA does not increase perioperative morbidity and mortality including perioperative complications. Given the results of this study, further research is warranted to attempt to keep patient screening costs down while optimizing outcomes.

Section snippets

Methods

The Nationwide Inpatient Sample (NIS) is a survey of hospitals conducted by the federal Healthcare Cost and Utilization Project, which has been deemed statistically valid.¹ Based on a random inclusion of 20% of the nation's hospitals, the numbers from these hospitals are then weighted or extrapolated to produce national estimates. We used the NIS to identify 22,996 patients who underwent total shoulder arthroplasty and hemiarthroplasty in the United States between January 1, 2005 and December

Results

In-hospital mortality for patients with OSA was similar to those without a diagnosis of OSA (odds ratio, 1.083). Mortality occurred in 54 patients overall and in 2 patients with OSA. Overall mortality data was analyzed using regression analysis (Table I).

In-hospital complications in patients without OSA compared to those with OSA was similar on all fronts (Table II). Of the entire sample, 88 patients developed a pulmonary embolism (PE). Four patients with OSA developed a PE (4.5% of all

Discussion

Screening programs for obstructive sleep apnea are being increasingly instituted as a component of hospital policies and becoming part of standard preoperative testing.⁹ This is in large part a response to the reported complications in surgical patients with a diagnosis of OSA undergoing hip and knee replacement.3, 11 Perioperative mortality after shoulder arthroplasty has been reported as low.¹³ With this rising trend in testing, it seems prudent to evaluate whether blanket application is

Conclusion

This study does not support OSA as a significant risk factor for in-hospital morbidity and mortality following shoulder arthroplasty. This may be due to increased monitoring in those patients carrying a diagnosis of OSA. However, in-hospital costs do not appear to be higher for OSA patients. Additionally length of stay in patients with OSA was shorter. This information may be helpful for risk-benefit counseling in patients concerned about OSA status. Further analysis is need in a prospective

Disclaimer

None of the authors, their immediate family, nor any research foundation with which they are affiliated received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Presence of obstructive sleep apnea is associated with higher future readmissions and outpatient visits-a nationwide administrative dataset study
2022, Sleep Medicine
Hospital readmissions and outpatient visits contribute to the significant burden on healthcare systems. Obstructive sleep apnea (OSA) is a chronic medical condition that is associated with cardiovascular comorbidities and other chronic conditions. Inpatient and outpatient healthcare utilization rates in patients with OSA following hospitalization are unclear.
This. retrospective case–control cohort study utilized a nationwide database to assess if OSA is associated with higher healthcare utilization post-hospitalization. We compared healthcare utilization among patients with OSA versus without OSA between 2009 and 2014 after matching for demographic variables, geographic location, hospital environment, reason for admission, and severity of illness during hospitalization. We measured future healthcare utilization by the number of ICU admissions, hospital admissions, emergency room visits, and outpatient visits after being discharged from the index hospitalization.
Two equal-sized cohorts comprised of 85,912 matched pairs were obtained. The OSA cohort demonstrated significantly higher rates of future ICU admissions, hospital admissions, emergency room visits, and outpatient visits. Matching for comorbid cardiovascular conditions continued to demonstrate higher healthcare utilization in the OSA group. Short-term outcomes during the index hospitalization were relatively similar between groups.
This retrospective database study demonstrated that OSA may be an independent marker of higher future healthcare utilization. On the other hand, the length of stay during the index hospitalization was not elevated. Prospective studies are needed to confirm these findings and investigate the impact of directing additional resources to inpatients with OSA.
Healthcare utilization after elective surgery in patients with obstructive sleep apnea – analysis of a nationwide data set
2021, Sleep Medicine
Citation Excerpt :
Nevertheless, we found that despite the increased presence of these comorbidities, the length of stay during the index surgery was not significantly increased. Similar to our study, at least two prior studies [18,19], but not all [20], in orthopedic surgical patients have demonstrated that the length of stay on patients with OSA was lower than those without OSA. We speculate that the length of stay is similar to controls due to increased awareness of OSA related perioperative complications in the community.
Obstructive sleep apnea is prevalent among those undergoing elective surgery and likely introduces a risk of adverse outcomes. To understand its impact, we aimed to compare healthcare utilization in postsurgical patients with obstructive sleep apnea compared to controls matched on the surgical care environment.
This is a retrospective case–control cohort study using a nationwide database. Among patients undergoing elective surgical procedures during 2009–2014, we compared patients with obstructive sleep apnea with those without obstructive sleep apnea. The two cohorts were matched based on age, sex, type of surgery, performing surgeon, the hospital where the procedure was performed, and various All-Patient-Refined Diagnosis-Related-Groups severity indices. The primary effect of interest was short-term healthcare utilization. We also compared long-term hospital admissions, intensive care unit admissions, emergency room visits and outpatient visits.
47,719 subjects and controls were matched on a 1:1 basis. As the subjects were matched, the two groups did not differ on age, percent female, and various Diagnosis-Related-Groups severity indices. The obstructive sleep apnea group had more comorbid conditions and a higher Elixhauser index. Short-term healthcare utilization measured by the length of stay and mortality related to index procedure did not increase in the sleep apnea group. In hierarchical logistical regression analysis, the presence of sleep apnea predicted higher long-term health care utilization.
Our data suggests that the presence of sleep apnea was not associated with increased post elective surgical length of stay and mortality; however, the presence of obstructive sleep apnea was associated with long-term health care utilization.
Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle
2019, Injury
Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups.
Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older.
A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001).
Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.
Complications associated with surgical treatment of sleep-disordered breathing among hospitalized U.S. adults
2018, Journal of Cranio-Maxillofacial Surgery
The purpose of this cross-sectional study is to examine the relationship between surgical treatments for sleep-disordered breathing (SDB) and composite measure of surgical complications in a nationally representative sample of hospital discharges among U.S. adults. We performed secondary analyses of 33,679 hospital discharges from the 2002–2012 Nationwide Inpatient Sample that corresponded to U.S. adults (≥18 years) who were free of head-and-neck neoplasms, were diagnosed with SDB and had undergone at least one of seven procedures. Multivariate logistic regression models were constructed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI), controlling for age, sex, race/ethnicity, obstructive sleep apnea (OSA) and obesity diagnoses. Positive associations were found between composite measure of surgical complications and specific procedures: palatal procedure (aOR = 12.69, 95% CI: 11.91,13.53), nasal surgery (aOR = 6.47, 95% CI: 5.99,6.99), transoral robotic assist (aOR = 5.06, 95% CI: 4.34–5.88), tongue base/hypopharynx (aOR = 4.24, 95% CI: 3.88,4.62), maxillomandibular advancement (MMA) (aOR = 3.24, 95% CI: 2.74,3.84), supraglottoplasty (aOR = 2.75, 95% CI: 1.81,4.19). By contrast, a negative association was found between composite measures of surgical complications and tracheostomy (aOR = 0.033, 95% CI: 0.031,0.035). In conclusion, most procedures for SDB, except tracheostomy, were positively associated with complications, whereby palatal procedures exhibited the strongest and supraglottoplasty exhibited the weakest association.
Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty
2018, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
This finding is of particular interest in that it identified a risk factor that is modifiable. Previous studies have identified risk factors such as diabetes, obstructive sleep apnea, congestive heart failure, renal failure, age, female sex, and chronic pulmonary disease that lead to increased hospital stays, readmissions, complications, and thus an increased cost burden.2,11,12,20,26,35 Recognizing tobacco use as a modifiable risk factor is important because it allows improved preoperative counseling.
In the current health care environment, it is becoming increasingly important to recognize risks factors that may affect a patient's postoperative outcome. To determine the potential impact of tobacco as a risk factor, we evaluated postoperative pain, narcotic use, length of stay, reoperations, and complications in the global 90-day episode of care for patients undergoing anatomic total shoulder arthroplasty (TSA) who were current tobacco users, former users, or nonusers.
Database search identified 163 patients with primary anatomic TSA done for glenohumeral arthritis; these were divided into 3 groups: current tobacco users (28), nonusers (88), and former users (47). All surgeries were done with the same technique and implants.
Patients in the current tobacco use group had significantly higher visual analog scale scores preoperatively and at 12 weeks postoperatively than nonusers and former users. Mean improvement in visual analog scale scores was significantly less in current tobacco users. Cumulative oral morphine equivalent use at 12 weeks was significantly higher in current tobacco users than in nonusers and former users. The average oral morphine equivalent per day was also significantly higher in the current tobacco users than in nonusers and former users. There were no significant differences in length of stay or complications.
Although length of stay, complication rates, hospital readmissions, and reoperation rates were not significantly different, tobacco users reported increased postoperative pain and narcotic use in the global period after TSA. Former tobacco users were found to have a postoperative course similar to that of nonusers, suggesting that discontinuation of tobacco use can improve a patient's episode of care performance after TSA.
Probability of Undiagnosed Obstructive Sleep Apnea Does Not Correlate With Adverse Pulmonary Events nor Length of Stay in Hip and Knee Arthroplasty Using Intrathecal Opioid
2017, Journal of Arthroplasty
Recent emphasis on bundled payments and outcomes tracking has increased the focus on preoperative optimization in patients undergoing elective lower extremity arthroplasty. Since patients with obstructive sleep apnea (OSA) have an increased risk of adverse perioperative pulmonary events, screening for undiagnosed OSA is sometimes included as part of preoperative risk assessment. However, there are limited data regarding quantification of OSA risk in lower extremity arthroplasty patients, and little is known about the utility of quantitative OSA screening and the risk of pulmonary complications in hip and knee arthroplasty patients who receive intrathecal morphine anesthetic.
A retrospective review of 990 patients at a tertiary care, urban academic medical center who underwent lower extremity arthroplasty with a multimodal pain regimen including intrathecal morphine anesthesia, comparing the rate of pulmonary complications and length of stay between patients previously diagnosed with OSA and those identified as low, moderate, and high risk of undiagnosed OSA established by screening with the STOP-BANG questionnaire in the preoperative setting.
Using logistic regression and adjusting for age, gender, and body mass index, the results suggested the rate of complications was not different across the sleep apnea risk groups (P = .4024). In addition, linear regression suggested length of stay did not differ significantly by sleep apnea risk group (P = .2823).
In patients receiving intrathecal morphine as part of a multimodal pain regimen undergoing hip or knee arthroplasty, neither risk of adverse pulmonary events nor length of stay appeared to correlate with preoperative risk of undiagnosed OSA.

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: This study was exempt from IRB Ethical Committee approval.

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Review ArticleSelect Online ArticleObstructive sleep apnea as a risk factor after shoulder arthroplasty

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Disclaimer

J Arthroplasty

J Arthroplasty

J Clin Epidemiol

Mayo Clin Proc

J Arthroplasty

Br J Anaesth

Review Article
Select Online Article
Obstructive sleep apnea as a risk factor after shoulder arthroplasty