Cost and Effectiveness of Postoperative Fever Diagnostic Evaluation in Total Joint Arthroplasty Patients

Ward, Derek; Hansen, Erik N.; Takemoto, Steven K.; Bozic, Kevin J.

doi:10.1016/j.arth.2010.03.016

Cited by 63 publications

(77 citation statements)

References 17 publications

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“…Although these nonspecific indicators may represent part of a normal physiologic response to surgery, the threat of a developing subclinical infection may lead to an expensive and unguided workup. In the absence of other clinical signs and symptoms, workup of a postoperative fever is only warranted with persistent fevers beyond the second postoperative day [10]. Elevations in postoperative WBC values may also trigger an expensive and unguided workup in search of an early infection.…”

Section: Discussionmentioning

confidence: 99%

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Leukocytosis Is Common After Total Hip and Knee Arthroplasty

Deirmengian

Zmistowski

Jacovides

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Postoperative infection is a potentially devastating complication after THA and TKA. In the early postoperative period, clinicians often find nonspecific indicators of infection. Although leukocytosis may be a sign of a developing infection in the early postoperative period, it may also be part of a normal surgical response. Questions and Purposes We determined (1) the natural history of white blood cell values after primary THA and TKA, (2) factors associated with early postoperative leukocytosis, and (3) the predictive value of white blood cell count for early postoperative periprosthetic joint infection. Patients and Methods Using our institutional database, we identified all THA and TKA cases between January 2000 and December 2008. We determined the incidence of leukocytosis and characterized the natural history of postoperative white blood cell counts. We then investigated potential indicators of postoperative leukocytosis, including development of early periprosthetic infection. ResultsThe average postoperative white blood cell count increased to approximately 3 9 10 6 cells/lL over the first 2 postoperative days and then declined to a level slightly higher than the preoperative level by Postoperative Day 4.

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Section: Discussionmentioning

confidence: 99%

“…to surgery, and inappropriate workup is costly and unnecessary and may lead to inappropriate changes in clinical management [6,10].…”

Section: Introductionmentioning

confidence: 99%

Leukocytosis Is Common After Total Hip and Knee Arthroplasty

Deirmengian

Zmistowski

Jacovides

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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“…1,2,5,6,11,14-16, [21][22][23]28 Of the 686 BC drawn, only 24 were positive (see Appendix 1 for summary table; out of 686 drawn). 5,6,14,16,[21][22][23]28 Only two patients with positive BC had clinical sepsis, two BC were specified to be contaminants in the study and one was found on postoperative day (POD) 16.…”

Section: Resultsmentioning

confidence: 99%

Post-operative fever in orthopaedic surgery: How effective is the ‘fever workup?’

Ashley

Spiegel

Cahill

et al. 2017

J Orthop Surg (Hong Kong)

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Background: Defining the appropriate threshold at which to initiate a fever workup is imperative to promote patient safety, appropriate resource utilization, and antibiotic stewardship. Our group performed a systematic review of the available literature on perioperative fever (POF) workups in orthopaedic patients to evaluate the frequency, timing and utility of blood cultures (BC) and other investigations in the POF workup, to determine the clinical relevance of any infections and to evaluate their cost effectiveness. Methods: Studies were identified by searching MEDLINE, EMBASE, Pubmed, Cochrane and Google Scholar for articles through September 2016. Forty-nine articles were retrieved and 22 articles met the pre-determined inclusion criteria. Proportions of positive studies were noted and averaged using random effects analysis. Results: Post-operative pyrexia ranged in prevalence between 8.1% and 87.3%. The studies routinely performed during a fever workup had wide ranges of diagnostic yield, including chest X-rays from 0% to 40%, urinalyses from 8.2% to 38.7%, urine cultures from 0% to 22.4% and BC from 0% to 13.3%. Only two patients with positive BC developed clinical sepsis. Cost per fever evaluation ranged from $350 to $950. Conclusion: The findings of this review suggest that early post-operative fever is an expected event following orthopaedic surgery. Based on the available literature, any kind of workup in the absence of localizing symptoms in the third post-operative day or before is unwarranted and is an inappropriate use of hospital resources.

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“…Several authors have discussed the use and application of the analytic hierarchy process in health and medical decision making. Although other methods of cost-efficiency/cost-effectiveness analysis are available and have been used in the setting of the orthopaedic research [26,29], we believed that benefits, opportunities, costs, and risks analysis using analytic hierarchy process was more appropriate for the inclusion of qualitative measurements, such as in our study. Furthermore, we expect that our paper will serve to introduce a formalized and accessible method of decision making to the orthopaedic community.…”

Section: Discussionmentioning

confidence: 99%

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

Díaz-Ledezma¹,

Lichstein²,

Parvızı³

2014

Clinical Orthopaedics &Amp; Related Research

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Background In the setting of finite healthcare resources, developing cost-efficient strategies for periprosthetic joint infection (PJI) diagnosis is paramount. The current levels of knowledge allow for PJI diagnostic recommendations based on scientific evidence but do not consider the benefits, opportunities, costs, and risks of the different diagnostic alternatives. Questions/purposes We determined the best diagnostic strategy for knee and hip PJI in the ambulatory setting for Medicare patients, utilizing benefits, opportunities, costs, and risks evaluation through multicriteria decision analysis (MCDA). Methods The PJI diagnostic definition supported by the Musculoskeletal Infection Society was employed for the MCDA. Using a preclinical model, we evaluated three diagnostic strategies that can be conducted in a Medicare patient seen in the outpatient clinical setting complaining of a painful TKA or THA. Strategies were (1) screening with serum markers (erythrocyte sedimentation rate [ESR]/ C-reactive protein [CRP]) followed by arthrocentesis in positive cases, (2) immediate arthrocentesis, and (3) serum markers requested simultaneously with arthrocentesis. MCDA was conducted through the analytic hierarchy process, comparing the diagnostic strategies in terms of benefits, opportunities, costs, and risks. Results Strategy 1 was the best alternative to diagnose knee PJI among Medicare patients (normalized value: 0.490), followed by Strategy 3 (normalized value: 0.403) and then Strategy 2 (normalized value: 0.106). The same ranking of alternatives was observed for the hip PJI model (normalized value: 0.487, 0.405, and 0.107, respectively). The sensitivity analysis found this sequence to be robust with respect to benefits, opportunities, and risks. However, if during the decisionmaking process, cost savings was given a priority of higher than 54%, the ranking for the preferred diagnostic strategy changed. Conclusions After considering the benefits, opportunities, costs, and risks of the different available alternatives, our preclinical model supports the American Academy of Orthopaedic Surgeons recommendations regarding the use of serum markers (ESR/CRP) before arthrocentesis as the best diagnostic strategy for PJI among Medicare patients. Level of Evidence Level II, economic and decision analysis. See Instructions to Authors for a complete description of levels of evidence.

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Cost and Effectiveness of Postoperative Fever Diagnostic Evaluation in Total Joint Arthroplasty Patients

Cited by 63 publications

References 17 publications

Leukocytosis Is Common After Total Hip and Knee Arthroplasty

Leukocytosis Is Common After Total Hip and Knee Arthroplasty

Post-operative fever in orthopaedic surgery: How effective is the ‘fever workup?’

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

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