Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty

Journal Pre-proof Preoperative Depression Is Associated with Increased Risk Following Revision Total Joint Arthroplasty Jacob M. Wilson, MD, Kevin X. Farley, Greg A. Erens, MD, Thomas L. Bradbury, MD, George Guild, MD PII:

S0883-5403(19)31097-6

DOI:

https://doi.org/10.1016/j.arth.2019.11.025

Reference:

YARTH 57642

To appear in:

The Journal of Arthroplasty

Received Date: 23 September 2019 Revised Date:

30 October 2019

Accepted Date: 14 November 2019

Please cite this article as: Wilson JM, Farley KX, Erens GA, Bradbury TL, Guild G, Preoperative Depression Is Associated with Increased Risk Following Revision Total Joint Arthroplasty, The Journal of Arthroplasty (2019), doi: https://doi.org/10.1016/j.arth.2019.11.025. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.

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Preoperative Depression Is Associated with Increased Risk Following Revision Total Joint Arthroplasty

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Abstract

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Introduction: The incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to

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increase. Preoperative depression is known to influence outcomes following primary arthroplasty.

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Despite this, it remains unknown whether the same relationship exists for patients undergoing revision

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procedures. The purpose of this study, therefore, was to investigate this relationship.

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Methods: This is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from

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the Truven Marketscan® database. Patients with a diagnosis of prosthetic joint infection were excluded.

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Two cohorts were created: those with preoperative depression and those without. We included

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patients that were enrolled in the database for 1-year pre and postoperatively. Demographic and

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complication data were collected, and statistical analysis was then performed comparing complications

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between cohorts.

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Results: 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this

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study. Of these, 1,305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis

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found that, after rTHA, preoperative depression was associated with extended length of stay, non-home

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discharge, 90-day readmission, 90-day ED visit, PJI, revision surgery, and increased costs (p<0.001).

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Similarly, following rTKA, depression was associated with extended length of stay, non-home discharge,

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90-day readmission, 90-day ED visit, revision surgery, and increased costs (p<0.001).

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Conclusions: Depression prior to revision total joint arthroplasty is common and is associated with

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increased risk of complication and increased healthcare resource utilization following both rTHA and

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rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk

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factor.

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Key Words: total hip; arthroplasty; depression; total knee; narcotic; complications; revision

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Introduction

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Total knee (TKA) and total hip arthroplasty (THA) are two of the most common procedures

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performed in medicine and their incidence continues to rise.[1-3] Not surprisingly, the incidence of

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revision TKA and THA are also increasing.[4, 5] There is a need for ongoing identification of risk factors

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for complication following these procedures, especially in the setting of revision arthroplasty where the

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complication rates are known to be higher than those experienced in the primary setting.[6] One risk

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factor that has been repeatedly examined in primary THA and TKA is preoperative depression.[7-20]

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However, few studies to date have examined this risk factor in revision total joint arthroplasty.

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This is an important relationship to understand as the incidence of these psychiatric conditions

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has been reported to be higher in arthroplasty patients than in the general population.[7, 11, 13, 14, 16]

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Data from the World Health Organization (WHO) estimates that in 2015 the United States prevalence of

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depression was 5.9% (over 17 million people).[21] Again, however, it has been repeatedly demonstrated

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that primary arthroplasty patients have a much higher incidence of these conditions.[7, 11, 14] While

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there is some evidence that depressive symptoms decrease following total joint replacement, this is

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predicated on improvement in pain.[9, 10, 13, 22] Therefore, it remains unknown what the prevalence

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of depression is in those with failed primary total joint arthroplasty and what the implications of this

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diagnosis are following revision TKA or THA.

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The purpose of this study was to determine the relationship between preoperative depression

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and postoperative complications, healthcare utilization and inpatient costs following revision THA and

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TKA. We hypothesized that depression would be associated with increased complications, healthcare

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utilization, and care costs when compared to those without depression.

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Methods 3

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Data Source Patients for this study were identified and collected from the Truven MarketScan® Commercial

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Claims and Encounters and Medicare Supplemental and Coordination of Benefit databases (Truven

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Health, Ann Arbor, MI). This is a commercial claims database that includes information on patients with

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private insurance and on patients with Medicare and private supplemental insurance. Since its inception

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in 1995, the database has amassed over 240 million patients. The primary strengths of the database

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include the ability to follow patients longitudinally if they remain enrolled in the database and the

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inclusion of information on patients from the inpatient, outpatient, and pharmaceutical arenas.

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Included Patients

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From 2009-2017, the database was queried for patients undergoing revision total hip or revision

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total knee arthroplasty. These patients were identified using Current Procedural Terminology (CPT)

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codes. Specifically, the following codes were used to identify patients undergoing revision TKA: 27486

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(revision TKA, with or without allograft; one component), 27487 (revision TKA, with or without allograft;

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femoral and entire tibial component) and those undergoing revision THA: 27134 (revision THA, both

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components), 27137 (revision THA, acetabular component only), and 27138 (revision THA, femoral

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component only). To make for cleaner analysis, we chose to exclude patients with prosthetic joint

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infection (PJI). To do this, we excluded patients with the following CPT codes: 27488 (Removal of

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prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer,

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knee), 27090 (removal of hip prosthesis) and 27091 (removal of prothesis, with or without spacer

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placement). We additionally queried International Classification of Diseases (ICD) codes and any patients

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with a preoperative diagnosis of PJI were then excluded (ICD-9 code 996.66; ICD-10 code T84.5).

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Additionally, in order to ensure that observed complications were associated with the revision

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procedure, we excluded patients who had their primary procedure within 90-days of their revision

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procedure. Last, patients without continuous enrollment in the database for 1-year pre and postoperatively were excluded. At this point, patients were separated into two cohorts. Those with and those without

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depression. We identified depression using ICD-9 and ICD-10 diagnoses codes. This included the

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following codes: 3004, 30112, 3090, 3091, 311,29682, 29620-6, 29630-6, F32, F33, F341, F432. Table 1.

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Patients were included if they had a documented history of depression within the year preceding

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surgery.

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Baseline Patient Information

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The following information was collected for each included patient: age, sex, geographic region

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of treatment, surgery type (CPT code signifying 1 or 2 component revision), insurance type, and

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comorbidities. We collected and controlled for the following comorbidities: obesity, chronic kidney

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disease (CKD), alcohol use disorder, tobacco use, hypertension (HTN), coronary artery disease (CAD),

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congestive heart failure (CHF), rheumatic disease, and diabetes mellitus (DM). Each of these parameters

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were compared between cohorts.

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Complication, Healthcare Utilization, and Costs Data

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Following finalization of patient inclusion, the database was queried for the following

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complication data: PJI, Infection (PJI and superficial surgical site infection), wound complication, sepsis,

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and thromboembolic event. These were all collected for 90-days postoperatively. Repeat revision

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surgery was also collected, but for 1-year following surgery. The following healthcare utilization

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parameters were collected: extended length of stay (LOS; ≥4 days), non-home discharge, 90-day

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readmission, 90-day all cause emergency department (ED) visit, 90-day pain-related ED visit, and opioid

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prescription after 6-months postoperative. Additionally, we collected net payments for the inpatient

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stay for each patient and compared them between cohorts. This payment data represents the amount

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of money paid by insurance for the entire care episode (i.e. the actual paid amount, not charges).

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Statistical Analysis

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Statistical analysis was conducted using SPSS (Version 25, IBM Corporation, Armonk, NY). A p-

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value of <0.05 was selected as significant for this study. All analysis was conducted on revision TKA and

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revision THA patients separately. First, baseline patient demographic and comorbid data were compared

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between cohorts using chi-square analysis. Chi-square analysis was then used to compare the rates at

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which our complication and healthcare utilization data occurred between cohorts. We then

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subsequently performed multivariate binomial logistic regression controlling for all variables listed in

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Table 2, to assess the independent association between preoperative depression and postoperative

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complication, healthcare utilization and inpatient episode of care costs.

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Institutional Review Board (IRB) Approval

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This study was IRB approved by our institution.

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Results

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Demographics and Baseline Patient Information

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In total, 10,017 patients undergoing revision THA were identified in the database. This included

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8,712 patients (86.9%) without and 1,305 (13.1%) with a diagnosis of depression. Patients with

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depression were more likely to be young, female, obese, have alcohol use disorder, tobacco users, have

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CHF, and be undergoing a single component revision (p≤0.011). Depressed patients were less likely to

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have CAD (p=0.025). There were not differences between non-depressed and depressed patients with

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regards to geographic region, CKD, HTN, rheumatic disease, or diabetes (p>0.05).

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Similarly, there were 13,973 patients identified undergoing revision TKA. This consisted of

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11,961 patients (85.6%) who were not depressed and 2012 (14.4%) who were depressed. The depressed

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patients in this group were more likely to be young, female, from the West and less likely from the

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Northeast. There were also differences in comorbidity profiles where depressed patients were more

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likely to be: obese, have alcohol use disorder, be tobacco users, and have rheumatic disease. Depressed

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patients were less likely to have CAD. Table 2.

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Depression, Postoperative Complications, Healthcare Utilization, and Costs Following Revision THA

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Outcomes and complication data were collected for patients undergoing revision THA. First,

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these were compared between cohorts using univariate analysis. This revealed that the following were

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higher in the depression group when compared to those without depression: infection, PJI, sepsis,

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revision surgery, extended LOS, non-home discharge, 90-day readmission, and all cause and pain related

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ED visits (p≤0.005). There were no differences in rates of wound complications, thromboembolic events,

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or prolonged opioid use between the two groups (p>0.05). Univariate analysis also revealed that

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depressed patients had higher inpatient hospital costs when compared to those without preoperative

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depression. Table 3.

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Subsequently, multivariate logistic regression was performed to control for confounding

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variables. This revealed that even when controlling for baseline patient demographic and comorbid data

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that patients with depression had significantly higher odds of incurring: extended length of stay (≥4

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days; Odds Ratio (OR) 1.28, 95% confidence interval (CI) 1.12-1.47, p<0.001), non-home discharge (OR

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1.60, 95%CI 1.38-1.85, p<0.001), 90-day readmission (OR 1.37, 95%CI 1.16-1.63, p<0.001), all cause ED

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visit (OR 1.55, 95%CI 1.34-1.78, p<0.001), pain-related ED visit (OR 2.1, 95%CI 1.33-3.30, p=0.001),

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infection (OR 1.34, 95%CI 1.07-1.66, p=0.010), PJI (OR 1.52, 95%CI 1.15-2.01, p=0.004), sepsis (OR 1.86,

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95%CI 1.17-2.95, p=0.008), and revision surgery (OR 1.36, 95%CI 1.14-1.63, p=0.001). Additionally,

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multivariable logistic regression found that $2,660 (95%CI 1,120-3,999; p<0.001) of increased costs were

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attributable to a preoperative diagnosis of depression. No significant differences were identified

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between depression and wound complication, thromboembolic events, or prolonged opioid

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prescriptions (p>0.146). Table 4.

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Depression, Postoperative Complications, Healthcare Utilization, and Costs Following Revision TKA

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Complication data was also collected and compared between cohorts for those patients

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undergoing revision TKA. When compared to the non-depressed cohort patients with depression had

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significantly higher rates of the following on univariate analysis: wound complications, sepsis, revision

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surgery, non-home discharge, 90-day readmissions, and 90-day all cause and pain related ED visits

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(p<0.05). There were no significant differences identified in rates of extended length of stay, infection,

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PJI, thromboembolic events, or prolonged opioid use (p≥0.113). Table 3.

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Next, a multivariate logistic regression model was used to determine if depression was an

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independent risk factor for these findings. Even after controlling for patient information and

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comorbidity data, depressed patients had significantly increased odds of the following: extended length

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of stay (≥4 days; OR 1.17, 95%CI 1.03-1.32, p=0.016), non-home discharge (OR 1.44, 95%CI 1.26-1.64,

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p<0.001), 90-day readmission (OR 1.43, 95%CI 1.22-1.68, p<0.001), all cause ED visit (OR 1.52, 95%CI

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1.34-1.74, p<0.001), pain-related ED visit (OR 2.06, 95%CI 1.46-2.91, p=0.001), sepsis (OR 1.75, 95%CI

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1.1-2.77, p=0.018), and revision surgery (OR 1.20, 95%CI 1.01-1.44, p=0.046). Depression was found to

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have no impact on infection, PJI, wound complications, thromboembolic events, or prolonged

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(>6month) opioid prescriptions (p≥0.161). However, compared to those who were not depressed,

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depressed patients were found to have increased hospital costs of $3,051 (95% CI 1,916-4,186;

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p<0.001), even after controlling for baseline confounders. Table 4.

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Discussion

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Revision total hip and knee arthroplasty procedures are becoming more common.[1, 4, 5]

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However, the complication rates after revision procedures continue to be much higher than those 8

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reported following primary arthroplasty procedures.[6] Taken together, there is a continued need for

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identification of risk factors for complication and increased healthcare utilization. One such risk factor

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that has garnered significant attention in primary arthroplasty patients, but has been largely ignored in

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the revision setting is a preoperative diagnosis of depression.

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In primary total joint arthroplasty, a preoperative diagnosis of depression has been associated

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with increased medical complications,[7, 11, 12, 18, 23] prosthetic joint infection,[18, 24, 25] worse

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subjective improvement in pain,[20, 26] decreased satisfaction,[8] readmission,[15] postoperative

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transfusion,[12] non-home discharge,[12, 27] length of stay,[16, 19] and increased costs.[23, 27] The

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results of the current investigation, which investigated revision procedures, is largely in agreement with

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the above prior findings in primary arthroplasty patients. In the revision THA patient we found that a

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preoperative diagnosis of depression was associated with increased healthcare utilization, increased

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infection, increased revision rates, and increased hospital costs. In revision TKA patients we found that

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depression was associated with the same outcomes with the exception of increased surgical site

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infection and PJI.

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An interesting finding of this study is that patients undergoing revision arthroplasty are

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frequently depressed. We found that 13.1% of revision THA and 14.4% of revision TKA patients had a

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diagnosis of preoperative depression in the year preceding surgery. This is much higher than the

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national prevalence of 5.9%,[28] and higher than the prevalence found in similar studies in the primary

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arthroplasty population (10-11%).[7, 11] A component of this is likely explained by selection bias as

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patients with depression are known to have less improvement in pain following surgery and higher rates

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of revision.[8, 20, 26, 29] While the prevalence of depression is still likely underestimated in this study,

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our cohort was more likely to be young females, similar to the demographics found in prior

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investigations.[7, 11, 28]

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The relationship between depression and arthroplasty outcomes, however, is complex. It is well

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known that patients in chronic pain are at risk of developing psychological manifestations of their pain,

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including depression and anxiety.[30] Additionally, there is some evidence to suggest that anxiety and

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depressive symptoms may be decreased following total knee arthroplasty and that perhaps some

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component of these preoperative psychological symptoms are manifestations of pain.[9, 10, 13, 22] The

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beneficial effects that TKA has on mental health can persist for years.[17] Therefore, patients with

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depression should not be denied surgery based on their elevated risk as their depressive symptoms may

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improve postoperatively.

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However, we did find that patients who have depression undergoing revision arthroplasty

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procedures are at elevated risk. We found that rates of infection, sepsis, and specifically PJI, were higher

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in the depressed cohort than the non-depressed controls. This was significant, however, only after

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revision THA. This is similar to findings in primary arthroplasty patients.[18] While the connection

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between the two may seem elusive, there is actually a fairly well established connection between

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postoperative infection and depressed state.[31] There is evidence that psychological stress in humans

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induces an inflammatory state via release of pro-inflammatory cytokines.[31] This preoccupation of the

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immune system may make patients more susceptible to infection, especially when coupled with the

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proinflammatory postsurgical state. Additionally, depression may lead to a shift if in T-cell phenotype,

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leading to further susceptibility.[32, 33] As a result, an association of depression with postoperative

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infection has been observed in orthopedics as well as other fields.[24, 25, 34-36]

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We also found significantly increased healthcare utilization among patients with depression

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following both revision TKA and THA. While studies on depression in the primary arthroplasty literature

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have had inconsistent results regarding hospital length of stay,[7] the majority of studies agree with our

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findings that patients with depression are at higher risk for extended length of stay. [16, 19] This is not

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surprising given difficulty with postoperative pain control [26] [29] in these patients and given that 10

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length of stay is longer even in general ward patients with depression.[37] Additionally, our findings of

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increased emergency department visits and readmissions are likely a result of our increased rates of

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complications. The same is true of revision surgery given that depressed patients had 52% increased

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odds of PJI following revision THA. These outcomes culminated in increased net payments of >$2,600

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dollars for depressed patients following revision THA and TKA. This increased cost is similar to prior

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investigations.[23]

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Last, despite the fact that Signh et al found that depression predicts moderate to severe pain

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following revision TKA[26] and revision THA[29] our results demonstrated that a preoperative diagnosis

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of depression is not associated with prolonged (>6 months) opioid use. This is in contrast to results

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previously reported in primary arthroplasty.[38] The reason for this discrepancy may be explained by

248

our private insurance patient population or by our modern cohort (2009-2017) during which the opioid

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epidemic has become a focus of the medical community. This is especially true given that only 8.2-9.6%

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of our patients remained on opioid 6-months after their procedures, a number on par with those

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reported previously for primary procedures at 1-year.[39] While patients often receive opioids from

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other providers, in the Truven database, these prescriptions would also be captured.

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There are multiple limitations to the current study and the results of the study must be

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interpreted with these in mind. First, similar to prior studies,[7, 11] we are subject to complete and

255

accurate coding for the identification of depressed patients. Prior studies using mental health

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questionnaires preoperatively have found higher rates of psychological distress.[13, 14, 16] This is likely

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explained by prior literature showing diagnostic recognition of psychiatric conditions is poor.[40]

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Therefore, it is likely that a subset of patients with mild depressive symptoms are not captured by this

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study. Additionally, for the purposes of this investigation, we excluded patients undergoing revision for

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PJI. This methodological decision clearly made for cleaner, easier to interpret analysis, but does limit the

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generalizability of our results. This is especially true as infection represents the indication for 15% of 11

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revision THA[41] and 25% of revision TKA.[42] Along the same lines, only insured patients were included

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in this analysis. This may further limit the generalizability to uninsured patients or those with Medicaid.

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Last, given the retrospective nature of this study, causality is unable to be determined. Despite these

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limitations, which are inherent to analysis of large databases, the Truven Marketscan database

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represents a strength of this study. This database allowed for longitudinal analysis of a large number of

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patients, permitting the identification of differences between groups, even in rare outcomes of interest.

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In conclusion, patients with preoperative depression who are undergoing revision total hip or

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knee arthroplasty are at higher odds of incurring several postoperative complications, having higher

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healthcare utilization, and are associated with increased net hospital payments. These findings should

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be used to counsel patients and further work will be necessary to discern to what degree depression is a

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modifiable risk factor.

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17. Jones AR, Al-Naseer S, Bodger O, James ETR, Davies AP. Does pre-operative anxiety and/or depression affect patient outcome after primary knee replacement arthroplasty? Knee 25(6): 1238, 2018 18. Klement MR, Nickel BT, Penrose CT, Bala A, Green CL, Wellman SS, Bolognesi MP, Seyler TM. Psychiatric disorders increase complication rate after primary total knee arthroplasty. Knee 23(5): 883, 2016 19. March MK, Harmer AR, Dennis S. Does Psychological Health Influence Hospital Length of Stay Following Total Knee Arthroplasty? A Systematic Review. Arch Phys Med Rehabil 99(12): 2583, 2018 20. Singh JA, Lewallen DG. Depression in primary TKA and higher medical comorbidities in revision TKA are associated with suboptimal subjective improvement in knee function. BMC Musculoskelet Disord 15: 127, 2014 21. Organization GWH. Depression and Other Common Mental Disorders: Global Health Estimates. In.: Licence: CC BY-NC-SA 3.0 IGO. 2017 22. Tarakji BA, Wynkoop AT, Srivastava AK, O'Connor EG, Atkinson TS. Improvement in Depression and Physical Health Following Total Joint Arthroplasty. J Arthroplasty 33(8): 2423, 2018 23. Rasouli MR, Menendez ME, Sayadipour A, Purtill JJ, Parvizi J. Direct Cost and Complications Associated With Total Joint Arthroplasty in Patients With Preoperative Anxiety and Depression. J Arthroplasty 31(2): 533, 2016 24. Bozic KJ, Lau E, Kurtz S, Ong K, Berry DJ. Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 470(1): 130, 2012 25. Bozic KJ, Lau E, Kurtz S, Ong K, Rubash H, Vail TP, Berry DJ. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 94(9): 794, 2012 26. Singh JA, Lewallen DG. Medical and psychological comorbidity predicts poor pain outcomes after total knee arthroplasty. Rheumatology (Oxford) 52(5): 916, 2013 27. Stundner O, Kirksey M, Chiu YL, Mazumdar M, Poultsides L, Gerner P, Memtsoudis SG. Demographics and perioperative outcome in patients with depression and anxiety undergoing total joint arthroplasty: a population-based study. Psychosomatics 54(2): 149, 2013 28. Brody DJ PL, Hughes JP. Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016. In: Statistics NCfH, ed. NCHS Data Brief, no 303. Hyattsville, MD. 2018 29. Singh JA, Lewallen D. Age, gender, obesity, and depression are associated with patient-related pain and function outcome after revision total hip arthroplasty. Clin Rheumatol 28(12): 1419, 2009 30. Merskey H. Psychological aspects of pain. Curr Med Res Opin 2(9): 515, 1974 31. Ghoneim MM, O'Hara MW. Depression and postoperative complications: an overview. BMC Surg 16: 5, 2016 32. Elenkov IJ. Systemic stress-induced Th2 shift and its clinical implications. Int Rev Neurobiol 52: 163, 2002 33. Elenkov IJ, Chrousos GP. Stress Hormones, Th1/Th2 patterns, Pro/Anti-inflammatory Cytokines and Susceptibility to Disease. Trends Endocrinol Metab 10(9): 359, 1999 34. Doering LV, Cross R, Vredevoe D, Martinez-Maza O, Cowan MJ. Infection, depression, and immunity in women after coronary artery bypass: a pilot study of cognitive behavioral therapy. Altern Ther Health Med 13(3): 18, 2007 35. Gordon RJ, Weinberg AD, Pagani FD, Slaughter MS, Pappas PS, Naka Y, Goldstein DJ, Dembitsky WP, Giacalone JC, Ferrante J, Ascheim DD, Moskowitz AJ, Rose EA, Gelijns AC, Lowy FD, Ventricular Assist Device Infection Study G. Prospective, multicenter study of ventricular assist device infections. Circulation 127(6): 691, 2013 36. Chang SM, Parney IF, McDermott M, Barker FG, 2nd, Schmidt MH, Huang W, Laws ER, Jr., Lillehei KO, Bernstein M, Brem H, Sloan AE, Berger M, Glioma Outcomes I. Perioperative complications and 14

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neurological outcomes of first and second craniotomies among patients enrolled in the Glioma Outcome Project. J Neurosurg 98(6): 1175, 2003 37. Bressi SK, Marcus SC, Solomon PL. The impact of psychiatric comorbidity on general hospital length of stay. Psychiatr Q 77(3): 203, 2006 38. Namba RS, Singh A, Paxton EW, Inacio MCS. Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty. J Arthroplasty 33(8): 2449, 2018 39. Cook DJ, Kaskovich SW, Pirkle SC, Mica MAC, Shi LL, Lee MJ. Benchmarks of Duration and Magnitude of Opioid Consumption After Total Hip and Knee Arthroplasty: A Database Analysis of 69,368 Patients. J Arthroplasty 34(4): 638, 2019 40. Wancata J, Windhaber J, Bach M, Meise U. Recognition of psychiatric disorders in nonpsychiatric hospital wards. J Psychosom Res 48(2): 149, 2000 41. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 91(1): 128, 2009 42. Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 468(1): 45, 2010

391

392

Table 1. International Classification of Diseases (ICD) 9 and 10 codes to identify depression Code Description 3004 Dysthymic disorder 30112 Chronic depressive personality disorder 3090 Adjustment disorder with depressed mood 3091 Prolonged depressive reaction 311 Depressive disorder, not elsewhere classified 29682 Atypical depressive disorder 29620 Major depressive affective disorder, single episode, unspecified 29621 Major depressive affective disorder, single episode, mild 29622 Major depressive affective disorder, single episode, moderate 29623 Major depressive affective disorder, single episode, severe, without mention of psychotic behavior 29624 Major depressive affective disorder, single episode, severe, specified as with psychotic behavior 29625 Major depressive affective disorder, single episode, in partial or unspecified remission 29626 Major depressive affective disorder, single episode, in full remission 29630 Major depressive affective disorder, recurrent episode, unspecified 29631 Major depressive affective disorder, recurrent episode, mild 29632 Major depressive affective disorder, recurrent episode, moderate 29633 Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior 29634 Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior 29635 Major depressive affective disorder, recurrent episode, in partial or unspecified remission 29636 Major depressive affective disorder, recurrent episode, in full remission F32 Major depressive disorder, single episode F33 Major depressive disorder, recurrent F341 Dysthymic disorder F432 Adjustment disorder with depressed mood

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Table 2. Demographics and comorbidities of opioid use groups Demographic Total Number of Included Patients

393

Age Group <55 55-64 65-74 75-84 85+ Sex Male Female Region Northeast Midwest South West Surgery Type (Component Replaced) Revision THA, Both Components Revision THA, Acetabulum Revision THA, Femur Revision TKA, One Component Revision TKA, Both Components Insurance Comprehensive Preferred Provider Organization Health Maintainence Organization Point-of-service High Deductible Health Plans Comorbidities Obesity Chronic Kidney Disease Alcohol Use Disorders Tobacco Use Hypertension Coronary Artery Disease Congestive Heart Failure Rheumatic Disease Diabetes

Revision THA

Revision TKA

No Depression

Depression

8712 (86.9%)

1305 (13.1%)

P-Value

No Depression Depression

P-Value

1,802 (20.7%) 3,025 (34.7%) 1,704 (19.6%) 1,666 (19.1%) 515 (5.9%)

309 (23.7%) 546 (41.8%) 234 (17.9%) 162 (12.4%) 54 (4.1%)

<0.001

2,036 (17.0%) 4,780 (40.0%) 2,823 (23.6%) 1,994 (16.7%) 328 (2.7%)

487 (24.2%) 957 (47.6%) 387 (19.2%) 154 (7.7%) 27 (1.3%)

<0.001

4,113 (47.2%) 4,599 (52.8%)

399 (30.6%) 906 (69.4%)

<0.001

5,069 (42.4%) 6,892 (57.6%)

468 (23.3%) 1,544 (76.7%)

<0.001

1,703 (19.5%) 2,606 (29.9%) 2,946 (33.8%) 1,411 (16.2%)

240 (18.4%) 380 (29.1%) 456 (34.9%) 221 (16.9%)

0.739

2,012 (16.8%) 4,095 (34.2%) 4,236 (35.4%) 1,553 (13.0%)

295 (14.7%) 698 (34.7%) 686 (34.1%) 319 (15.9%)

0.002

5,080 (58.3%) 2,293 (26.3%) 1,339 (15.4%) n.a. n.a.

719 (55.1%) 353 (27.0%) 233 (17.9%) n.a. n.a.

<0.001

n.a. n.a. n.a. 4,774 (39.9%) 7,187 (60.1%)

n.a. n.a. n.a. 817 (40.6%) 1,195 (59.4%)

0.557

2,035 (24.0%) 4,526 (53.4%) 864 (10.2%) 511 (6.0%) 541 (6.4%)

233 (18.3%) 715 (56.2%) 157 (12.3%) 79 (6.2%) 88 (6.9%)

<0.001

2,901 (24.9%) 6,008 (51.5%) 1,168 (10.0%) 814 (7.0%) 764 (6.6%)

363 (18.6%) 1,087 (55.7%) 213 (10.9%) 129 (6.6%) 158 (8.1%)

<0.001

828 (9.5%) 537 (6.2%) 82 (0.9%) 514 (5.9%) 5,139 (59.0%) 1,520 (17.4%) 511 (5.9%) 514 (5.9%) 1,489 (17.1%)

199 (15.2%) 71 (5.4%) 46 (3.5%) 176 (13.5%) 800 (61.3%) 195 (14.9%) 100 (7.7%) 80 (6.1%) 217 (16.6%)

<0.001 0.307 <0.001 <0.001 0.112 0.025 0.011 0.742 0.678

1,797 (15.0%) 651 (5.4%) 57 (0.5%) 469 (3.9%) 7,982 (66.7%) 2,177 (18.2%) 690 (5.8%) 649 (5.4%) 3,172 (26.5%)

530 (26.3%) 123 (6.1%) 47 (2.3%) 172 (8.5%) 1,367 (67.9%) 325 (16.2%) 109 (5.4%) 148 (7.4%) 512 (25.4%)

<0.001 0.224 <0.001 <0.001 0.286 0.027 0.530 0.001 0.313

11961 (85.6%) 2012 (14.4%)

394

16

Table 3. Univariate Analysis of Complications Revision THA Revision TKA No Depression Depression P-Value No Depression Depression P-Value Extended LOS (≥4 Day) 2,560 (29.4%) 433 (33.2%) 0.005 2,327 (19.5%) 422 (21.0%) 0.113 Non-home Discharge 2,029 (24.2%) 383 (30.4%) <0.001 2,117 (18.5%) 414 (21.5%) 0.002 90-Day Readmission 969 (11.1%) 220 (16.9%) <0.001 950 (7.9%) 244 (12.1%) <0.001 ED Visit 1,456 (16.7%) 331 (25.4%) <0.001 1,574 (13.2%) 391 (19.4%) <0.001 Pain-Related ED Visit 77 (0.9%) 28 (2.1%) <0.001 127 (1.1%) 52 (2.6%) <0.001 Infection 547 (6.3%) 117 (9.0%) <0.001 729 (6.1%) 140 (7.0%) 0.138 Prosthetic Joint Infection 286 (3.3%) 71 (5.4%) <0.001 332 (2.8%) 68 (3.4%) 0.113 Wound Complication 327 (3.8%) 62 (4.8%) 0.082 392 (3.3%) 85 (4.2%) 0.030 Sepsis 83 (1.0%) 29 (2.2%) <0.001 95 (0.8%) 25 (1.2%) 0.045 Thromboembolic Event 480 (5.5%) 85 (6.5%) 0.143 636 (5.3%) 112 (5.6%) 0.646 Revision Surgery* 837 (9.6%) 178 (13.6%) <0.001 829 (6.9%) 174 (8.6%) 0.006 Opioid Prescription after 6-Months 712 (8.2%) 110 (8.4%) 0.753 1,152 (9.6%) 181 (9.0%) 0.369 Net Payments for Admission (USD)** $23,033±278 $26,466±703 <0.001 $21,556±229 $25,666±516 <0.001 * Revision surgery and opioid overdose displayed with 1-year follow up, all other complications displayed for 90 days postoperative follow up ** Displayed as mean ± standard error of the mean Complication

395

Table 4. Adjusted Risks of Complications

396

Revision THA Revision TKA Complication Odds Ratio P-Value Odds Ratio P-Value Extended LOS (≥4 Days) 1.28 (1.12-1.47) <0.001 1.17 (1.03-1.32) 0.016 Non-home Discharge 1.60 (1.38-1.85) <0.001 1.44 (1.26-1.64) <0.001 90-Day Readmission 1.37 (1.16-1.63) <0.001 1.43 (1.22-1.68) <0.001 ED Visit 1.55 (1.34-1.78) <0.001 1.52 (1.34-1.74) <0.001 Pain-Related ED Visit 2.10 (1.33-3.30) 0.001 2.06 (1.46-2.91) <0.001 Infection 1.34 (1.07-1.66) 0.010 1.13 (0.93-1.38) 0.228 Prosthetic Joint Infection 1.52 (1.15-2.01) 0.004 1.17 (0.88-1.56) 0.270 Wound Complication 1.09 (0.81-1.46) 0.560 1.20 (0.93-1.56) 0.161 Sepsis 1.86 (1.17-2.95) 0.008 1.75 (1.10-2.77) 0.018 Thromboembolic Event 1.20 (0.94-1.54) 0.146 1.06 (0.85-1.31) 0.613 Revision Surgery* 1.36 (1.14-1.63) 0.001 1.20 (1.01-1.44) 0.046 Opioid Prescription after 6-Months 1.04 (0.83-1.30) 0.749 0.93 (0.78-1.10) 0.421 Net Payments for Admission (USD)** +$2,660 (1,120-3,999) <0.001 +$3,051 (1,916-4,186) <0.001 * Revision surgery and opioid overdose displayed with 1-year follow up, all other complications displayed for 90 days post-operative follow up ** Beta value of linear regression, presents dollar increase in total hospital payments associated with a diagnosis of depression

17