Where Are We Now?
As the demands for healthcare services have increased, and the applicable resources have become more expensive and/or scarce, risk stratification has evolved into a critical strategy for optimal patient management, as well as a tactic for forecasting a patient’s chances of success or complications during an episode of care. Utilizing detailed checklists of comorbidities and socioeconomic status, stakeholder organizations such as the American College of Cardiology, the American College of Surgeons National Surgical Quality Improvement Program, and the American Joint Replacement Registry have produced guidelines or calculators that help define statistical ranges of risk for various complications and poor outcomes after surgery for patients with similar characteristics [1, 2, 4]. These tools have assisted surgeons in the informed consent process, and also in their decision making as to when and if to recommend surgery. A weakness in the current risk-stratification methodologies is the relative lack of accuracy and specificity in predicting complications and readmissions for any given patient [3].
Where Do We Need To Go?
One hopes that improved risk stratification will lead to reduction of the most-serious postoperative complications such as acute myocardial infarction and death. Also, the overall economic burden and human suffering associated with perioperative complications should be diminished. This retrospective case control study by Kumar et al. provides additional predictive guidelines for those patients with cardiac events prior to elective TKA. As a result of their analysis, the authors concluded elective TKA should be performed at least one year after acute myocardial infarction or stenting for optimal risk reduction.
This study is a potential improvement in our ability to categorize high risk patients before elective TKA and then schedule their knee surgery at the safest time relative to previous cardiac events. We will need additional dependable patient-level information, predictive modelling, and consensus-based best practices to manage our patients’ perioperative modifiable risk factors in the future [5].
How Do We Get There?
As clinicians, we must be responsible stewards of society’s healthcare resources; and, for elective surgery in particular, we have the professional obligation to optimize our patient’s perioperative health status to give them the best chance of an excellent outcome with the lowest risk. More-robust and larger patient-population databases and registries and prospective analyses will improve our ability to accurately risk stratify our patients prior to procedures. The rapid spread of electronic health records, various registries, and the recent government mandated implementation of ICD-10 should facilitate these efforts. Consensus-derived definitions of complications and best-practice management of comorbidities, combined with accurate coding and data entry will ultimately help reach our goal: Better predictive and planning capabilities on behalf of our patients.
References
American College of Surgeons NSQIP Surgical Risk Calculator. Available at: http://riskcalculator.facs.org/PatientInfo/PatientInfo. Accessed November 16, 2015.
American Joint Replacement Registry Risk Calculator. Available at: https://teamwork.aaos.org/ajrr/SitePages/Risk%20Calculator.aspx. Accessed November 16, 2015.
Edelstein A, Kwasny M, Suleiman L, Khakhkhar R, Moore M, Beal M, Manning D. Can the American College of Surgeons Risk Calculator predict 30-day complications after knee and hip arthroplasty? J Arthroplasty. 2015;30(9 suppl):5–10.
Fleisher LA, Fleischmann KE, Auerback AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardilvascular evaluation and management of patients undergoing noncardiac surgery: Executive summary: A report of the American College of Cardiology/ American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64:2373–2405.
Yu S, Garvin KL, Healy WL, Pellegrini VD, Iorio R. Preventing hospital readmissions and limiting the complications associated with total joint arthroplasty. Instructional Course Lecture. J Am Acad Ortho Surg. 2015;23:e61–e71.
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This CORR Insights® is a commentary on the article “Risk of Post-TKA Acute Myocardial Infarction in Patients With a History of Myocardial Infarction or Coronary Stent” by Kumar and colleagues available at: DOI: 10.1007/s11999-015-4616-z.
The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or The Association of Bone and Joint Surgeons®.
This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-015-4616-z.
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Attarian, D.E. CORR Insights®: Risk of Post-TKA Acute Myocardial Infarction in Patients With a History of Myocardial Infarction or Coronary Stent. Clin Orthop Relat Res 474, 487–488 (2016). https://doi.org/10.1007/s11999-015-4642-x
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DOI: https://doi.org/10.1007/s11999-015-4642-x