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      History of COVID-19 Was Not Associated with Length of Stay or In-Hospital Complications After Elective Lower Extremity Joint Replacement

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          Abstract

          Background

          The impact of previous SARS-CoV-2 infection on the morbidity of elective total joint arthroplasty (TJA) is not fully understood. This study reports on the association between previous COVID-19 disease, hospital length of stay (LOS), and in-hospital complications after elective primary TJA.

          Methods

          Demographics, comorbidities, LOS, and in-hospital complications of consecutive 340 patients with history of COVID-19 were compared to 5,014 patients without history of COVID-19 undergoing TJA. History of COVID-19 was defined as a positive IgG antibody test for SARS-CoV-2 before surgery. All patients were given both antibody and PCR tests prior to surgery.

          Results

          Patients with history of COVID-19 were more likely to be obese (43.8% vs. 32.4%, p<0.001), Black (15.6% vs. 6.8%, p<0.001) or Hispanic (8.5% vs. 5.4%, p=0.028) compared to patients without history of COVID-19. COVID-19 treatment was reported by 6.8% of patients with a history of COVID-19. Patients with history of COVID-19 did not have a significantly longer median LOS after controlling for other factors (for hip replacements, median 2.9h longer, 95% CI -2.0 to 7.8, p=0.240; for knee replacements, median 4.1h longer, 95% CI -2.4 to 10.5, p=0.214) but a higher percentage were discharged to a post-acute care facility (4.7% vs. 1.9%, p=0.001). There was no significant difference in in-hospital complication rates between the two groups (0/340=0.0% versus 22/5,014=0.44%, p=0.221).

          Conclusion

          We do not find differences in LOS or in-hospital complications between the two groups. However, more work is needed to confirm these findings, particularly for patients with a history of more severe COVID-19.

          Level of evidence

          II

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          Most cited references25

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          Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.

          Hude Quan, Vijaya Sundararajan, Patricia Halfon … (2005)
          Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms. ICD-10 coding algorithms were developed by "translation" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD-10 codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms. Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD-9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD-9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm. These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.
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            Comorbidity measures for use with administrative data.

            A Elixhauser, C. Steiner, D Harris … (1998)
            This study attempts to develop a comprehensive set of comorbidity measures for use with large administrative inpatient datasets. The study involved clinical and empirical review of comorbidity measures, development of a framework that attempts to segregate comorbidities from other aspects of the patient's condition, development of a comorbidity algorithm, and testing on heterogeneous and homogeneous patient groups. Data were drawn from all adult, nonmaternal inpatients from 438 acute care hospitals in California in 1992 (n = 1,779,167). Outcome measures were those commonly available in administrative data: length of stay, hospital charges, and in-hospital death. A comprehensive set of 30 comorbidity measures was developed. The comorbidities were associated with substantial increases in length of stay, hospital charges, and mortality both for heterogeneous and homogeneous disease groups. Several comorbidities are described that are important predictors of outcomes, yet commonly are not measured. These include mental disorders, drug and alcohol abuse, obesity, coagulopathy, weight loss, and fluid and electrolyte disorders. The comorbidities had independent effects on outcomes and probably should not be simplified as an index because they affect outcomes differently among different patient groups. The present method addresses some of the limitations of previous measures. It is based on a comprehensive approach to identifying comorbidities and separates them from the primary reason for hospitalization, resulting in an expanded set of comorbidities that easily is applied without further refinement to administrative data for a wide range of diseases.
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              Neurological associations of COVID-19

              Mark Ellul, Laura Benjamin, Bhagteshwar Singh … (2020)
              Summary Background The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare. Recent developments A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barré syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2–6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin. Where next? Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barré syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Arthroplast Today
                Journal ID (iso-abbrev): Arthroplast Today
                Title: Arthroplasty Today
                Publisher: Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.
                ISSN (Electronic): 2352-3441
                Publication date PMC-release: 10 December 2021
                Publication date (Electronic): 10 December 2021
                Affiliations
                [1 ]Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
                [2 ]Cantonal Hospital Baden, Im Ergel 1, CH-5404 Baden, Switzerland
                [3 ]Weill Cornell Medical College, Department of Population Health Sciences, 1300 York Ave, New York, NY, 10065, USA
                Author notes
                [∗ ]Corresponding author: Friedrich Boettner, MD, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, Correspondence telephone: +1 212 774 2127 Correspondence
                Article
                Publisher Item ID: S2352-3441(21)00235-1
                DOI: 10.1016/j.artd.2021.11.021
                PMC ID: 8660178
                PubMed ID: 34909457
                SO-VID: 1cd34b6f-7125-4fe4-81bc-0726fb663522
                Copyright © © 2021 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 23 June 2021
                Date revision received : 11 October 2021
                Date accepted : 25 November 2021
                Categories
                Subject: Original Research

                Keywords: total joint arthroplasty,covid-19,sars-cov-2,elective surgery,complications,length of stay
                Data availability:
                Keywords: total joint arthroplasty, covid-19, sars-cov-2, elective surgery, complications, length of stay

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