TJA: Wild Discrepancies in Risk Prediction Calculators

If the tools you are relying on fail, then what are you left with? In this era of extreme cost-cutting, it is more important than ever to be able to rely on the tools in the orthopedic toolbox.

A new study that addresses this issue, “Readmission, Complication, and Disposition Calculators in Total Joint Arthroplasty: A Systemic Review,” appears in the November 2, 2020 edition of The Journal of Arthroplasty.

Jeffrey B. Stambough, M.D., assistant professor in the Department of Orthopaedic Surgery at the University of Arkansas for Medical Sciences and co-author on this work explained to OTW the issue he was hoping to address: “As the arthroplasty landscape has moved more towards bundled care arrangements, there has been a need to better account for certain patient outcomes so that surgeons and their teams can predict potential problems before they arise. When looking to control costs in recent years, the three biggest areas have been focus on decreasing readmissions, trying to discharge patients to home, and avoid certain early complications.”

“When we as a group were trying to use tools already available in the literature and apply to our patients, we found inconsistencies in what prediction kits were out there in terms of risk factor and patient comorbidity variables and whether certain tools had been validated to external patient populations.”

So the researchers looked through three major databases for publications on total joint arthroplasty (TJA) risk stratification tools for readmission, discharge disposition, and early complications.

“After our literature review and exclusions process,” Dr. Stambough told OTW, “we found 10 prediction tools that met our criteria for further study. On deeper inspection, there is a lot of variability in how each calculator was generated and how it can be applied.”

“Some utilize preoperative data with or without functional status and are very involved, others include intra-operative variables, others are based on a variety of surgeries (not just total joints), while a few more take a simplistic approach and include only a few factors. We recommend surgeons evaluate each prediction tool individually depending on their intended use.”

“In all, we concluded that in the current total joint risk stratification realm, there is no perfect single tool that can be applied to all situations. I am also copying the conclusion statement of the paper as well, as it captures the essence of these implications moving forward [in next paragraph].”

The authors wrote, “The extensive variation among TJA risk calculators underscores the need for tools with more individualized stratification capabilities and verification. The transition to outpatient and same-day discharge TJA may preclude or change the need for many of these calculators. Further studies are needed to develop more streamlined risk calculator tools that predict readmission and surgical complications.”