Rachel V. Thakore

Bio: Rachel V. Thakore is an academic researcher from Vanderbilt University. The author has contributed to research in topics: Hip fracture & Trauma center. The author has an hindex of 16, co-authored 40 publications receiving 919 citations. Previous affiliations of Rachel V. Thakore include Vanderbilt University Medical Center.

Use of the National Surgical Quality Improvement Program in orthopaedic surgery.

Abstract: Background The goal of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is to improve patient safety. The database has been used by hospitals across the United States to decrease the rate of adverse events and improve surgical outcomes, including dramatic decreases in 30-day mortality, morbidity, and complication rates. However, only a few orthopaedic surgical studies have employed the ACS NSQIP database, all of which have limited their analysis to either single orthopaedic procedures or reported rates of adverse events without considering the effect of patient characteristics and comorbidities.

Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study.

Abstract: Objectives:To compare patient satisfaction between telemedicine and in-person follow-up appointments for orthopedic trauma.Design:Prospective randomized controlled trial (pilot study).Setting:Level I trauma center.Patients/Participants:Twenty-four patients were enrolled and randomized into 2 groups.

Surgical site infection in orthopedic trauma: A case-control study evaluating risk factors and cost.

Abstract: Background With the shift of our healthcare system toward a value-based system of reimbursement, complications such as surgical site infections (SSI) may not be reimbursed. The purpose of our study was to investigate the costs and risk factors of SSI for orthopedic trauma patients.

What factors influence follow-up in orthopedic trauma surgery?

Abstract: Among surgical patients, follow-up visits are essential for monitoring post-operative recovery and determining ongoing treatment plans. Non-adherence to clinic follow-up appointments has been associated with poorer outcomes in many different patient populations. We sought to identify factors associated with non-attendance at follow-up appointments for orthopedic trauma patients. A retrospective chart review at a level I trauma center identified 2,165 patients who underwent orthopedic trauma surgery from 2008 to 2009. Demographic data including age, sex, race, tobacco use, American Society of Anesthesiologist (ASA) score, insurance status, distance from the hospital, and follow-up time were collected. Injury characteristics including fracture type, anatomic location of the operation, length of hospital stay, living situation and employment status were recorded. Attendance at the first scheduled follow-up visit was recorded. Multivariable log-binomial regression analyses were used with statistical significance maintained at p 2, or had a fracture of the hip or pelvis were significantly less likely to follow-up. Age, sex, and race were not significantly associated with failure to follow-up. Follow-up appointments are essential for preventing complications among orthopedic trauma patients. By identifying patients at risk of failure to follow-up, orthopedic surgeons can appropriately design and implement long-term treatment plans specifically targeted for high-risk patients.

Hip fractures are risky business: an analysis of the NSQIP data.

Abstract: Introduction Hip fractures are one of the most common types of orthopaedic injury with high rates of morbidity. Currently, no study has compared risk factors and adverse events following the different types of hip fracture surgeries. The purpose of this paper is to investigate the major and minor adverse events and risk factors for complication development associated with five common surgeries for the treatment of hip fractures using the NSQIP database. Methods Using the ACS-NSQIP database, complications for five forms of hip surgeries were selected and categorized into major and minor adverse events. Demographics and clinical variables were collected and an unadjusted bivariate logistic regression analyses was performed to determine significant risk factors for adverse events. Five multivariate regressions were run for each surgery as well as a combined regression analysis. Results A total of 9640 patients undergoing surgery for hip fracture were identified with an adverse events rate of 25.2% ( n = 2433). Open reduction and internal fixation of a femoral neck fracture had the greatest percentage of all major events (16.6%) and total adverse events (27.4%), whereas partial hip hemiarthroplasty had the greatest percentage of all minor events (11.6%). Mortality was the most common major adverse event (44.9–50.6%). For minor complications, urinary tract infections were the most common minor adverse event (52.7–62.6%). Significant risk factors for development of any adverse event included age, BMI, gender, race, active smoking status, history of COPD, history of CHF, ASA score, dyspnoea, and functional status, with various combinations of these factors significantly affecting complication development for the individual surgeries. Conclusions Hip fractures are associated with significantly high numbers of adverse events. The type of surgery affects the type of complications developed and also has an effect on what risk factors significantly predict the development of a complication. Concerted efforts from orthopaedists should be made to identify higher risk patients and prevent the most common adverse events that occur postoperatively.

Infection after fracture fixation: Current surgical and microbiological concepts.

Abstract: One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.

Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery

Abstract: Background Many patients having discretionary orthopaedic surgery take opioids daily, either with a prescription or illicitly, however little is known regarding the prevalence and effect of high-risk opioid use (eg, abuse, dependence) in the perioperative orthopaedic setting.

Hypoalbuminemia Independently Predicts Surgical Site Infection, Pneumonia, Length of Stay, and Readmission After Total Joint Arthroplasty

Abstract: This study investigates the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days after total joint arthroplasty Patients who underwent elective primary total hip and knee arthroplasty as part of the American College of Surgeons National Surgical Quality Improvement Program were identified Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration <35 g/dL) with adjustment for patient and procedural factors A total of 49603 patients were included In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission Future efforts should investigate methods of correcting nutritional deficiencies prior to total joint arthroplasty If successful, such efforts could lead to improvements in short-term outcomes for patients

Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review.

Abstract: s, or otherwise presenting non-original data; 6 articles were not related to surgery; 8 used or referred to telemedicine outside of direct patient care; 148 articles presented studies performed outside the US; 80 articles described the use of telemedicine in phases of surgical care other than postoperative (eg preoperative, intraoperative, etc). This left 21 articles for final review (Fig. 1). Of the included studies, 3 were randomized controlled trials, 6 were pilot or feasibility studies, 4 were retrospective record reviews, 2 were case series, and 6 were surveys. These studies are summarized in Table 1. Telemedicine protocols Telemedicine was used during the postoperative period on 3 primary timetables: for scheduled follow-up, for routine and ongoing monitoring, or for management of issues as they arose. Seven studies examined the potential for replacing follow-up clinic visits with a telephone call or an online videoconference, either from the patient’s home or from an affiliated remote clinic site. Among the studies using telemedicine for ongoing monitoring, patients’ reported symptoms were collected either by automated telephone survey or videophone with live patient interviews. Specific objective clinical data were collected using text messages for daily surgical drain output, electronic transmission of home spirometry results, and more complex multi-modal monitoring of symptoms, blood pressure, and medication adherence. The 2 case series included reported the use of text messaging and smartphone digital photography to manage specific concerns as they arose. Many of these protocols required that participants have access to particular kinds of technology, such as smartphones or computers, or access to the internet. Some studies provided all or part of the necessary technology to participants, but many did not, to the exclusion of otherwise eligible participants. In their study of a remote medication adherence protocol in kidney Figure 1. Flow diagram depicting systematic review strategy. Vol. 222, No. 5, May 2016 Gunter et al Telemedicine for Post-Discharge Surgical Care 917 transplant patients, McGillicuddy and colleagues excluded 12.2% of patients who had agreed to participate due to inadequate cellular coverage in their homes. Sathiyakumar and associates excluded patients who did not have access to the technology required to complete remote follow-up using Skype, though they did not report how many patients were ultimately excluded for this; they did have 1 patient drop out of the study due to a weak internet connection. In a similar study using Skype to replace follow-up clinic visits, Sharareh and Schwarzkopf excluded 56.4% of approached patients because they “did not have appropriate electronic devices or did not have internet access to be able to undergo telemedicine appointments.” Although Viers and coworkers provided webcams for participants to complete remote follow-up via videoconference, they excluded 26% of the patients they approached either because they did not have the appropriate equipment or because they were not comfortable with the technology. Patient and provider satisfaction In surveys of patients’ willingness to use telemedicine, the majority of patients reported being willing to participate and thought it would aid communication with their provider. In studies in which patients had already participated in a postoperative protocol using telemedicine, they reported high satisfaction and ease of use. In addition to patient satisfaction, providers also expressed satisfaction with various modalities of telemedicine. A national survey of burn centers by Holt and coauthors found that 62% of burn centers were interested in learning more about telemedicine implementation. Outcomes (clinical and time and money saved) The studies that reported patient travel distance, time, and cost demonstrated universal and significant savings in all domains (Fig. 2). Patients who participated in telemedicine protocols also avoided taking time off from work, having a person accompany them who also had to take time away from personal responsibilities, and having to spend at least 1 night in a hotel. Beyond savings to individual patients and their families or caregivers, Hwa and Wren reported a significant saving to their health system. Performing postoperative follow-up over the telephone rather than in the clinic made 110 additional clinic slots available for new patients over the 10-month study period. Table 1. Summary of Included Studies First author, year n Specialty Study design Intervention Results Prospective RCTs Cleeland, 2011 79 Thoracic surgery RCT Automated telephone questionnaire with triggered alerts to provider after thoracotomy for lung cancer or lung metastases. T ephone symptom monitoring resulted in faster esolution of postoperative symptoms, lower ymptom severity, and less symptom interference ith daily activities. McGillicuddy, 2013 19 Transplant surgery RCT Smartphone-based (Droid X, Motorola) medication adherence and blood pressure selfmanagement system using a wireless Bluetooth blood pressure monitor (FORA D15b, Fora Care Inc) and a wireless GSM electronic medication tray (Med Minder, Maya, Inc,) in renal transplant recipients compared to standard care. P ients in the smartphone group had better edication adherence (p < 0.05) and lower ystolic blood pressure (p 1⁄4 0.009) at 3 months ompared with standard care patients; physicians ade more medication adjustments in martphone group; patients using the martphone system reported high satisfaction nd ease of use with the system. Viers, 2015 55 Urology RCT Online videoconferencing via internally designed interface using Vidyo Software and SBR Health Software for routine follow-up after radical prostatectomy, compared with in-person clinic visit. E ivalent clinic efficiency between ideoconference and in-person visits; high atient and provider satisfaction in the ideoconference group; no acute urologic issues t 3 months follow-up; significant travel time nd distance saved in videoconference group Pilot and feasibility studies Albert, 2013 18 Orthopaedic surgery Feasibility study Smartphone accelerometer to determine level of activity in amputees. S artphone accelerometer adds objective data egarding patient activity data to subjective linical assessments, which could more ppropriately match patients with the prosthesis hat meets their needs. Hwa, 2013 110 General surgery Pilot study Telephone follow-up after open hernia repair or laparoscopic cholecystectomy in VA patients. S ificant travel saved for patients; no omplications occurred as a result of telephone ollow-up; telephone follow-up opened 110 linic spots over study period. Sathiyakumar, 2015 17 Orthopaedic trauma Pilot study Online videoconferencing via Skype used for 2 of 4 follow-up appointments after closed extremity fracture compared with in-person clinic visits. P ients were accepting of Skype follow-up and aved significant travel time and distance; one omplication each in control arm and Skype rm; no rehospitalizations Sharareh, 2014 78 Orthopaedic surgery Nonrandomized prospective study Online videoconferencing via Skype used for routine postoperative follow-up after total joint arthroplasty compared with in-person clinic visit. P ients receiving Skype follow-up had fewer nscheduled clinic visits (3 vs 14, p 1⁄4 0.01), ade fewer calls to the clinic (6 vs 40, p < 0.01), nd were more satisfied with their postoperative are (9.88 vs 8.10 on 10-point scale, p 1⁄4 0.05); 1 omplication in the Skype group, not related to elemedicine use.