[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Figure.
Cohort Selection Flow Diagram
Cohort Selection Flow Diagram

The criteria for exclusions were checked consecutively. ICD-9 indicates International Classification of Diseases, Ninth Revision; TJR, total joint replacement.

Table.  
Baseline Characteristics of Study Cohorta
Baseline Characteristics of Study Cohorta
1.
Agency for Healthcare Research and Quality. Healthcare cost and utilization project. https://www.ahrq.gov/data/hcup/index.html. Accessed November 7, 2018.
2.
Maradit Kremers  H, Larson  DR, Crowson  CS,  et al.  Prevalence of total hip and knee replacement in the United States.  J Bone Joint Surg Am. 2015;97(17):1386-1397. doi:10.2106/JBJS.N.01141PubMedGoogle ScholarCrossref
3.
Louati  K, Vidal  C, Berenbaum  F, Sellam  J.  Association between diabetes mellitus and osteoarthritis: systematic literature review and meta-analysis.  RMD Open. 2015;1(1):e000077. doi:10.1136/rmdopen-2015-000077PubMedGoogle ScholarCrossref
4.
Yang  L, Sun  Y, Li  G, Liu  J.  Is hemoglobin A1c and perioperative hyperglycemia predictive of periprosthetic joint infection following total joint arthroplasty? a systematic review and meta-analysis.  Medicine (Baltimore). 2017;96(51):e8805. doi:10.1097/MD.0000000000008805PubMedGoogle ScholarCrossref
5.
Stryker  LS, Abdel  MP, Morrey  ME, Morrow  MM, Kor  DJ, Morrey  BF.  Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty.  J Bone Joint Surg Am. 2013;95(9):808-814, S1-S2. doi:10.2106/JBJS.L.00494PubMedGoogle ScholarCrossref
6.
Nussenbaum  FD, Rodriguez-Quintana  D, Fish  SM, Green  DM, Cahill  CW.  Implementation of preoperative screening criteria lowers infection and complication rates following elective total hip arthroplasty and total knee arthroplasty in a veteran population.  J Arthroplasty. 2018;33(1):10-13. doi:10.1016/j.arth.2017.07.031PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Views 645
    Research Letter
    Orthopedics
    September 4, 2019

    Assessment for Perioperative Hyperglycemia Prior to Total Joint Replacement in Patients With and Without Diabetes

    Author Affiliations
    • 1Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Harvard Medical School, Boston, Massachusetts
    • 4Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
    • 5Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
    JAMA Netw Open. 2019;2(9):e1910589. doi:10.1001/jamanetworkopen.2019.10589
    Introduction

    More than 1 000 000 total joint replacements (TJRs) are performed annually in the United States,1 most of which are for osteoarthritis.2 Diabetes is a frequent comorbidity in patients with osteoarthritis3 and suboptimal glucose control preoperatively is associated with poor TJR outcomes.4,5 Despite the concern for hyperglycemia in the period before TJR, there is a paucity of data regarding the frequency of preoperative outpatient screening. We aimed to assess how frequently hemoglobin A1c (HbA1c) was measured 90 days prior to TJR among Medicare enrollees.

    Methods

    We conducted a cohort study using claims data from Medicare Parts A (hospital), B (medical), and D (pharmacy) from January 2010 to December 2014; data were analyzed from May 2018 to July 2019. The index date was the date of first TJR (total hip or knee) during the study period. Patients were aged 65 years or older and were continuously enrolled in Medicare for at least 360 days prior to the index date.

    This study was approved by the Brigham and Women’s Health institutional review board, which waived the requirement for obtaining patients’ consent because data were deidentified and patients incurred minimal risk. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or Current Procedural Terminology codes were used to identify diabetes, complications of diabetes (nephropathy, neuropathy, retinopathy, or foot problems associated with diabetes), TJR, and comorbidities. Using claims from the 270 days prior to the 90-day outcome period, we created 4 mutually exclusive groups: (1) no diabetes (no ICD-9 code for diabetes or diabetes complications and no claim for insulin or other antidiabetic medications); (2) diabetes and not receiving medication (≥1 ICD-9 code for diabetes but no claim for insulin or other antidiabetic medications); (3) diabetes and receiving noninsulin medications for diabetes (≥1 ICD-9 code for diabetes and ≥1 claim for noninsulin antidiabetic medications); and (4) diabetes and receiving insulin (≥1 ICD-9 code for diabetes and ≥1 claim for insulin).

    The primary outcome was the proportion of patients who had an HbA1c level tested in the 90 days prior to TJR. We also assessed the proportion of patients who had a code for serum blood glucose level tested separately or in metabolic panels in the 90 days preceding TJR.

    Results

    We had access to 1 046 660 claims for TJR; of these, 465 566 patients met the inclusion criteria (Figure). Among the groups, mean age ranged from 73 to 75 years and 64% to 68% were female (Table). In the 90 days prior to TJR, 4.9% (95% CI, 4.8%-5.0%) of patients without diabetes had HbA1c testing compared with 25.8% (95% CI, 25.4%-26.2%) of those with diabetes not receiving medication, 39.0% (95% CI, 38.6%-39.4%) of those with diabetes receiving noninsulin medications, and 43.4% (95% CI, 42.8%-44.1%) of those with diabetes receiving insulin. Serum glucose testing was performed in 37.2% (95% CI, 37.0%-37.4%) of those without diabetes, 45.7% (95% CI, 45.2%-46.1%) of those with diabetes not receiving medication, 47.7% (95% CI, 47.3%-48.1%) of those with diabetes receiving noninsulin medications, and 50.2% (95% CI, 49.5%-50.9%) of those with diabetes receiving insulin. The proportion of patients with HbA1c or serum glucose level tested was 37.6% in those without diabetes, 48.6% in those with diabetes not receiving medication, 52.9% for those with diabetes receiving noninsulin medication, and 56.8% for those with diabetes receiving insulin.

    Discussion

    In this large Medicare cohort undergoing TJR, preoperative HbA1c testing was performed in 26% to 43% of patients with diabetes and in only 5% of those without diabetes. Prior research has shown that an elevated HbA1c level is associated with postoperative complications and, furthermore, that screening and addressing risk factors such as HbA1c preoperatively may reduce complications, highlighting the importance of HbA1c screening.4-6

    Limitations of our study include possible misclassification of diabetes, as we relied on ICD-9 codes, although we also used medication dispensing data to maximize accuracy. We were unable to assess for screening with fingerstick blood glucose or inpatient testing. Data were available from 2010 to 2014 and may not reflect current practice.

    In a real-world clinical setting, hyperglycemia is often not screened for prior to TJR. Further study on the utility of perioperative hyperglycemia monitoring and optimization is warranted.

    Back to top
    Article Information

    Accepted for Publication: July 15, 2019.

    Published: September 4, 2019. doi:10.1001/jamanetworkopen.2019.10589

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 MacFarlane LA et al. JAMA Network Open.

    Corresponding Author: Lindsey A. MacFarlane, MD, MPH, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 20115 (lmacfarlane@bwh.harvard.edu).

    Author Contributions: Drs MacFarlane and Kim had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: MacFarlane, Jin, Kim.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: MacFarlane, Jin, Lii.

    Critical revision of the manuscript for important intellectual content: MacFarlane, Franklin, Katz, Kim.

    Statistical analysis: MacFarlane, Jin, Lii, Kim.

    Obtained funding: Kim.

    Administrative, technical, or material support: MacFarlane, Katz, Kim.

    Supervision: Kim.

    Conflict of Interest Disclosures: Dr MacFarlane reported receiving personal fees from Flexion outside the submitted work. Dr Franklin reported receiving grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study; and grants from National Institutes of Health, the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality outside the submitted work. Dr Katz reported receiving grants from Flexion Therapeutics and Samumed outside the submitted work. Dr Kim reported receiving grants from Pfizer, AbbVie, Roche, and Bristol-Myers Squibb outside the submitted work. No other disclosures were reported.

    Funding/Support: This work was supported by National Institutes of Health grant R01AR069557.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Agency for Healthcare Research and Quality. Healthcare cost and utilization project. https://www.ahrq.gov/data/hcup/index.html. Accessed November 7, 2018.
    2.
    Maradit Kremers  H, Larson  DR, Crowson  CS,  et al.  Prevalence of total hip and knee replacement in the United States.  J Bone Joint Surg Am. 2015;97(17):1386-1397. doi:10.2106/JBJS.N.01141PubMedGoogle ScholarCrossref
    3.
    Louati  K, Vidal  C, Berenbaum  F, Sellam  J.  Association between diabetes mellitus and osteoarthritis: systematic literature review and meta-analysis.  RMD Open. 2015;1(1):e000077. doi:10.1136/rmdopen-2015-000077PubMedGoogle ScholarCrossref
    4.
    Yang  L, Sun  Y, Li  G, Liu  J.  Is hemoglobin A1c and perioperative hyperglycemia predictive of periprosthetic joint infection following total joint arthroplasty? a systematic review and meta-analysis.  Medicine (Baltimore). 2017;96(51):e8805. doi:10.1097/MD.0000000000008805PubMedGoogle ScholarCrossref
    5.
    Stryker  LS, Abdel  MP, Morrey  ME, Morrow  MM, Kor  DJ, Morrey  BF.  Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty.  J Bone Joint Surg Am. 2013;95(9):808-814, S1-S2. doi:10.2106/JBJS.L.00494PubMedGoogle ScholarCrossref
    6.
    Nussenbaum  FD, Rodriguez-Quintana  D, Fish  SM, Green  DM, Cahill  CW.  Implementation of preoperative screening criteria lowers infection and complication rates following elective total hip arthroplasty and total knee arthroplasty in a veteran population.  J Arthroplasty. 2018;33(1):10-13. doi:10.1016/j.arth.2017.07.031PubMedGoogle ScholarCrossref
    ×