Depression Associated with Increased Morbidity Risk After TJA

Maureen Leahy

Depression is associated with an increased risk of postoperative psychosis, anemia, pulmonary embolism (PE), and infection following total joint arthroplasty (TJA), according to study data presented Tuesday. The study also revealed that the diagnosis of depression among TJA patients is on the rise.

Although the effects of depression on pain relief and function following TJA have been studied, little is known about its effect on postoperative morbidity and mortality, the authors noted. They sought to assess the incidence of the diagnosis of depression in TJA patients and determine its impact on early outcomes.

Collecting the data
Presenter James A. Browne, MD, and his colleagues from the University of Virginia used ICD-9-CM diagnosis and procedure codes to identify patients in the Nationwide Inpatient Sample (NIS) database who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 1998 and 2008. They limited their detailed analysis to 497,222 patients who had undergone THA or TKA between 2006 and 2008.

“We used the NIS database to look at the changing incidence of the diagnosis of depression in those patients undergoing hip and knee replacement during the decade 1998 to 2008. Our detailed analysis focused on 2006 through 2008 only,” explained Dr. Browne. “This gave us the most recent [approximately] 500,000 patients to study, which we believe most closely reflects current practice.”

Of the 497,222 patients (305,791 females, 191,431 males; average
age = 64 years), 61.5 percent had undergone TKA and 38.5 percent had undergone THA. Most patients were white (85 percent); the most common payer was Medicare
(55 percent).

Approximately 10 percent of patients were identified as depressed, based on the Agency for Healthcare Research and Quality comorbidity measure of depression. The researchers used multivariate regression analysis to compare the incidence of depression with in-hospital morbidity and mortality following TJA. Hospital length of stay and total charges were also examined.

Depression increases morbidity risks
The researchers found that the diagnosis of depression among TJA patients increased steadily from 2.8 percent in 1998 to 11.1 percent in 2008. Multivariate analysis revealed that TJA patients with depression were younger than patients without depression (63 years and 66 years, respectively; P < 0.001), and were significantly more likely to be white, female, and have Medicaid as a primary payer (P < 0.05 for all comparisons).

Patients with depression also had a higher comorbidity burden than patients without depression. Among the postoperative complications examined, depression was found to be independently associated with a greater risk of in-hospital postoperative psychosis, anemia, PE, and infection. Depression was not associated with in-hospital mortality. Interestingly, depression was associated with a lower risk for cardiac complications and gastrointestinal complications. Patients with depression had similar lengths of stay and hospital charges as those not
depressed.

“Our data suggest that the diagnosis of depression is associated with increased risks for morbidity following TJA. This information is important when counseling patients with a history of mental health issues and identifying patients preoperatively who may benefit from treatment of unrecognized depression,” said Dr. Browne. “We also believe this information is important when risk-adjusting patient outcome data. Further studies are required to confirm these findings and to identify potential underlying mechanisms to explain these associations.”

Dr. Browne’s coauthors of “The Impact of Depression Following Total Joint Arthroplasty: A Nationwide Database Study” are Wendy Novicoff, PhD; Michele R. D’Apuzzo, MD; and Benjamin Sandberg, MS.

Disclosure information: None of the authors report any conflicts.

2013 Annual Meeting News
Tuesday through Friday, February 19 – 23, 2013.
http://www.aaos.org/news/acadnews/2013/AAOS10_3_20.asp