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The relationship between preoperative anemia and length of hospital stay among patients undergoing orthopedic surgery at a teaching hospital in Ethiopia: a retrospective cohort study

Perioperative Medicine volume 13, Article number: 120 (2024) Cite this article

Abstract

Introduction

Preoperative anemia in orthopedic surgery is linked to adverse outcomes such as longer hospital stays, higher rates of blood transfusion, and increased risk of death. Effectively addressing and managing this condition is essential for improving patient outcomes and shortening the length of hospital stays. In Ethiopia and other low-income countries, studies on preoperative anemia and its impact on the length of hospital stay following orthopedic surgery are limited. Therefore, this study aimed to assess the relationship between preoperative anemia and length of hospital stay among patients who underwent orthopedic surgery in Northwest Ethiopia.

Methods

A retrospective cohort study was conducted from June 01, 2019, to June 30, 2021, at Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia. Data on demographic and clinical characteristics were collected using the Research Electronic Data Capture (REDCap) data collection system. Prolonged length of stay was defined as when a patient stays more than the 75th percentile of the LOS of all patients after orthopedic surgery. Multivariable logistic regression assessed the association between preoperative anemia and prolonged hospital stay length.

Results

Of 959 orthopedic patients enrolled in this study, 481 (50.16%) had preoperative anemia. The majority of patients underwent intramedullary nailing (27.63%) followed by debridement and irrigation (19.29%), and open reduction and internal fixation (17.00%) orthopedic procedures. The median length of hospital stays of all patients who underwent orthopedic surgery was 6 days (IQR 3, 13). During the follow-up, 212 patients had a prolonged length of stay following orthopedic surgery in the hospital. Of 212 patients who had prolonged hospital stays, 124 (58.49%) patients were anemic compared to 88 (41.51%) non-anemic patients. The odds of prolonged stay after orthopedic surgery were 1.77 (AOR = 1.77, 95% CI 1.25, 2.50) times higher among patients with preoperative anemia than those without preoperative anemia.

Conclusion

Preoperative anemia was independently associated with prolonged hospital stay among orthopedic surgery patients. Appropriate screening and treatment of preoperative anemia in orthopedic patients is essential.

Background

Anemic is defined as a hematocrit of < 36% or hemoglobin levels < 13 g/dl in men and < 12 g/dl in women (Beutler and Waalen 2006). It is frequently observed in patients undergoing major orthopedic surgeries, like hip and knee arthroplasty, with prevalence rates ranging from 15 to 48% (Jans et al. 2014; Leahy et al. 2017). This anemia may result from factors like blood loss, nutritional deficiencies, functional iron deficiency, or a combination of these elements, which can increase risks during the perioperative and postoperative phases (Duarte et al. 2021). If left undetected, anemia can pose significant health challenges that may affect the success of planned orthopedic procedures. Studies indicate that 21% to 35% of patients undergoing elective primary and revision total joint arthroplasty are anemic (Goodnough et al. 2011; Bierbaum et al. 1999; Spahn 2010).

Preoperative anemia in orthopedic surgery is linked to adverse outcomes such as longer hospital stays, higher rates of blood transfusion, and increased risk of death (Lu et al. 2017; Gruson et al. 2002). Recognized as an independent risk factor, preoperative anemia significantly contributes to perioperative complications and can complicate recovery. Therefore, effectively addressing and managing this condition is essential for improving patient outcomes, reducing the likelihood of complications, and enhancing the overall success of surgical interventions (Musallam et al. 2011).

There have been increasing efforts to improve both the quality and value provided in healthcare systems. One area of ongoing study is reducing extended length of stay (LOS) in hospital patients, defined as the number of additional days a patient spends as an inpatient after being deemed medically fit for discharge (O'Keefe et al. 1999). Delayed discharges result in significant financial burdens and can lead to avoidable morbidity and mortality. Consequently, length of stay has been used in many studies as a surrogate marker for the quality of care provided (Zimlichman et al. 2013; De Jong et al. 2006).

Preoperative anemia, even in mild cases, has been shown to be an independent risk factor for poorer outcomes following major surgical procedures, including orthopedic surgeries (Fowler et al. 2015). Studies have demonstrated that preoperative anemia is associated with longer hospital stays, increased intensive care unit admissions, and, consequently, higher morbidity, poorer overall outcomes, and increased healthcare costs (Lunn and Elwood 1970).

Preoperative anemia optimization programs have been particularly well-suited for implementation in elective orthopedic surgery (Goodnough et al. 2011). Despite this, the practice of screening and treating anemia before surgery is not consistently adopted, as over 70% of patients with anemia do not receive any treatment for it prior to their surgical procedure (Scrimshire et al. 2020).

Studies have shown that increasing preoperative hemoglobin levels can lead to shorter patient hospital stays (Abdullah et al. 2017). Orthopedic surgeons should know the causes of anemia and the appropriate treatment options. Addressing the underlying cause of preoperative anemia is crucial for optimizing surgical outcomes (Shanbhag et al. 2019). In Ethiopia and other low-income countries, studies conducted on preoperative anemia and its impact on LOS following orthopedic surgery are limited. Therefore, this study assessed the relationship between preoperative anemia and LOS among orthopedic surgery patients in Northwest Ethiopia. We hypothesized a positive correlation between preoperative anemia and length of hospital stay, indicating that patients with preoperative anemia will experience a longer hospitalization duration than non-anemic patients. The finding of this study will help implement evidence-based practice to improve the duration of stay in the hospital after orthopedic surgery.

Methods

Study design and setting

A retrospective cohort study was conducted from June 01, 2019, to June 30, 2021, at Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia, to assess the effect of preoperative anemia on hospital LOS following orthopedic surgery.

Clinical setting, surgery, and anesthesia

Tibebe Ghion Specialized Hospital is a tertiary-level teaching hospital located in Bahir Dar, the capital city of Amhara Regional State. The hospital, affiliated with the College of Medicine and Health Science, Bahir Dar University, provides academic and clinical services for an estimated population of more than five million people. The hospital has dedicated two operating rooms for all emergency and elective orthopedic patients. Senior orthopedic surgeons, nurses, and anesthetists care for orthopedic patients needing surgery 24/7. Routine laboratory and advanced imaging (X-ray, C-arm, Ultrasound, CT scan, and MRI) services are available for all patients. The hospital currently has more than 500 beds.

Various traumatic and non-traumatic orthopedic surgeries in our clinical setting include fracture repairs, debridement, and abscess drainage. All procedures are open surgeries. Anesthesia management for orthopedic patients frequently uses ultrasound-guided nerve block, spinal anesthesia, and general anesthesia.

Inclusion and exclusion criteria

Inclusion criteria

The study participants were all adult (18 +) patients who underwent orthopedic surgery during the study period were included.

Exclusion criteria

We excluded patients who died in the hospital and who had incomplete data.

Data collection tool, procedure, and quality control

We used a data collection tool previously used to monitor anesthesia and surgical care delivery in low-resource settings to collect the data (Sileshi et al. 2017). Research Electronic Data Capture (REDCap) data collection system was utilized. The data collection tool encompasses information on the demographic and clinical characteristics of the participants.

The attending anesthetist or anesthesia student collected initial demographic and clinical patient information using electronic tablets. A data manager of the research team retrieved the patient’s data until discharge and then collected the hospital LOS data. The data manager also handles missing information. Collected data were entered offline into the REDCap mobile application and then uploaded to the REDCap database using the internet. Overall, the functionality of the data collection system, including the electronic tablets, was consistently maintained by information technology (IT) personnel who were part of the research team.

A simulation-based training regarding the data collection system and ethics of data collection was given to anesthetists, anesthesia students, data managers, and IT experts. The database containing the patient data is restricted to authorized users only.

Study variables

LOS was measured as the number of days a patient stays in the hospital following orthopedic surgery until discharge. The outcome variable of the study was prolonged LOS, defined as when a patient stays more than the 75th percentile of the LOS of all patients after orthopedic surgery.

We considered whether patients had preoperative anemia as a categorical variable. Preoperative anemia was defined as, according to WHO, hemoglobin (Hb) level below 12 g/dL (hematocrit < 36%) for nonpregnant women and 13.0 g/dL (hematocrit < 39%) for men (World Health Organization Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity 2011).

Variables frequently reported to affect LOS after orthopedic procedures include age, sex, American Society of Anesthesiologists (ASA) physical status, comorbidity, urgency of surgery, trauma, type of anesthesia, length of surgery, blood loss, and blood transfusion.

Data processing and analysis

From the REDCap database, data was imported into STATA version 17 for further analysis. Descriptive statistics such as frequencies, percentages, mean with standard deviation, and median with interquartile range were computed to summarize and present study subject characteristics. Results were presented and expressed in tables and graphs after analysis. Pearson's chi-square test was used to assess patient characteristics with respect to preoperative anemia status.

Multivariable logistic regression was used to assess the association between preoperative anemia and prolonged LOS. The Stepwise (Enter) method of selection was used to select significant variables in the multivariable logistic regression model. Crude and adjusted odds ratios and their 95% confidence interval are used as indicators of the strength of the association. A p < 0.05 is used as the cut-off level to declare statistical significance. The Hosmer–Lemeshow goodness-of-fit test checked model fitness for logistic regression (p-value = 0.1215).

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline was used for reporting this study.

Results

Baseline demographic and clinical characteristics of study subjects

We captured 1300 patients undergoing orthopedic surgery at Tibebe Ghion Specialized Hospital during the study period. From these, 988 patients were eligible for this study. Among 988 eligible cases, 20 (2.02%) had incomplete data, and 9 (0.91%) died during the follow-up, making 959 cases included in the final analysis (Fig. 1). The non-preoperative anemia group included 478 (49.84%) patients, while the preoperative anemia group included 481 (50.16%, 95% CI: 46. 99%, 53.32%). In this cohort, the median age was 30 (IQR 24, 45), and) most participants were males. There were no statistically significant differences in sex, the urgency of surgery, trauma, type of anesthesia, length of surgery, and blood loss between different groups (p-value > 0.05). There was a significantly higher median age among orthopedic patients in the preoperative anemia group compared to the non-anemic group (p-value < 0.05). The number of patients who exhibited higher ASA physical status score III/IV in the preoperative anemia group (27 (5.61%) was higher than that in the non-preoperative anemia group (10 (2.09%) (p-value < 0.05). Participants who had comorbidities were significantly higher among preoperative anemia (117 (24.32%) compared to non-preoperative anemia group (52 (10.88%) (p-value < 0.05). The transfusion rate of the preoperative anemia group was 83 (17.26%), higher than that of the non-preoperative anemia group, 28 (5.86%) (p-value < 0.05) (Table 1).

Table 1 Baseline demographic and clinical characteristics of study subjects
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Fig. 1
figure 1

Flow chart showing the number of orthopedic cases included in the study

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Orthopedic cases and procedures

Of the 959 patients presenting for orthopedic surgery, the top five most common cases were femoral fracture, tibial fracture, radioulnar facture, humeral facture, and tibiofibular fracture with a frequency of 303 181. 105, 102, and 71 cases, respectively (Fig. 2). In this study, the majority of patients underwent intramedullary nailing (27.63%) followed by debridement and irrigation (19.29%), and open reduction and internal fixation (ORIF) (17.00%) orthopedic procedures (Fig. 3).

Fig. 2
figure 2

Orthopedic case mix at Tibebe Ghion Specialized Hospital, Northwest Ethiopia, June 2019–June 2021

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Fig. 3
figure 3

Orthopedic procedures at Tibebe Ghion Specialized Hospital, Northwest Ethiopia, June 2019–June 2021

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The relationship between preoperative anemia and length of hospital stay after orthopedic surgery

The median LOS of all orthopedic surgery patients was 6 days (IQR 3, 13). We consider prolonged LOS when a patient stays more than the 75th percentile (13 days) of the LOS of all patients. During the follow-up, 212 patients had a prolonged LOS following orthopedic surgery in the hospital. Of 212 patients who had prolonged hospital stays, 124 (58.49%) patients were anemic compared to 88 (41.51%) non-anemic patients (Fig. 4).

Fig. 4
figure 4

Prolonged LOS among anemic versus non-anemic patients who underwent orthopedic surgery at Tibebe Ghion Specialized Hospital, Northwest Ethiopia

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After adjusting possible confounder variables, preoperative anemia was independently associated with prolonged LOS among patients who underwent orthopedic surgery. The odds of prolonged LOS after orthopedic surgery were 1.77 (AOR = 1.77, 95% CI 1.25, 2.50) times higher among patients with preoperative anemia than those without preoperative anemia (Table 2). In this cohort, every one-gram-per-deciliter increase in preoperative hemoglobin level is associated with a reduced patient's LOS in the hospital by 17% (AOR = 0.83, 95% CI 0.77, 0.90) (Table 3).

Table 2 Bivariable and multivariable analysis of prolonged LOS (> 13 days) among patients who underwent orthopedic surgery atTibebe Ghion Specialized Hospital, Northwest Ethiopia
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Table 3 Multivariable analysis to assess the effect of preoperative hemoglobin level on prolonged LOS (> 13 days) among patients who underwent orthopedic surgery atTibebe Ghion Specialized Hospital, Northwest Ethiopia
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Discussion

In this retrospective cohort study of 959 consecutive patients who underwent elective and emergency orthopedic surgery in a tertiary teaching hospital in Ethiopia, half (50.16%) of patients had preoperative anemia. This finding aligns with a study conducted in Southern Ethiopia, which reported that 52.83% of orthopedic patients had preoperative anemia (Gelebo et al. 2023). However, the prevalence of preoperative anemia in our study was higher than in previous studies conducted in Northwest Ethiopia (Diress and Ayele 2023). The explanation for this discrepancy is a difference in the study population in which emergency orthopedic patients were included in this cohort, which will significantly increase the likelihood of preoperative anemia due to traumatic injury and blood loss. The finding of this study revealed that the proportion of orthopedic patients who were anemic was higher than reports from Singapore (Abdullah et al. 2017), the United States of America (Kendoff et al. 2011), Europe (Lasocki et al. 2015, Theusinger et al. 2007, Wan et al. 2020), and Australia (Delaforce et al. 2020). A difference in socio-economic status could explain this discrepancy in which anemia is highly prevalent in countries with low socio-economic status, such as Ethiopia (Balarajan et al. 2011).

The multivariable binary logistic regression model revealed that preoperative anemia was independently associated with prolonged LOS after orthopedic surgery. Patients with preoperative anemia had 1.77 times increased odds of prolonged LOS compared to patients without preoperative anemia. This finding is consistent with studies that have established preoperative anemia independently associated with increased LOS after major orthopedic surgery (Abdullah et al. 2017; Duarte et al. 2021; Zhang et al. 2024). Preoperative anemia reduces physiological oxygen-carrying capacity, which impairs other organ systems such as cardiac perfusion, lung function, and wound healing; these unwanted physiological impairments lead to prolonged LOS (Bisbe et al. 2017). Furthermore, orthopedic patients who were anemic during the preoperative period had higher rates of postoperative in-hospital complications such as pulmonary embolism, deep venous thrombosis, and sepsis, which these postoperative complications indirectly affect hospital stay negatively (Harris et al. 2023; Jiang et al. 2023).

As demonstrated by previous similar studies (Abdullah et al. 2017; Harris et al. 2023; Jiang et al. 2023), in this study, a one g/dl increment in preoperative hemoglobin level is associated with a 17% reduction in prolonged LOS after orthopedic procedures. These findings necessitate the appropriate screening and treatment of preoperative anemic in orthopedic patients as part of preoperative patient optimization. Improved patient care and cost minimization through reduced allogenic blood transfusion and LOS might be achieved by implementing diagnosis and treatment of preoperative anemia (Wan et al. 2020). Intravenous iron is considered an effective treatment modality for correcting preoperative anemia and improving postoperative outcomes. However, the availability of intravenous iron in low-resource settings like Ethiopia makes it challenging to integrate this treatment modality into clinical practice.

Local adaptation and implementation of patient blood management (PBM) approaches is considered a key and revolutionary strategy to decrease the negative consequences of preoperative anemia among surgical patients, including patients undergoing orthopedic surgery (Franchini et al. 2019). As per this approach, the goal of perioperative anemia management includes early diagnosis, targeted treatment, blood conservation, restrictive transfusion, and ongoing quality assurance (Kiyatkin et al. 2023). Implementing the PBM approach into routine perioperative practice needs national-level quality improvement initiatives (Céspedes et al. 2024); however, until the initiation of national-level quality improvement initiatives, a patient-centered approach to PBM should be delivered in a way that is also hospital-centered (Desai et al. 2018).

Limitations of the study

Due to the nature of the design, we could not assess postoperative complications after orthopedic surgery, such as surgical site infection, deep venous thrombosis, and shock, which affects the LOS after surgery. In addition, we assess various orthopedic surgical procedures that might affect this study's transferability for specific orthopedic procedures. Furthermore, the definition of prolonged length of stay using the 75th centriole can be seen as an arbitrary cut-off point; however, there is no internationally accepted definition of prolonged LOS.

Conclusion

Our finding revealed that half of orthopedic patients had preoperative anemia. Preoperative anemia was independently associated with prolonged LOS among patients who underwent orthopedic surgery. These necessitate strategies to screen and correct preoperative anemia in patients before undergoing orthopedic procedures.

Data availability

The data generated during and analyzed during this study are available from the corresponding request upon a reasonable request.

Abbreviations

AOR:

Adjusted odds ratio

ASA:

American Society of Anesthesiologist

COR:

Crude odds ratio

IQR:

Interquartile range

PBM:

Patient blood management

SD:

Standard deviation

LOS:

Length of stay

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Acknowledgements

We want to thank all anesthesia staffs participating in data collection at Tibebe Ghion Specialized Hospital.

Funding

We received financial support from the ImPACT Africa project. The funder has no role in the study’s design, analysis, and interpretation of data.

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Authors and Affiliations

  1. Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

    Amanuel Sisay Endeshaw, Fikadu Tadesse Diress, Atalay Eshetie Demilie & Fantahun Tarekegn Kumie

  2. School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Melatmariam Sisay Endeshaw

  3. Department of Orthopedics and Traumatology, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

    Workineh Mengesha Kefale & Biniyam Teshome Addisu

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  1. Amanuel Sisay Endeshaw
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Contributions

AS Endeshaw and FT Diress: Took part in conceptualization, methodology, formal analysis, investigation, resources, data curation, writing - original manuscript draft, writing – review & editing, visualization, MS Endeshaw, WM Kefale and BT Addisu: Took part in methodology, formal analysis, investigation, writing --review & editing, visualization. AE Demilie and FT Kumie: Manuscript writing – review & editing, investigation, data curation, methodology. All authors approved the final draft of manuscript.

Corresponding author

Correspondence to Amanuel Sisay Endeshaw.

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Ethics approval and consent to participate

The protocol for this study was approved by the Institutional Review Board (IRB) College of Medicine and Health Sciences, Bahir Dar University (Ref №. 0163/2018). Since it is secondary data, informed consent was waived for all study subjects by the Institutional Review Board (IRB) College of Medicine and Health Sciences, Bahir Dar University, and Tibebe Ghion Specialized Hospital. The confidentiality and security of all patient information were maintained to prevent unauthorized access. All methods were carried out in accordance with relevant guidelines and regulations in accordance with the Declaration of Helsinki.

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The authors declare no competing interests.

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Endeshaw, A.S., Diress, F.T., Endeshaw, M.S. et al. The relationship between preoperative anemia and length of hospital stay among patients undergoing orthopedic surgery at a teaching hospital in Ethiopia: a retrospective cohort study. Perioper Med 13, 120 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13741-024-00482-9

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Keywords

Perioperative Medicine

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