|
1
|
Kohring AS, Lutz R, Parikh N, Hobbs J, Bridges TN, Krueger CA. Analysis of Costs Associated With Increased Length of Stay After Total Joint Arthroplasty at a Single Private Practice. J Am Acad Orthop Surg 2025; 33:e24-e35. [PMID: 38773848 DOI: 10.5435/jaaos-d-23-01262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/27/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION As the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) increases, so does the financial burden of these services. Despite efforts to optimize spending and bundled care payments, THA and TKA costs still need to be assessed. Our study explores the relationship between perioperative costs and length of stay (LOS) for THA and TKA. METHODS A total of 614 patients undergoing THA or TKA at a single private practice with LOS from zero to 3 days were identified. All patients were insured by private or Medicare Advantage insurance from a single provider. Primary outcomes included total costs and their relationship with LOS, classified into surgeon reimbursement, facility costs, and anesthesia costs. Secondary outcomes included readmission rates and discharge disposition. Analyses involved Student t -test, analysis of variance, and chi-square tests. RESULTS Longer LOS was associated with increased total, facility, and anesthesia costs. Costs for THA patients were stable except for reduced surgeon reimbursement with longer LOS. Patients undergoing TKA experienced an increase in facility costs with longer LOS. Total facility and anesthesia costs increased with LOS for Medicare Advantage patients, but surgeon reimbursement remained stable. Privately insured patients experienced higher total and facility costs but stable surgeon reimbursement and anesthesia costs regardless of LOS. CONCLUSION Our study shows an increase in total cost with longer LOS, especially pronounced in privately insured patients. A notable reduction was observed in the surgeon reimbursement for Medicare Advantage patients with extended LOS. These findings underscore the need for efficient surgical practices and postoperative care strategies to optimize hospital stays and control costs.
Collapse
Affiliation(s)
- Adam S Kohring
- From the Jefferson Health New Jersey, Stratford, NJ (Kohring, Lutz, and Bridges), and Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA (Parikh, Hobbs, and Krueger)
| | | | | | | | | | | |
Collapse
|
|
2
|
Velichala SR, Wyatt PB, Reiter CR, Ernst BS, Satalich J, Ross JA. Risk Factors and Incidence of 30-Day Readmission Following Outpatient Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)01201-4. [PMID: 39549885 DOI: 10.1016/j.arth.2024.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 11/05/2024] [Accepted: 11/07/2024] [Indexed: 11/18/2024] Open
Abstract
BACKGROUND Reflecting advancements in surgical techniques and postoperative care, total knee arthroplasty (TKA) is being performed increasingly as an outpatient procedure. This study aimed to report the frequency and timing of unplanned readmission after outpatient TKA with updated data, identify risk factors for readmission after outpatient TKA, and identify common causes for readmission after outpatient TKA with a much larger cohort compared to previous studies. METHODS This study retrospectively analyzed data from 31,347 patients who underwent outpatient TKAs between 2012 and 2021. Adverse events and unplanned readmissions were identified. Timing and reason for readmission were recorded. Statistical analysis involved multivariate logistic regression to identify patient risk factors for readmission. RESULTS Following surgery, 1.86% of cases reported an unplanned readmission within 30 days. Multivariate analysis demonstrated that age (odds ratio (OR): 1.042; P < 0.001), body mass index (OR: 1.023; P = 0.002), operative time (OR: 1.003; P = 0.017), congestive heart failure (OR: 3.079; P < 0.001), chronic obstructive pulmonary disease (OR: 2.577; P < 0.001), bleeding disorders (OR: 1.706; P = 0.025), hypertension (1.436; P < 0.001), and partially dependent functional status (OR: 2.486; P = 0.036) significantly increased the risk of 30-day readmission. Reasons unrelated to the surgical site contributed the most to readmission at 68.3%, while reasons related to the surgical site made up 27.3%, followed by knee-related complaints (4.4%). The most common days on which readmissions occurred were postoperative days two, four, and one. CONCLUSIONS Our analysis revealed a low readmission risk (1.86%) after outpatient TKA. Readmission rates were found to decrease over the observed time, despite a dramatic increase in outpatient cases. The most common reason for 30-day readmission was an organ or space surgical site infection. Identified risk factors for readmission highlight areas for targeted mitigation to enhance patient outcomes and healthcare efficiency.
Collapse
Affiliation(s)
| | - Phillip B Wyatt
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Charles R Reiter
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Brady S Ernst
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia
| | - James Satalich
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia
| | - Jeremy A Ross
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia
| |
Collapse
|
|
3
|
Parikh N, Woelber E, Bido J, Hobbs J, Perloff J, Krueger CA. Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program. J Arthroplasty 2024; 39:2427-2432. [PMID: 38734329 DOI: 10.1016/j.arth.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS Data was obtained from the CMS QPP for total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS There were 4 TKA and 3 THA surgeons who were cost-efficiency outliers within our area. Outliers and nonoutlier surgeons had patients who had similar body mass index, American Society of Anesthesiologists Physical Status Score, and age-adjusted Charlson Comorbidity Index scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < .001; 0.94 versus 1.15, P < .001) and lower out-of-pocket costs ($86.10 versus $135.46, P < .001; $116.10 versus $177.40, P < .001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSIONS The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.
Collapse
Affiliation(s)
- Nihir Parikh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Erik Woelber
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Juneau Bone and Joint Center, Juneau, Alaska
| | | | - John Hobbs
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Perloff
- The Institute for Accountable Care, Washington, District of Columbia; The Institute for Healthcare Systems, Brandeis University, Waltham, Massachusetts
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
|
4
|
Berkovic D, Vallance P, Harris IA, Naylor JM, Lewis PL, de Steiger R, Buchbinder R, Ademi Z, Soh SE, Ackerman IN. A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection. BMC Med 2023; 21:511. [PMID: 38129857 PMCID: PMC10740291 DOI: 10.1186/s12916-023-03219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection. METHODS A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed. RESULTS Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814). CONCLUSIONS There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.
Collapse
Affiliation(s)
- Danielle Berkovic
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Patrick Vallance
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia and Faculty of Medicine, University of Adelaide, Adelaide, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth HealthCare, University of Melbourne, Melbourne, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Health Economics and Policy Evaluation Research (HEPER), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Sze-Ee Soh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| |
Collapse
|
|
5
|
Archer A, Salem HS, Coppolecchia A, Mont MA. Lengths of Stay and Discharge Dispositions after Total Knee Arthroplasty: A Comparison of Robotic-Assisted and Manual Techniques. J Knee Surg 2023; 36:404-410. [PMID: 34610638 DOI: 10.1055/s-0041-1735280] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As evidence signifies that short-stay total knee arthroplasties (TKA) can be safe options, it is important to identify factors that contribute to early discharge. There is evidence that robotic-assisted TKAs may lead to shorter lengths of postoperative stays. However, this has not been evaluated as the primary outcome of interest in a large-scale population. The purpose of this study was to compare manual and robotic-assisted TKAs with regard to: (1) length of stay (LOS) and (2) discharge dispositions. TKAs performed between January 1, 2018, to March 31, 2019, were identified. After applying inclusion and exclusion criteria, a total of 10,296 patients were included: 5,993 in the manual and 4,303 in the robotic-assisted group. Length of stay, discharge dispositions, and Charlson comorbidity indices (CCIs) were recorded for all patients. The mean LOS was significantly lower in robotic-assisted (1.68 ± 0.86 days) compared with manual (1.86 ± 0.94 days) TKA procedures (p < 0.00001). In the robotic-assisted group, 2,049 (47.6%) were discharged in 1 day or less compared with 2,325 (38.8%) in the manual group (p < 0.0001). The proportion discharged home was significantly higher for patients who underwent robotic-assisted (91.3%) compared with manual (87.4%) TKAs (p < 0.00001). When comparing only patients who were discharged home and who did not have home health services, the rate was 51.8% in the robotic-assisted group compared with 44.0% in the manual group (p < 0.00001). The mean CCI was similar for patients who underwent robotic-assisted (2.9 ± 1.4 points) compared with manual (3.0 ± 1.5 points) TKAs. There was a trend toward shorter mean LOS for robotic-assisted versus manual TKA at 17 of the 24 included hospital sites (70.8%). Compared with manual, robotic-assisted TKAs demonstrated shorter lengths of postoperative stays and less need for skilled care after discharge. These results suggest the health care burden resulting from an upsurge of TKA procedures in our aging population might be addressed in part by increased utilization of robotic assistance.
Collapse
Affiliation(s)
- Allison Archer
- Division of Joint Replacement, Stryker, Mahwah, New Jersey
| | - Hytham S Salem
- Division of Joint Replacement, Lenox Hill Hospital, New York, New York
| | | | - Michael A Mont
- Division of Joint Replacement, Lenox Hill Hospital, New York, New York
| |
Collapse
|
|
6
|
Gong S, Yi Y, Wang R, Han L, Gong T, Wang Y, Shao W, Feng Y, Xu W. Outpatient total knee and hip arthroplasty present comparable and even better clinical outcomes than inpatient operation. Front Surg 2022; 9:833275. [PMID: 36147695 PMCID: PMC9485540 DOI: 10.3389/fsurg.2022.833275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background The purpose of this study was to compare total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days after outpatient and standard inpatient total knee and total hip arthroplasty (TKA, THA). Methods A literature search was conducted from the PubMed, Cochrane Library, and Embase databases for articles published before 20 August 2021. The types of studies included prospective randomized controlled trials, prospective cohort studies, retrospective comparative studies, retrospective reviews of THA and TKA registration databases, and observational case-control studies. Comparisons of interest included total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days. The statistical analysis was performed using Review Manager 5.3. Results Twenty studies with 582,790 cases compared relevant postoperative indicators of outpatient and inpatient total joint arthroplasty (TJA) (TKA and THA). There was a significant difference in the total complications at 30 days between outpatient and inpatient THA (p = 0.001), readmissions following TJA (p = 0.03), readmissions following THA (p = 0.001), stroke/cerebrovascular incidents following TJA (p = 0.01), cardiac arrest following TJA (p = 0.007), and blood transfusions following TJA (p = 0.003). The outcomes showed an obvious difference in 90-day total complications between outpatient and inpatient TJA (p = 0.01), readmissions following THA (p = 0.002), and surgical-related pain following TJA (p < 0.001). We did not find significant differences in the remaining parameters. Conclusion Outpatient procedures showed comparable and even better outcomes in total complications, complications stratified by type, readmissions, and reoperations at 30 and 90 days compared with inpatient TJA for selected patients.
Collapse
Affiliation(s)
- Song Gong
- Department of Orthopedics, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yihu Yi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ruoyu Wang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lizhi Han
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Tianlun Gong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuxiang Wang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wenkai Shao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yong Feng
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: Yong Feng Weihua Xu
| | - Weihua Xu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: Yong Feng Weihua Xu
| |
Collapse
|
|
7
|
Perim DA, Heyer JH, Amdur R, Pandarinath R. Absence of a "July Effect" on Hospital Length of Stay After Primary Total Hip or Knee Arthroplasty. Orthopedics 2021; 44:e503-e508. [PMID: 34292833 DOI: 10.3928/01477447-20210618-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is a commonly held belief in a "July effect" resulting in suboptimal outcomes as residents begin or advance in their training each summer. Previous studies have shown an absence of a July effect on clinical outcomes after total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, it remains unknown whether there is a July effect on hospital length of stay (LOS) after primary THA/TKA. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2012 for cases of primary THA/TKA, excluding emergency cases or cases where the ATTEND variable indicating resident participation was coded as missing or unknown. The primary outcome was prolonged LOS, defined as greater than 4 days postoperative. Secondary outcomes, including mortality, unplanned return to the operating room, and adverse clinical events, were also recorded. Univariate and multivariate analyses, including correction for comorbidities, evaluated associations between resident involvement in a case and any outcomes, and whether this association was different in quarter 3 (July through September) vs the remainder of the year. A total of 34,818 cases were included. Residents were involved in 9669 (28%). Length of stay greater than 4 days occurred in 12% of resident cases overall vs 11% of non-resident cases. Quarter 3 also had significantly more cases with prolonged LOS (12%) vs quarters 1 and 2 and quarter 4 (all 11%). On multivariate analysis, the resident effect on LOS greater than 4 days remained significant during the entire year; however, resident involvement in quarter 3 was not associated with prolonged LOS. These results do not support the presence of a July effect on LOS after primary THA/TKA. [Orthopedics. 2021;44(4):e503-e508.].
Collapse
|
|
8
|
Stiegel KR, Valentine MT, Lash JG, Cardenas JM, Harrington MA, Green DM. Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population. J Arthroplasty 2021; 36:1478-1483. [PMID: 33546951 DOI: 10.1016/j.arth.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/25/2020] [Accepted: 12/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty is the most common elective orthopedic procedure in the Veterans Affairs hospital system. In 2019, physical medicine and rehabilitation began screening patients before surgery to select candidates for direct transfer to acute rehab after surgery. The primary outcome of this study was to demonstrate that the accelerated program was successful in decreasing inpatient costs and length of stay (LOS). The secondary outcome was to show that there was no increase in complication, reoperation, and readmission rates. METHODS A retrospective review of total joint arthroplasty patients was conducted with three cohorts: 1) control (n = 193), 2) transfer to rehab orders on postop day #1 (n = 178), and 3) direct transfers to rehab (n = 173). To assess for demographic disparities between cohorts, multiple analysis of variance tests followed by a Bonferroni P-value correction were used. Differences between test groups regarding primary outcomes were assessed with analysis of variance tests followed by pairwise t-tests with Bonferroni P-value corrections. RESULTS There were no significant differences between the cohort demographics or comorbidities. The mean total LOS decreased from 7.0 days in the first cohort, to 6.9 in the second, and 6.0 in the third (P = .00034). The mean decrease in cost per patient was $14,006 between cohorts 1 and 3, equating to over $5.6 million in savings annually. There was no significant change in preintervention and postintervention short-term complications (P = .295). CONCLUSIONS Significant cost savings and decrease in total LOS was observed. In the current health care climate focused on value-based care, a similar intervention could be applied nationwide to improve Veterans Affair services.
Collapse
Affiliation(s)
- Kelly R Stiegel
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - Matthew T Valentine
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - Jonathan G Lash
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - Justin M Cardenas
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - Melvyn A Harrington
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX
| | - David M Green
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX; Department of Orthopedic Surgery, Michael E. DeBakey Veterans Administration Hospital, Houston, TX
| |
Collapse
|
|
9
|
Why Do Patients Stay Longer Than Three Nights Following Hip and Knee Arthroplasty? J Arthroplasty 2020; 35:2323-2326. [PMID: 32381444 DOI: 10.1016/j.arth.2020.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/02/2020] [Accepted: 04/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prolonged length of stay (PLOS) is frequently cited by secondary data studies as an adverse outcome following hip and knee arthroplasty. Although perhaps indisputable that PLOS increases the cost of hospitalization, it is unknown whether it is an appropriate measure of the quality of an arthroplasty procedure. METHODS We searched our institution's database for all hip and knee arthroplasty procedures over a 5-year period using MS-DRG (Medicare Severity-Diagnosis Related Group) 469 and 470. Cases with greater than 3 night stays were identified. Charts were manually reviewed by 2 independent reviewers to identify the primary reason for PLOS, and the need for 30-day readmission or reoperation. RESULTS Of a total 4347 hip and knee arthroplasty cases, 218 (5.0%) were identified with LOS greater than 3 nights. The majority of prolonged stays were due to exclusively medical reasons (81 cases: 37.2%; 95% confidence interval [CI] 31.0-43.7). The second most common cause was inpatient days prior to the arthroplasty procedure (45 cases: 20.6%; 95% CI 15.8-26.5). Orthopedic reasons for PLOS were significantly less common than medical reasons (36 cases: 16.5%; 95% CI 12.2-22.0, P < .0001), most often due to failure to meet therapy goals. Neither readmission (31 cases: 14.2%) nor reoperation (10 cases: 4.6%) was associated with an underlying reason for PLOS. CONCLUSION When evaluating LOS as a measure of quality of an arthroplasty procedure, readers of secondary "big data" studies should be aware that there are significant limitations to its utility. Even after controlling for potential confounders, we found that PLOS does not necessarily reflect an adverse outcome.
Collapse
|
|
10
|
The Feasibility of Outpatient Revision Total Knee Arthroplasty in Selected Case Scenarios. J Arthroplasty 2020; 35:S92-S96. [PMID: 32139191 DOI: 10.1016/j.arth.2020.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As total knee arthroplasty (TKA) continues moving to the outpatient arena, the demand for revision surgery will subsequently increase which draws into question the feasibility for some revision scenarios as an outpatient. The purpose of this study is to report on the safety of outpatient revision knee arthroplasty. METHODS From June 2013 through December 2018, 102 patients (106 knees) underwent revision knee arthroplasty at a free-standing ambulatory surgery center. Mean patient age was 58.0 years, and 43% of patients were male. Procedures included the following: 45 cases of unicompartmental arthroplasty to TKA, 54 TKA revisions, and 52 cases involved a full exchange of components. RESULTS Ninety-three patients (88%) were discharged the same day without incident, none required transfer to acute facility, and 13 required overnight stay with 4 of these for convenience and 9 for medical reasons. There were no major complications within the first 48 hours postoperative. One patient required readmission for treatment of ileus 11 days postoperative. There were no other readmissions, no subsequent surgeries, and no deaths within 90 days. One or more major comorbidities were present in 66 patients. CONCLUSION Outpatient revision knee arthroplasty was found to be safe in carefully selected patients and case scenarios. Presence of medical comorbidities was not associated with risk of complications. The paradigm changes of patient education, medical optimization, and a multimodal program to mitigate the risk of blood loss and reduce need for narcotics facilitates performing some revision arthroplasties safely in an outpatient setting.
Collapse
|
|
11
|
Crawford DA, Adams JB, Berend KR, Lombardi AV. Low complication rates in outpatient total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:1458-1464. [PMID: 31104079 DOI: 10.1007/s00167-019-05538-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/07/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE The primary purpose of this study is to report the incidence of complications associated with outpatient total knee arthroplasty (TKA). Secondarily, 2-year minimum outcomes are reported. METHODS Between 2013 and 2016, 928 patients underwent 1143 outpatient TKAs with the Vanguard Complete Knee System (Zimmer Biomet, Warsaw, IN). Patients were selected for outpatient surgery if they were medically optimized without a failing organ system and had sufficient support at home. Overnight stays, medical complications and early perioperative complications were assessed in this entire cohort. Two-year minimum follow-up was available on 793 patients (978 knees). Patient records were analyzed for outcome measures and revisions. RESULTS In 124 procedures, the patient stayed overnight for 23-h observation. Thirty-seven (3.2%) were for convenience reasons and 87 (7.6%) for medical observation. Heart disease and chronic obstructive pulmonary disease were associated with increased risk of overnight stay. Excluding manipulations, reoperation within 90 days occurred in eight (0.7%) knees. Patients with 2-year minimum follow-up had significant improvements in ROM, Knee Society Clinical, Functional and Pain scores (p < 0.005). Nine (0.8%) patients required revision. Manipulations were performed on 118 (10.3%) patients. The overall deep infection rate was 0.17% (2/1143). CONCLUSIONS Outpatient TKA is safe for a large proportion of patients. Certain medical co-morbidities increase the risk of overnight stay. Patients had significant improvement in ROM and outcome scores with low revision rate. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- David A Crawford
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.
| | - Joanne B Adams
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA
| | - Keith R Berend
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.,Mount Carmel Health System, 7333 Smith's Mill Road, New Albany, OH, 43054, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.,Mount Carmel Health System, 7333 Smith's Mill Road, New Albany, OH, 43054, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, 376W 10th Ave, Suite 725, Columbus, OH, 43210, USA
| |
Collapse
|
|
12
|
PT Achievement in Public Hospitals and Its Effect on Outcomes. Geriatrics (Basel) 2019; 4:geriatrics4040058. [PMID: 31635236 PMCID: PMC6960488 DOI: 10.3390/geriatrics4040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 11/17/2022] Open
Abstract
The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.
Collapse
|
|
13
|
Charpentier PM, Srivastava AK, Zheng H, Ostrander JD, Hughes RE. Readmission Rates for One Versus Two-Midnight Length of Stay for Primary Total Knee Arthroplasty: Analysis of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Database. J Bone Joint Surg Am 2019; 100:1757-1764. [PMID: 30334886 DOI: 10.2106/jbjs.18.00166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The length of stay (LOS) in the hospital for total knee arthroplasty (TKA) has been declining over recent decades. The purpose of this study was to determine if patients with an LOS for TKA that includes only 1 midnight have an increased odds of 90-day readmission compared with those with a 2-midnight LOS. We also sought to identify any predictors of 90-day hospital readmission among those readmitted during our period of analysis. METHODS A retrospective review of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was performed to identify patients with a 1-midnight or 2-midnight LOS for TKA during a 5-year period. The primary end point of this study was inpatient readmission within the 90-day postoperative period. A multiple logistic regression model and propensity score matching were used to compare the odds of 90-day readmission between 1-midnight and 2-midnight LOS. The secondary end points of this study were 90-day complications. RESULTS There were 96,250 TKA procedures identified in the database, and 46,709 met our inclusion criteria for LOS. No difference in 90-day-readmission odds between patients with a 1-midnight LOS and those with a 2-midnight LOS for primary TKA was identified. Male sex, single marital status, age of ≥80 years, type-I diabetes, previous smoking, narcotic use prior to surgery, and a higher American Society of Anesthesiologists (ASA) scores increased the odds of 90-day readmission. Patients in the age group of ≥50 to <65 years, those with a higher preoperative hemoglobin level, and those with a positive social history of alcohol use were found to have decreased odds of readmission. CONCLUSIONS We found no association between the LOS for primary TKA (1 midnight compared with 2 midnights) and the 90-day readmission risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- P M Charpentier
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia.,Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan
| | - A K Srivastava
- Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan.,OrthoMichigan, Flint, Michigan
| | - H Zheng
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - J D Ostrander
- Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan.,OrthoMichigan, Flint, Michigan
| | - R E Hughes
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
|
14
|
Predictors of Increased Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion: Analysis of National Database. Spine Deform 2019; 6:226-230. [PMID: 29735130 DOI: 10.1016/j.jspd.2017.09.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/17/2017] [Indexed: 01/06/2023]
Abstract
STUDY DESIGN Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample (NIS). OBJECTIVE To examine the predictors of increased hospital stay in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion. SUMMARY OF BACKGROUND DATA As policy makers and hospitals are increasingly looking to cut costs, length of stay (LOS) after surgery has come into focus as an area for improvement. Despite this, there is limited research about the factors contributing to increased LOS for AIS patients undergoing posterior spinal fusion. METHODS The Nationwide Inpatient Sample was used to identify pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion from 2004 to 2009, using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. Patient demographics, surgical variables, hospital characteristics, and in-hospital outcomes were retrieved. LOS was divided into two groups (longer- and shorter-stay groups) by its average. Longer stay was defined as ≥6 days. Multivariable logistic regression analysis was performed to identify the predictors of increased LOS in AIS patients undergoing posterior spinal fusion. RESULTS Significant predictors of increased LOS in posterior spinal fusion for AIS patients included increased Elixhauser Comorbidity Score, number of fused levels ≥9 vertebrae, teaching hospital status, in-hospital complications, and nonroutine disposition. Wound-related complications were the strongest predictor and patients with wound-related complications were 3.14-fold more likely to have an increased LOS compared to those without wound-related complications. CONCLUSIONS This study identified significant predictors of increased hospital stay in posterior spinal fusion for pediatric patients with idiopathic scoliosis and patients at higher risk of longer hospitalization can be recognized. Eventually these data are expected to help optimize LOS and cost containment.
Collapse
|
|
15
|
Ihekweazu UN, Sohn GH, Laughlin MS, Goytia RN, Mathews V, Stocks GW, Patel AR, Brinker MR. Socio-demographic factors impact time to discharge following total knee arthroplasty. World J Orthop 2018; 9:285-291. [PMID: 30598872 PMCID: PMC6306518 DOI: 10.5312/wjo.v9.i12.285] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/06/2018] [Accepted: 12/10/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA).
METHODS The study included primary TKA’s performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS.
RESULTS Eight hundred and six consecutive primary SSP TKA’s were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA’s performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient’s living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery.
CONCLUSION The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.
Collapse
Affiliation(s)
- Ugonna N Ihekweazu
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Garrett H Sohn
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, United States
| | - Mitzi S Laughlin
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Robin N Goytia
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Vasilios Mathews
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Gregory W Stocks
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Anay R Patel
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| | - Mark R Brinker
- Fondren Orthopedic Group, Houston, TX 77030, United States
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Houston, TX 77030, United States
| |
Collapse
|
|
16
|
Mahan MC, Jildeh TR, Tenbrunsel TN, Davis JJ. Mepivacaine Spinal Anesthesia Facilitates Rapid Recovery in Total Knee Arthroplasty Compared to Bupivacaine. J Arthroplasty 2018; 33:1699-1704. [PMID: 29429882 DOI: 10.1016/j.arth.2018.01.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Mepivacaine as a spinal anesthetic for rapid recovery in total knee arthroplasty (TKA) has not been assessed. The purpose of this study is to compare spinal mepivacaine vs bupivacaine for postoperative measures in patients undergoing primary TKA. METHODS Retrospective review of a prospectively collected single-institution database was performed on 156 consecutive patients who underwent primary TKA. Fifty-three patients were administered mepivacaine and 103 patients were administered bupivacaine. Primary outcomes were urinary retention, length of stay, pain control, opioid consumption, and distance associated with physical therapy. Statistical analysis with univariate logistic regression was performed to evaluate the effect of anesthetic with primary outcomes. RESULTS Patients undergoing TKA with mepivacaine had a shorter length of stay (28.1 ± 11.2 vs 33.6 ± 14.4 hours, P = .002) and fewer episodes of straight catheterization (3.8% vs 16.5%, P = .021) compared to bupivacaine. Patients administered mepivacaine exhibited slightly higher VAS pain scores and morphine consumption in the postanesthesia care unit (1.3 ± 1.9 vs 0.5 ± 1.3, P = .002; 2.2 ± 3.3 vs 0.8 ± 2.1 equivalents/h, P = .002), but otherwise exhibited no difference in VAS scores or morphine consumption afterwards. There was no need to convert to general anesthesia or transient neurologic symptom complication in either group. CONCLUSION Mepivacaine for spinal anesthesia with TKA had adequate duration to complete the surgery and facilitated a more rapid recovery with less urinary complications and a shorter length of stay. Patients administered mepivacaine did not display worse pain control or transient neurologic symptoms afterwards.
Collapse
Affiliation(s)
- M Chad Mahan
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI
| | - Toufic R Jildeh
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI
| | | | - Jason J Davis
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
|
17
|
Pollock M, Somerville L, Firth A, Lanting B. Outpatient Total Hip Arthroplasty, Total Knee Arthroplasty, and Unicompartmental Knee Arthroplasty: A Systematic Review of the Literature. JBJS Rev 2018; 4:01874474-201612000-00004. [PMID: 28060788 DOI: 10.2106/jbjs.rvw.16.00002] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The demand for total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) is growing rapidly because of the proven success of these procedures and an increase in the aging population. However, resources are limited and health-care budgets are finite. Recently, a number of care providers have started performing these procedures on an outpatient basis, with the patients being discharged from the hospital on the day of surgery. The primary objective of this systematic review was to examine the evidence regarding the safety and feasibility of performing THA, TKA, or UKA on an outpatient basis. METHODS An electronic search of 3 online databases (Embase, MEDLINE, and HealthSTAR) was conducted to identify eligible studies. The reference lists of identified articles were then screened. All studies evaluating outcomes following outpatient THA, TKA, or UKA were included. Eligible articles that included a comparative group were assessed for methodological quality with use of the Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions (ACROBAT-NRSI). Non-comparative studies were assessed for quality with use of the Effective Public Health Practice Project (EPHPP) Quality Assessment Instrument. RESULTS The electronic literature search yielded 805 articles. Following a review of the titles, abstracts and reference lists, 26 articles remained and were assessed for eligibility. Of those, 17 articles (≈79,500 patients) met the inclusion criteria and were included in the review. Although both quality-assessment tools showed that the majority of studies included in the review were of poor quality, there was no increase in readmission rates or perioperative complications among patients who underwent outpatient procedures. Studies assessing satisfaction illustrated a high level of satisfaction for the majority of patients. The average age of the patients in the THA studies ranged from 53.5 to 63 years. The TKA and UKA studies included an older population, with mean ages ranging from 55 to 68 years. The majority of the included studies included a larger percentage of males as compared with females. Of the 17 included studies, 4 were cohort studies with a control group and 13 were case series. All 4 cohort studies indicated that the complication rates and clinical outcomes were similar between the inpatient and outpatient groups. Furthermore, the 3 studies that involved an economic analysis indicated that outpatient arthroplasty is financially advantageous. CONCLUSIONS In selected patients, outpatient THA, TKA, and UKA can be performed safely and effectively. The included studies lacked sufficient internal validity, sample size, methodological consistency, and standardization of protocols and outcomes. There is a need for high-quality prospective cohort and randomized trials to definitively assess the safety and effectiveness of outpatient THA, TKA, and UKA. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | - Lyndsay Somerville
- London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Andrew Firth
- University of Western Ontario, London, Ontario, Canada
| | - Brent Lanting
- London Health Sciences Centre, University Hospital, London, Ontario, Canada
| |
Collapse
|
|
18
|
Krause A, Sayeed Z, El-Othmani M, Pallekonda V, Mihalko W, Saleh KJ. Outpatient Total Knee Arthroplasty: Are We There Yet? (Part 1). Orthop Clin North Am 2018; 49:1-6. [PMID: 29145977 DOI: 10.1016/j.ocl.2017.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Recent trends in total joint care have moved toward outpatient surgery. Total knee arthroplasty (TKA) remains a definitive management for end-stage osteoarthritis and has experienced increased utilization over the past several decades. The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated as different institutions report different experiences from their pathways. This article will discuss current data and recommendations for implementing successful TKA and unicompartmental knee arthroplasty outpatient protocols. Specifically, this review will provide information regarding cost reduction, patient selection criteria, and preoperative medical optimization.
Collapse
Affiliation(s)
- Andrew Krause
- Department of Orthopaedics, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - Zain Sayeed
- Department of Orthopaedics, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - Mouhanad El-Othmani
- Department of Orthopaedics, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - Vinay Pallekonda
- Department of Anesthesiology - NorthStar Anesthesia at Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - William Mihalko
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering University of Tennessee, 956 Court Avenue, Memphis, TN 32116, USA
| | - Khaled J Saleh
- Department of Orthopaedics, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA.
| |
Collapse
|
|
19
|
Kim KY, Anoushiravani AA, Elbuluk A, Chen K, Davidovitch R, Schwarzkopf R. Primary Total Hip Arthroplasty With Same-Day Discharge: Who Failed and Why. Orthopedics 2018; 41:35-42. [PMID: 29192937 DOI: 10.3928/01477447-20171127-01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/02/2017] [Indexed: 02/03/2023]
Abstract
As the emphasis on value-based care within total joint arthroplasty increases, this procedure is becoming more prevalent in the outpatient setting. The goals of this study were to report on the authors' early experiences with same-day discharge and to identify patient characteristics that are associated with failure to discharge after total hip arthroplasty within this program. All patients who were enrolled in the same-day discharge total hip arthroplasty program at the study institution between January 2015 and July 2016 were included. Demographics, baseline characteristics, and clinical and quality outcomes were compared between patients who successfully completed this program and those who did not. Of the 163 study subjects, 143 (87.7%) were discharged successfully on the same day as surgery. Women, patients younger than 40 years, and patients older than 60 years all had an increased risk of failing the program. Body mass index of 26 kg/m2 or less was associated with a 40% greater risk of failure. Patients with an American Society of Anesthesiologists score of 3 had a 3-fold risk of failure compared with patients with an American Society of Anesthesiologists score of 2 or less. The screening protocol for same-day discharge at the study institution had an 87.7% rate of successful same-day discharge. Further investigation is needed to identify patients who are at risk of failing the same-day discharge initiative. [Orthopedics. 2018; 41(1):35-42.].
Collapse
|
|
20
|
Molloy IB, Martin BI, Moschetti WE, Jevsevar DS. Effects of the Length of Stay on the Cost of Total Knee and Total Hip Arthroplasty from 2002 to 2013. J Bone Joint Surg Am 2017; 99:402-407. [PMID: 28244911 PMCID: PMC5324037 DOI: 10.2106/jbjs.16.00019] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Utilization of total knee and hip arthroplasty has greatly increased in the past decade in the United States; these are among the most expensive procedures in patients with Medicare. Advances in surgical techniques, anesthesia, and care pathways decrease hospital length of stay. We examined how trends in hospital cost were altered by decreases in length of stay. METHODS Procedure, demographic, and economic data were collected on 6.4 million admissions for total knee arthroplasty and 2.8 million admissions for total hip arthroplasty from 2002 to 2013 using the National (Nationwide) Inpatient Sample, a component of the Healthcare Cost and Utilization Project. Trends in mean hospital costs and their association with length of stay were estimated using inflation-adjusted, survey-weighted generalized linear regression models, controlling for patient demographic characteristics and comorbidity. RESULTS From 2002 to 2013, the length of stay decreased from a mean time of 4.06 to 2.97 days for total knee arthroplasty and from 4.06 to 2.75 days for total hip arthroplasty. During the same time period, the mean hospital cost for total knee arthroplasty increased from $14,988 (95% confidence interval [CI], $14,927 to $15,049) in 2002 to $22,837 (95% CI, $22,765 to $22,910) in 2013 (an overall increase of $7,849 or 52.4%). The mean hospital cost for total hip arthroplasty increased from $15,792 (95% CI, $15,706 to $15,878) in 2002 to $23,650 (95% CI, $23,544 to $23,755) in 2013 (an increase of $7,858 or 49.8%). If length of stay were set at the 2002 mean, the growth in cost for total knee arthroplasty would have been 70.8% instead of 52.4% as observed, and the growth in cost for total hip arthroplasty would have been 67.4% instead of 49.8% as observed. CONCLUSIONS Hospital costs for joint replacement increased from 2002 to 2013, but were attenuated by reducing inpatient length of stay. With demographic characteristics showing an upward trend in the utilization of joint arthroplasty, including a shift toward younger population groups, reduction in length of stay remains an important target for procedure-level cost containment under emerging payment models.
Collapse
Affiliation(s)
- Ilda B. Molloy
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center (I.B.M., W.E.M., and D.S.J.), and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth (B.I.M.), Lebanon, New Hampshire,E-mail address for I.B. Molloy:
| | - Brook I. Martin
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center (I.B.M., W.E.M., and D.S.J.), and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth (B.I.M.), Lebanon, New Hampshire
| | - Wayne E. Moschetti
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center (I.B.M., W.E.M., and D.S.J.), and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth (B.I.M.), Lebanon, New Hampshire
| | - David S. Jevsevar
- Department of Orthopaedics, Dartmouth Hitchcock Medical Center (I.B.M., W.E.M., and D.S.J.), and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth (B.I.M.), Lebanon, New Hampshire
| |
Collapse
|
|
21
|
El Bitar YF, Illingworth KD, Scaife SL, Horberg JV, Saleh KJ. Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database. J Arthroplasty 2015; 30:1710-5. [PMID: 26009468 DOI: 10.1016/j.arth.2015.05.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/01/2023] Open
Abstract
Demand and cost of total knee arthroplasty (TKA) has increased significantly over the past decade resulting in decreased hospital length of stay (LOS) to counterbalance increasing cost of health care. The purpose of this study was to determine the factors that influence LOS following primary TKA. Discharge data from the 2009-2011 Nationwide Inpatient Sample were used. Patients included underwent primary TKA and were grouped based on LOS; 3 days or less, and 4 days or more. Majority of patients had a hospital LOS of 3 or less (74.8%). The most significant predictors of increased hospital LOS (≥ 4 days) were age ≥ 80 years, Hispanic race, Medicaid payer status, lower median household income, weekend admission, rural non-teaching hospital, discharge to another facility and any complication.
Collapse
Affiliation(s)
- Youssef F El Bitar
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Kenneth D Illingworth
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Steven L Scaife
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John V Horberg
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| |
Collapse
|
|
22
|
Bini SA, Inacio MCS, Cafri G. Two-Day Length of Stay is Not Inferior to 3 Days in Total Knee Arthroplasty with Regards to 30-Day Readmissions. J Arthroplasty 2015; 30:733-8. [PMID: 25550213 DOI: 10.1016/j.arth.2014.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 11/25/2014] [Accepted: 12/02/2014] [Indexed: 02/01/2023] Open
Abstract
The impact of a shortened length of stay (LOS) following total knee arthroplasty (TKA) on the risk of readmission is not well documented despite recent trends towards shorter hospitalization. We retrospectively compared the adjusted risk of 30-day readmission following TKA between patients with 2-, 3- and 4-day LOS using current postoperative care protocols. A total of 23,655 consecutive primary, unilateral TKAs operated between 01/01/2009 and 12/31/2011 were studied retrospectively using non-inferiority testing. The main outcome was 30-day readmission. Two-day LOS decreased the odds of readmission by a factor of 0.96, with an upper bound one-sided 95% confidence interval of 1.10. After adjusting for other variables, LOS of 2 days is not inferior to 3 days with respect to the risk of 30-day readmission.
Collapse
Affiliation(s)
- Stefano A Bini
- Department of Orthopaedic Surgery, The Permanente Medical Group, 280 Macarthur Blvd, Oakland, CA
| | - Maria C S Inacio
- Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA
| | - Guy Cafri
- Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA
| |
Collapse
|
|
23
|
Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, Manley MT. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthroplasty 2014; 29:510-5. [PMID: 23972298 DOI: 10.1016/j.arth.2013.07.020] [Citation(s) in RCA: 222] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/05/2013] [Accepted: 07/17/2013] [Indexed: 02/01/2023] Open
Abstract
The purpose of the present study is to determine the differences in cost, complications, and mortality between knee arthroplasty (TKA) patients who stay the standard 3-4 nights in a hospital compared to patients who undergo an outpatient procedure, a shortened stay or an extended stay. TKA patients were identified in the Medicare 5% sample (1997-2009) and separated into the following groups: outpatient, 1-2 days, 3-4 days, or 5+ days inpatient. At two years, costs associated with the outpatient and the 1-2 day stay groups were $8527 and $1967 lower than the 3-4 day stay group, respectively. Out to 2 years, the outpatient and 1-2 day stay groups reported less pain and stiffness, respectively, though the 1-2 day group also had a higher risk for revision.
Collapse
Affiliation(s)
| | | | - Arthur L Malkani
- University of Louisville, Department of Orthopedic Surgery, Louisville, Kentucky
| | | | | | | | - Michael T Manley
- Homer Stryker Center for Orthopedic Education, Mahwah, New Jersey
| |
Collapse
|
|
24
|
Krummenauer F, Guenther KP, Kirschner S. Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway--is investment always improvement? BMC Health Serv Res 2011; 11:338. [PMID: 22168149 PMCID: PMC3295718 DOI: 10.1186/1472-6963-11-338] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 12/14/2011] [Indexed: 02/07/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider. Methods A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation ≤ 100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff. Results An individual marginal cost effectiveness relation ≤ 100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p = 0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86 - 150 €/%) versus 118 €/% WOMAC gain (93 - 173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on. Conclusions The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider).
Collapse
Affiliation(s)
- Frank Krummenauer
- Institute for Medical Biometry and Epidemiology Faculty of Health Sciences, University of Witten/Herdecke, Germany.
| | | | | |
Collapse
|
|
25
|
Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, Sermeus W. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract 2010; 16:39-49. [PMID: 20367814 DOI: 10.1111/j.1365-2753.2008.01111.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
UNLABELLED SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.
Collapse
Affiliation(s)
- Pieter Van Herck
- Centre for Health Services and Nursing Research, Catholic University Leuven, Kapucijnenvoer 35 4th floor, 3000 Leuven, Belgium.
| | | | | | | | | | | | | |
Collapse
|
|
26
|
Witvrouw E, Pattyn E, Almqvist KF, Crombez G, Accoe C, Cambier D, Verdonk R. Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study. Knee Surg Sports Traumatol Arthrosc 2009; 17:1189-94. [PMID: 19468712 DOI: 10.1007/s00167-009-0817-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 04/27/2009] [Indexed: 10/20/2022]
Abstract
This study prospectively investigates whether catastrophizing thinking is associated with length of hospital stay after total knee arthroplasty. Forty-three patients who underwent primary total knee arthroplasty were included in this study. Prior to their operation all patients were asked to complete the pain catastrophizing scale, and a Western Ontario McMaster Universities Osteoarthritis index. A multiple regression analysis identified pain catastrophizing thinking and age as predictors of hospital stay after total knee arthroplasty. Patients with a higher degree of pain catastrophizing prior to the total knee arthroplasty and those with a higher age have a significantly greater risk for a longer hospital stay. Therefore, the results of this study indicate that the pre-operative level of pain catastrophizing in patients determine, in combination with other variables, the length and inter-individual variation in hospital stay after total knee arthroplasty. Reducing catastrophizing thinking about pain through cognitive-behavioral techniques is likely to reduce levels of fear after total knee arthroplasty. As a result, pain and function immediately post-operative might improve, leading to a decrease in length of hospital stay. Although during the last decades the duration of hospital stay is significantly reduced, this study shows that this can be improved when taking into account the contribution of psychological factors such as pain catastrophizing.
Collapse
Affiliation(s)
- Erik Witvrouw
- Department of Rehabilitation Sciences and Physical Therapy, Ghent University, Ghent, Belgium.
| | | | | | | | | | | | | |
Collapse
|
|
27
|
Tian W, DeJong G, Brown M, Hsieh CH, Zamfirov ZP, Horn SD. Looking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation. Arch Phys Med Rehabil 2009; 90:1260-8. [DOI: 10.1016/j.apmr.2008.10.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 10/04/2008] [Indexed: 11/16/2022]
|
|
28
|
Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 2009; 7:32. [PMID: 19570193 PMCID: PMC2715423 DOI: 10.1186/1741-7015-7-32] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 07/01/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs. METHODS Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2. RESULTS Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home. CONCLUSION The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.
Collapse
Affiliation(s)
- A Barbieri
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont A, Avogadro, Novara, Italy.
| | | | | | | | | | | | | |
Collapse
|
|
29
|
Kolisek FR, McGrath MS, Jessup NM, Monesmith EA, Mont MA. Comparison of outpatient versus inpatient total knee arthroplasty. Clin Orthop Relat Res 2009; 467:1438-42. [PMID: 19224306 PMCID: PMC2674170 DOI: 10.1007/s11999-009-0730-0] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 01/20/2009] [Indexed: 02/07/2023]
Abstract
UNLABELLED New protocols have been designed for outpatient total knee arthroplasty procedures, but concerns exist about the potential for increased complication rates. We compared the results of two selected matched cohorts of 64 patients who underwent total knee arthroplasty during the same time period. One cohort of patients, who had no severe medical conditions, lived within one hour of the office, and had help at home, followed an accelerated pathway in which they were discharged within 23 hours of surgery, and the other cohort followed a standard inpatient protocol, with a mean hospital stay of 2.3 days (range, 2-4 days). There were no perioperative complications in either cohort, and none of the patients who followed the outpatient protocol returned to the hospital for any reason. At a mean followup of 24 months (range, 12-41 months), the mean Knee Society knee scores of the outpatient and inpatient cohorts were 96 points (range, 67-100 points) and 95 points (range, 78-100 points), respectively. The mean Knee Society function scores were 89 points (range, 50-100 points) and 90 points (range, 60-100 points), respectively. We believe outpatient total knee arthroplasty may be a safe procedure in certain selected patients, with similar outcomes to a traditional protocol. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | - Mike S. McGrath
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | | | | | - Michael A. Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| |
Collapse
|
|
30
|
Cook JR, Warren M, Ganley KJ, Prefontaine P, Wylie JW. A comprehensive joint replacement program for total knee arthroplasty: a descriptive study. BMC Musculoskelet Disord 2008; 9:154. [PMID: 19019241 PMCID: PMC2596133 DOI: 10.1186/1471-2474-9-154] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 11/19/2008] [Indexed: 01/30/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is a commonly performed surgical procedure in the US. It is important to have a comprehensive inpatient TKA program which maximizes outcomes while minimizing adverse events. The purpose of this study was to describe a TKA program – the Joint Replacement Program (JRP) – and report post-surgical outcomes. Methods 74 candidates for a primary TKA were enrolled in the JRP. The JRP was designed to minimize complications and optimize patient-centered outcomes using a team approach including the patient, patient's family, and a multidisciplinary team of health professionals. The JRP consisted of a pre-operative class, standard pathways for medical care, comprehensive peri-operative pain management, aggressive physical therapy (PT), and proactive discharge planning. Measures included functional tests, knee range of motion (ROM), and medical record abstraction of patient demographics, length of stay, discharge disposition, and complications over a 6-month follow-up period. Results All patients achieved medical criteria for hospital discharge. The patients achieved the knee flexion ROM goal of 90° (91.7 ± 5.4°), but did not achieve the knee extension ROM goal of 0° (2.4 ± 2.6°). The length of hospital stay was two days for 53% of the patients, with 39% and 7% discharged in three and four days, respectively. All but three patients were discharged home with functional independence. 68% of these received outpatient physical therapy compared with 32% who received home physical therapy immediately after discharge. Two patients (< 3%) had medical complications during the inpatient hospital stay, and 9 patients (12%) had complications during the 6-month follow-up period. Conclusion The comprehensive JRP for TKA was associated with satisfactory clinical outcomes, short lengths of stay, a high percentage of patients discharged home with outpatient PT, and minimal complications. This JRP may represent an efficient, effective and safe protocol for providing care after a TKA.
Collapse
Affiliation(s)
- Jon R Cook
- Department of Rehabilitation Sciences, Verde Valley Medical Center, 269 S. Candy Lane, Cottonwood, AZ, USA.
| | | | | | | | | |
Collapse
|
|
31
|
Abstract
Minimally invasive surgery (MIS) in Total Knee Arthroplasty (TKA) has been evolving since the early 1990s and was first described by several authors from the USA in early 2003-4. The evolution was driven from patients and clinicians alike and the technique has been used by several experienced knee surgeons worldwide. Although the procedure is demanding and the learning curve long, the benefits outweigh the difficulties faced during the learning process. Our experience with minimally invasive techniques started in 2003. At the beginning only a few procedures were carried out as rigorous exclusion criteria were applied. However, as confidence grew the number of operations has significantly increased. The average surgical time for minimally invasive technique is longer than for the standard technique, particularly in the early stages. More attention needs to be paid to the alignment, sizing and positioning of the prosthesis. According to our early experience, functional recovery is faster with MIS compared with standard technique. The MIS group achieved better knee flexion during the first three months (average of 116 degrees ) compared to open access surgery (average of 97 degrees ). There was no significant difference in alignment and component sizing between the two groups.
Collapse
Affiliation(s)
- N S Shankar
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead, Tyne & Wear NE9 6SX, UK.
| |
Collapse
|
|
32
|
Lombardi AV, Viacava AJ, Berend KR. Rapid recovery protocols and minimally invasive surgery help achieve high knee flexion. Clin Orthop Relat Res 2006; 452:117-22. [PMID: 16957640 DOI: 10.1097/01.blo.0000238824.56024.7a] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although the primary goal of total knee arthroplasty is to relieve pain, the attainment of high flexion has emerged as an important secondary goal. Clinical pathways are evolving and focus on rapid recovery. The entire perioperative process for the patient and family, including office and hospital procedures, has been streamlined and patients are advised from the initial evaluation they will be able to quickly return to activities of daily living. Currently, patients are out of bed within hours of surgery, engaging in activities that require a substantial range of motion in the treated knee. They are frequently discharged directly to home within 24 to 48 hours. We retrospectively reviewed two groups of patients undergoing primary total knee arthroplasty whose perioperative management differed only by surgical approach, namely, standard versus less invasive. Refined perioperative protocols in combination with a less invasive, mini-arthrotomy approach using special instrumentation resulted in earlier discharge to home, higher range of motion and improved clinical and pain scores.
Collapse
|