Case Control Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Mar 18, 2023; 14(3): 123-135
Published online Mar 18, 2023. doi: 10.5312/wjo.v14.i3.123
Rural implementation of the perioperative surgical home: A case-control study
Srinivasan Sridhar, Amy Mouat-Hunter, Bernadette McCrory
Srinivasan Sridhar, Center for Health Outcomes and Policy Evaluation, College of Public Health, The Ohio State University, Columbus, OH 43210, United States
Amy Mouat-Hunter, Preanesthesia Clinic, Bozeman Health, Bozeman, MT 59715, United States
Bernadette McCrory, Mechanical and Industrial Engineering, Montana State University, Bozeman, MT 59715, United States
Author contributions: Sridhar S performed the experiment, data curation, methodology, and writing the original draft; Mouat-Hunter A was responsible for project administration, validation, review and editing; McCrory B assisted in funding acquisition, project administration, supervision, review and editing.
Supported by Montana Healthcare Foundation, No. 21467213.
Institutional review board statement: This retrospective analysis was approved by the Montana State University Institutional Review Board (Approval# BM050819-EX).
Informed consent statement: All study participants provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors have no possible interest on the title page, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.
Data sharing statement: Data cannot be shared publicly because of HIPAA regulations. Data are available from the Bozeman Health (contact via phone or email) for researchers who meet the criteria for access to confidential data. The data underlying the results presented in the study are available from Bozeman Deaconess Hospital - (https://www.bozemanhealth.org/).
STROBE statement: The guidelines of the STROBE statement have been adopted.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Srinivasan Sridhar, PhD, Center for Health Outcomes and Policy Evaluation, College of Public Health, The Ohio State University, 1841 Neil Avenue, Cunz Hall, Columbus OH 43210, United States. sridhar.96@osu.edu
Received: August 25, 2022
Peer-review started: August 25, 2022
First decision: December 26, 2022
Revised: January 1, 2023
Accepted: February 15, 2023
Article in press: February 15, 2023
Published online: March 18, 2023
Processing time: 203 Days and 16.2 Hours
Abstract
BACKGROUND

Perioperative surgical home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologist to improve outcomes and patient satisfaction. PSH has proven success in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.

AIM

To evaluate the newly implemented PSH system at a community hospital by comparing the surgical outcomes using a longitudinal case-control study.

METHODS

The research study was conducted at an 83-bed, licensed level-III trauma rural community hospital. A total of 3096 TJR procedures were collected retrospectively between January 2016 and December 2021 and were categorized as PSH and non-PSH cohorts (n = 2305). To evaluate the importance of PSH in the rural surgical system, a case-control study was performed to compare TJR surgical outcomes (LOS, discharge disposition, and 90-d readmission) of the PSH cohort against two control cohorts [Control-1 PSH (C1-PSH) (n = 1413) and Control-2 PSH (C2-PSH) (n = 892)]. Statistical tests including Chi-square test or Fischer’s exact test were performed for categorical variables and Mann-Whitney test or Student’s t-test were performed for continuous variables. The general linear models (Poisson regression and binomial logistic regression) were performed to fit adjusted models.

RESULTS

The LOS was significantly shorter in PSH cohort compared to two control cohorts (median PSH = 34 h, C1-PSH = 53 h, C2-PSH = 35 h) (P value < 0.05). Similarly, the PSH cohort had lower percentages of discharges to other facilities (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%) (P value < 0.05). There was no statistical difference observed in 90-d readmission between control and PSH cohorts. However, the PSH implementation reduced the 90-d readmission percentage (PSH = 4.7%, C1-PSH = 6.1%, C2-PSH = 3.6%) lower than the national average 30-d readmission percentage which is 5.5%. The PSH system was effectively established at the rural community hospital with the help of team-based coordinated multi-disciplinary clinicians or physician co-management. The elements of PSH including preoperative assessment, patient education and optimization, and longitudinal digital engagement were vital for improving the TJR surgical outcomes at the community hospital.

CONCLUSION

Implementation of the PSH system in a rural community hospital reduced LOS, increased direct-to-home discharge, and reduced 90-d readmission percentages.

Keywords: Perioperative surgical home; Rural medicine; Case-control study; Total joint replacements; Health equity

Core Tip: The study evaluated the newly implemented perioperative surgical home (PSH) at a rural community hospital using a case-control design. With limited supporting microsystems, team-based physician co-management was vital to establish the PSH system and following protocols including preoperative assessment, patient education, and longitudinal digital engagement. The surgical outcomes - length of stay, discharge disposition, and 90-d readmission - were compared between the PSH cohort and the control cohorts. The results from this study highlighted the effectiveness of PSH in improving total joint replacement surgical outcomes, especially for high-risk patients who are older and have one or more medical complications.