Improving value in primary total joint arthroplasty care pathways: changes in inpatient physical therapy staffing

Similar Efficacy and Lower Cost Associated With Ceftazidime Compared to Tobramycin Coupled With Vancomycin in Antibiotic Spacers in the Treatment of Periprosthetic Joint Infection

BACKGROUND

Vancomycin and tobramycin have traditionally been used in antibiotic spacers. In 2020, our institution replaced tobramycin with ceftazidime. We hypothesized that the use of ceftazidime/vancomycin (CV) in antibiotic spacers would not lead to an increase in treatment failure compared to tobramycin/vancomycin (TV).

METHODS

From 2014 to 2022, we identified 243 patients who underwent a stage I revision for periprosthetic joint infection. The primary outcome was a recurrent infection requiring antibiotic spacer exchange. We were adequately powered to detect a 10% difference in recurrent infection. Patients who had a prior failed stage I or two-stage revision for infection, acute kidney injury prior to surgery, or end-stage renal disease were excluded. Given no other changes to our spacer constructs, we estimated cost differences attributable to the antibiotic change. Chi-square and t-tests were used to compare the two groups. Multivariable logistic regressions were utilized for the outcomes.

RESULTS

The combination of TV was used in 127 patients; CV was used in 116 patients. Within one year of stage I, 9.8% of the TV group had a recurrence of infection versus 7.8% of the CV group (P = .60). By final follow-up, results were similar (12.6 versus 8.6%, respectively, P = .32). Adjusting for potential risk factors did not alter the results. Cost savings for ceftazidime versus tobramycin are estimated to be $68,550 per one hundred patients treated.

CONCLUSIONS

Replacing tobramycin with ceftazidime in antibiotic spacers yielded similar periprosthetic joint infection eradication success at a lower cost. While larger studies are warranted to confirm these efficacy and cost-saving results, our data justifies the continued investigation and use of ceftazidime as an alternative to tobramycin in antibiotic spacers.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BACKGROUND

Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies.

METHODS

All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years).

RESULTS

There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs.

CONCLUSIONS

The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch

BACKGROUND

Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center.

METHODS

All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD.

RESULTS

Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830).

CONCLUSIONS

With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Association of Physical Therapy Treatment Frequency in the Acute Care Hospital With Improving Functional Status and Discharging Home

BACKGROUND

Physical therapists (PTs) are consulted to address functional deficits during hospitalization, but the effect of PT visit frequency on patients' outcomes is not clear.

OBJECTIVE

The objective of this study was to examine whether PT visit frequency is independently associated with functional improvement, discharge home, and both outcomes combined.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

Patients discharged from hospitals in 1 health system between 2017 and 2020, stratified by diagnostic subgroup: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic.

MEASURES

PT visit frequency was categorized as ≤2, >2-4, >4-7, >7 visits/week. Functional improvement was defined as ≥5-point improvement in Activity Measure for Post-Acute Care mobility score. Other outcomes were discharge home and both outcomes combined.

RESULTS

There were 243,779 patients included. Proportions within frequency categories ranged from 11.0% (>7 visits/wk) to 40.5% (≤2 visits/wk) and varied by subgroup. In the full sample, 36% of patients improved function, 64% were discharged home, and 27% achieved both outcomes. In adjusted analyses, relative to ≤2 visits/week, the adjusted relative risk (aRR) for functional improvement increased incrementally with higher frequency (aRR=1.20, 95% confidence interval: 1.14-1.26 for >2-4 visits to aRR=1.78, 95% confidence interval: 1.55-2.03 for >7 visits). For all patients and within subgroups, the higher frequency was also associated with a greater likelihood of discharging home and achieving both outcomes.

CONCLUSIONS

More frequent PT visits during hospitalization may facilitate functional improvement and discharge home. Most patients, however, receive infrequent visits. Further research is needed to determine the optimal delivery of PT services to meet individual patient needs.

Same-day discharge after early mobilisation and increased frequency of physiotherapy following hip and knee arthroplasty

Background

Advanced rehabilitation pathway (ARP) after hip and knee arthroplasties is popular globally and is gaining ground in South Africa (SA). A multidisciplinary team in Rustenburg, SA, has implemented an ARP with the first same-day discharge (SDD) from hospital. The lack of evidence of physiotherapy protocols within an ARP determined our study.

Objectives

Determine and compare hospital length of stay (LOS) (hours), patient satisfaction (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), patient safety (30-day re-admission) and cost between the two cohorts.

Method

A quantitative prospective patient (treatment) group receiving early mobilisation with increased frequency of physiotherapy on post-operative day zero (POD0) was compared to a conservatively managed retrospective historical (control) group following post-operative elective hip and knee arthroplasties.

Results

Results for the prospective group which were significantly improved relative to the retrospective group included decreased LOS (median 7.650, p < 0.001), less pain at 6 weeks (mean 16.20, standard deviation [SD] = 2.673, p < 0.001), less stiffness (mean 5.82, SD = 1.214, p = 0.007), higher function (mean 54.87, SD = 8.544, p < 0.001), lower hospital cost (mean R43 340, p < 0.001) and physiotherapy cost (mean R1069, p < 0.001), and total costs compared to the retrospective group (mean R117 062, p < 0.001).

Conclusion

Safe and cost-effective SDD is possible in an ARP with earlier mobilisation and increased frequency of physiotherapy on POD0.

Clinical implications

Achieving safe SDD after hip and knee arthroplasty surgeries saved costs and improved patient satisfaction, with a decrease in LOS being beneficial for medical funders and stakeholders including government aiming to implement National Health Insurance (NHI) in the future.

Determination of Factors Affecting Early Mobilization of Patients Who Have Undergone Knee and Hip Arthroplasty

PURPOSE

This study was conducted in order to determine the factors that affected the early mobilization after surgery of patients who had undergone knee and hip arthroplasty.

DESIGN

This study is descriptive correlational.

METHODS

The study population consists patients who met the inclusion criteria and were hospitalized in a State Hospital Orthopedics and Traumatology Clinic in Turkey in order have the knee or hip arthroplasty surgery between the dates of November 7, 2017 and September 21, 2018. While selecting the sample, the purposive sampling method was used. The sample consists of 60 patients who were in the universe of the study, who meet the inclusion criteria and who voluntarily agreed to participate in the study.

FINDINGS

The mean time of the first mobilization of the patients was 19 (9.15-72) hours. There were statistically significant relationships between mobilization time and age, gender, marital status, body mass index, past surgical history, chronic pain, blood transfusion before surgery, medical diagnosis, surgical procedure, bone cement usage, the score for American society of Anesthesiologists, surgical intervention time, post-operation nutrition, and defecation time.

CONCLUSION

The early mobilization time of the great majority of the patients who underwent knee and hip arthroplasty was in conformity with the enhanced recovery after surgery protocol.

Value-Based Healthcare Initiatives in Practice: A Systematic Review

EXECUTIVE SUMMARY

Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.

Mobility Technicians: A Viable Solution to Early Ambulation of Total Joint Replacement Patients

BACKGROUND

Early ambulation of patients with total joint replacement (TJR) has been shown to improve outcomes while reducing length of stay and postoperative complications. Limited physical therapy (PT) resources and late-in-the-day cases may challenge day-of-surgery (POD0) ambulation. At our institution, a Mobility Technician (MT) program, composed of specially trained nurse's aides, was developed to address this issue.

PURPOSE

The purpose of this study was to compare the effectiveness of the MT model with a traditional PT model in the early ambulation of patients with TJR.

METHODS

Patients undergoing unilateral primary TJR at a single institution between June 1, 2014, and October 31, 2018, were included. Ambulation measures were retrospectively assessed between pre- and post-MT program groups.

RESULTS

This study included 11,777 patients with TJR. Following the MT program, number of POD0 ambulations, POD0 ambulation distance, and total distance ambulated all increased while time-to-first ambulation decreased.

CONCLUSION

Preliminary analyses indicate that the MT program has been successful in the early ambulation of patients with TJR.

Mobilization after joint arthroplasty surgery: who benefits from standing within 12 hours?

BACKGROUND

Early mobilization following joint arthroplasty surgery has been shown to be beneficial for patients, but it is unclear whether it is associated with a shorter length of stay (LOS) for both hip and knee arthroplasty (KA) patients.

METHODS

We undertook a retrospective observational study, reviewing the case notes of 386 patients admitted to an enhanced recovery programme for total hip (THA) or total/unicompartmental KA. We evaluated the influence of early mobilization on LOS, adjusting for possible confounders, stratifying by surgery type.

RESULTS

THA patients first mobilized within 12 h of returning to the acute orthopaedic ward following surgery had a significantly shorter mean LOS (mean = 3.6, standard deviation = 1.1) than THA patients who first mobilized 12 or more hours (mean = 4.1, standard deviation = 1.2), P = 0.004. There was no statistical significant difference in the mean LOS between the KA patients mobilized earlier or later.

CONCLUSION

Early mobilization as part of an enhanced recovery programme was associated with decreased LOS for patients having THA; however, this was not the case for KA patients.

Higher incidence of manipulation under anesthesia following TKA associated with the periarticular infiltration of a liposomal bupivacaine cocktail compared to a modified Ranawat cocktail

BACKGROUND

The purpose of this study was to compare the frequency of postoperative stiffness requiring manipulation under anesthesia (MUA) before and after switching from the intraoperative use of liposomal bupivacaine (LB).

METHODS

This was an institutional review board (IRB)-exempt retrospective cohort study (IRB#71733) on all patients who underwent primary total knee arthroplasty (TKA) by a single surgeon between April 2016 and December 2017. We compared 169 knees that received LB group to 167 knees that received a modified Ranawat cocktail (MR group). Perioperative care pathways remained consistent during the study period, as were requirements for MUA which included flexion range of motion below approximately 90 at 6-12 weeks. To compare the incidence of MUA between the groups, a population-averaged Poisson regression analysis was used.

RESULTS

The two groups were similar, with mean age of 63 (range 31-91) in the LB group and 64 (range 42-84) in the MR group, a preponderance of females in both groups (p = 0.866), similar preoperative knee flexion between groups (p = 0.162), and similar Patient-Reported Outcomes Measurement Information System scores. The frequency of MUA, however, was significantly lower in the MR group (LB: 7.7% [95% CI 3.7-12%] vs. MR: 2.4% [95% CI <1-4.7%] [IRR 3.2, 95% CI 1.08-9.76, p . 0.037]).

CONCLUSIONS

In summary, this is a novel report of a potentially previously unrecognized increased incidence of MUA associated with the use of LB compared with a MR cocktail. Given no other notable changes to the perioperative care or MUA thresholds following TKA, the reasons for these findings are unclear but deserve additional investigation.

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

BACKGROUND

Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care.

METHOD

A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol.

RESULTS

Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles.

CONCLUSION

Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Ambulation milestones in post-operative physical therapy after total knee arthroplasty: how can we improve short-term outcomes?

Introduction: Post-operative day (POD) 0 physical therapy (PT) after total knee arthroplasty (TKA) has been associated with improved outcomes such as shorter hospital length of stay (LOS), though patient performance is variable. The purpose of this study was to evaluate PT performance and determine whether this affected LOS or discharge to home.Methods: Retrospective review including 412 patients who underwent TKA over 1 year. Specific data assessed included details about demographics, surgery/recovery, PT, LOS, and discharge destination.Results: Overall, 88.8% (366/412) of patients received POD 0 PT. About 73.9% of patients who did not receive POD 0 PT were prevented from doing so by reasons that kept them off of the orthopedic inpatient floor. Patients who walked greater than 10 feet on POD 0 or 100 feet on POD 1 were significantly more likely to have a shorter LOS and more likely to be discharged to home.Discussion: Objective milestones of walking 10 feet on POD 0 and 100 feet on POD 1 were associated with improved short-term outcomes. These performance markers may be useful for stratifying which patients are meeting milestones for early discharge. Late arrival to inpatient floor had the strongest associations with inability to perform PT.

Nursing care activities based on documentation

BACKGROUND

Nurses engage in various activities from the time of a patient's admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

METHODS

A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care.

RESULTS

It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients' home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%).

CONCLUSIONS

Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

Physical Therapy on Postoperative Day Zero Following Total Knee Arthroplasty: A Randomized, Controlled Trial of 394 Patients

BACKGROUND

Surgeons have increasingly emphasized early mobilization as a way to facilitate discharge following total knee arthroplasty (TKA). The purpose of this study was to determine whether starting formal physical therapy (PT) the afternoon of postoperative day (POD) 0, instead of starting PT the morning of POD 1, could shorten hospital length of stay (LOS).

METHODS

Patients undergoing elective TKA with a planned minimum 1-night hospital stay were randomized to start formal PT the afternoon following surgery or the morning of POD 1. LOS in hours was the primary outcome. An a priori sample size calculation suggested that 394 patients were required to show a 4-hour difference between groups.

RESULTS

Out of 394 patients enrolled and randomized, 378 (95.9%) completed the study. The observed difference in hospital LOS was not large enough to be of clinical significance (intention-to-treat analysis: median of 32.0 hours for POD 0 PT vs 31.0 hours for POD 1 PT, P = .65; as-treated analysis: median of 31.0 hours for POD 0 PT vs 32.0 hours for POD 1 PT, P = .12). Similarly, the observed differences in satisfaction with inpatient PT (10.0 vs 10.0, P = .77), patient-reported readiness for discharge at time of discharge (10.0 vs 10.0, P = .97), and POD 0 pain (3.3 vs 4.0, P = .79) were not large enough to be of clinical significance.

CONCLUSION

While PT on the day of surgery has been suggested as one method to facilitate discharge following TKA, this randomized trial did not demonstrate clinically meaningful differences in hospital LOS or patient satisfaction when PT is initiated on the day of surgery vs on the morning after surgery.

Time of return of neurologic function after spinal anesthesia for total knee arthroplasty: mepivacaine vs bupivacaine in a randomized controlled trial

Background

Mepivacaine as an intermediate-length spinal anesthetic for rapid recovery in total knee arthroplasty (TKA) has not been fully described. We compared spinal mepivacaine vs bupivacaine for postoperative neurologic function in patients undergoing primary TKA.

Methods

Thirty-two patients undergoing primary TKA were enrolled. Primary outcome measure was return of motor and sensory function. Secondary outcome measures included assessment of urinary function, pain via visual analog scale (VAS) scores, opioid usage, distance walked and pain with physical therapy, time to discharge readiness, and complications.

Results

Patients with mepivacaine spinal anesthetic had faster return of sensory function (164 ± 38.6 vs 212 ± 54.2 minutes, P = .015), return of motor function (153 ± 47.4 vs 200 ± 45.2 minutes, P = .025), and time to straight leg raise (148 ± 43.5 vs 194 ± 50.8 minutes, P = .023). The mepivacaine group experienced significantly fewer episodes of urinary retention and shorter time to urination (344 ± 154.4 vs 416 ± 96.3 minutes, P = .039). Patients exhibited slightly higher VAS pain scores in the postanesthesia care unit (1.0 ± 1.7 vs 2.7 ± 2.3, P = .046) with no difference in opioid consumption. There were no differences in VAS scores or opioid use on the inpatient ward. Patients achieved discharge readiness 71 minutes faster in the mepivacaine group. There was no need to convert to general anesthesia or transient nerve symptoms in either group.

Conclusions

Patients undergoing TKA with mepivacaine spinal anesthetic had a reliably more rapid neurologic recovery after TKA compared to bupivacaine.

Immediate Physical Therapy following Total Joint Arthroplasty: Barriers and Impact on Short-Term Outcomes

Background

Recent evidence suggests benefit to receiving physical therapy (PT) the same day as total joint arthroplasty (TJA), but relatively little is known about barriers to providing PT in this constrained time period. We address the following questions: (1) Are there demographic or perioperative variables associated with receiving delayed PT following TJA? (2) Does receiving immediate PT following TJA affect short-term outcomes such as length of stay, discharge disposition, or 30-day readmission? Methods. Primary TJA procedures at a single center were retrospectively reviewed. Immediate PT was defined as within eight hours of surgery. Demographic and perioperative variables were compared between patients who received immediate PT and those who did not. We identified an appropriately matched control group of patients who received immediate PT. Postoperative length of stay, discharge disposition, and 30-day readmissions were compared between matched groups.

Results

In total, 2051 primary TJA procedures were reviewed. Of these, 226 (11.0%) received delayed PT. These patients had a higher rate of general anesthesia (25.2% versus 17.8%, p=0.006), later operative start time (13:26 [11:31-14:38] versus 9:36 [8:24-11:16], p<0.001), longer operative time (1.8 [1.5-2.2] versus 1.6 [1.4-1.8] hours, p=0.002), and higher overall caseload on the day of surgery (6 [4-9] versus 5 [4-8], p=0.002). A matched group of patients who received immediate PT was identified. There were no differences in postoperative length of stay or discharge disposition between matched immediate and delayed PT groups, but delayed PT (OR 4.54; 95% CI 1.61-12.84; p=0.004) was associated with a higher 30-day readmission rate.

Conclusion

Barriers to receiving immediate PT following TJA included general anesthesia, later operative start time, longer operative time, and higher daily caseload. These factors present potential targets for improving the delivery of immediate postoperative PT. Early PT may help reduce 30-day readmissions, but additional research is necessary to further characterize this relationship.

Enhanced recovery in usual health care improves functional recovery after total knee arthroplasty

BACKGROUND

The success of total knee arthroplasty (TKA) is determined by an effective surgical procedure as well as a well-organized clinical care pathway. Research has shown that day-of-surgery mobilization decreases length of stay (LOS) and complication rates. We developed, implemented, and evaluated a new clinical care pathway for patients undergoing TKA, that included early mobilization, using 'Lean Six Sigma (LSS)', with the aim of accelerating functional recovery and reducing LOS.

METHODS

Data derived from physical therapy reports and LOS were compared between the old (n = 85) and the new (n = 85) clinical care pathways for time to functional recovery (using the modified Iowa Level of Assistance Scale), LOS and joint-related readmission. Group differences were evaluated using Mann-Whitney and Chi-Square tests. The clinical care pathway was redesigned using LSS-methods.

RESULTS

After implementation of the new pathway, median time to functional recovery improved from 4 (2-5) to 2 days (1-8)(P < 0.001) and LOS from 7 (5-11) to 4 days (3-12)(P < 0.001), joint-related readmission declined (3.5-2.4%)(P = 0.65).

CONCLUSION

Implementation of the new clinical care pathway accelerated functional recovery and reduced LOS for patients undergoing TKA. Future research should focus on having multiple discharge moments per day which might encourage patients to achieve functional recovery as soon as possible.

Short-term functional recovery after total joint arthroplasty is unaffected by bundled payment participation

Background

Bundled payment models for lower extremity total joint arthroplasty (TJA) aim to improve value by decreasing costs via efficient care pathways. It is unclear how such models affect patient-centered outcomes such as functional recovery. We aimed to determine whether participation in bundled payment for TJA negatively affects patients’ functional recovery.

Methods

All patients, regardless of payer, undergoing elective TJA between July 2014 and December 2016 were identified retrospectively and categorized into prebundle (n = 680) and postbundle (n = 1216) cohorts. Mixed-effects linear regression and Wald postests were used to test for differences in patients’ functional recovery during the hospital period and over 12 months after TJA between cohorts. We also used multivariate regression to test for differences in hospital length of stay (LOS) and postacute care (PAC) facility use between cohorts.

Results

Compared with the prebundle cohort, patients in the postbundle cohort demonstrated a small and nonmeaningful difference in the trajectory of functional recovery in the hospital [χ²(3) = 31.3, P < .01] and no difference in the 12 months after TJA [χ²(3) = 3.9, P = .28]. They had a 0.4-day shorter hospital LOS (95% confidence interval: −0.5, −0.3) and decreased odds for PAC facility use (adjusted odds ratio = 0.3; 95% confidence interval: 0.2, 0.4).

Conclusions

Participation in bundled payment for TJA was not associated with significant changes in patients’ functional recovery, an important patient-centered outcome. For the postbundle cohort, hospital LOS and PAC facility use were decreased, consistent with previous studies describing cost-saving strategies in bundled payment. These findings support the need for an ongoing study of the long-term sustainability of these value-based payment models.

Variation in Use of Postoperative Precautions and Equipment Following Total Hip Arthroplasty: A Survey of the AAHKS and CAS Membership

BACKGROUND

A traditional method to reduce dislocation risk following total hip arthroplasty involves prescribing postoperative precautions and ambulatory equipment to patients. The purpose of this study was to determine the prevalence of postoperative precaution and equipment use among North American arthroplasty surgeons for patients undergoing primary total hip arthroplasty.

METHODS

We conducted a survey of American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society members using an electronic questionnaire format to determine how often precautions and equipment were prescribed, and whether their use was associated with surgical approach and other surgeon demographics.

RESULTS

Of the respondents, 44% universally prescribed precautions while 33% never prescribed precautions. Use of the posterolateral approach, surgeon experience, and larger head size use were significantly associated (P < .01) with precaution and equipment use. Direct anterior approach surgeons were significantly less likely to prescribe precautions (P < .0001) and significantly less likely to prescribe equipment (P < .0001).

CONCLUSION

Although postoperative precautions continue to be used to some degree by the majority of members, their consumption of healthcare resources through utilization of additional care providers and purchasing of equipment, known association with reduced patient satisfaction, and lack of supporting evidence make them a target for future scrutiny.

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience

BACKGROUND

Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force.

METHODS

To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described.

RESULTS

Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements.

CONCLUSION

Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.

Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures with a risk of complications. Attempting to minimize complications, our institution implemented preoperative screening criteria for patients undergoing elective total joint replacement. Our study aimed to determine if screening criteria lowered total complications and/or surgical site infections (SSI).

METHODS

Two groups of consecutive patients undergoing TKA and THA at a single Veterans Affairs facility were evaluated prior to and after implementation of screening criteria, 520 and 475 respectively. Screening criteria included hemoglobin A1c ≤7, hemoglobin ≥11, body mass index ≤35, and albumin ≥3.5. Groups were analyzed for demographics, preoperative comorbidities, and postoperative complications. Rates of total complications and SSI were compared. Average follow-up was at least 2 years with minimum of 1 year.

RESULTS

Demographics and comorbidities outside the screening criteria were similar. Total complication rate was reduced from 35.4% to 14.8% (P < .01) after implementation of screening criteria. For TKA, total complications were reduced from 33.1% to 15.0% (P < .01) and for THA they were reduced from 42.4% to 14.2% (P < .01). SSI rates for combined TKA and THA were reduced from 4.4% to 1.3% (P < .01). For knees, SSI was reduced from 4.6% to 1.3% (P = .01) and was statistically significant. For THA, SSI decreased from 3.8% to 1.2% (P < .05).

CONCLUSION

Our institution saw a statistically significant decrease in both SSI and total complications following implementation of preoperative screening criteria for elective TKA and THA.

Increasing Perioperative Communication With Automated Mobile Phone Messaging in Total Joint Arthroplasty

BACKGROUND

Automated mobile phone messaging has not been reported in total joint arthroplasty (TJA). Our purpose was to compare Press Ganey (PG) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores between TJA patients who did and did not receive perioperative automated mobile phone messages.

METHODS

Patients were prospectively enrolled and received messages for 1 week prior until 2 weeks after TJA. Message content included reminders, activity, and pain control. Patients answered select PG/HCAHPS and questions regarding their experience with the automated communication platform. Average PG/HCAHPS scores were compared to historical TJA patients in the 3-year window prior (control group) with significance P < .05.

RESULTS

Thirty-seven consecutive patients were approached and 92% (n = 34) were enrolled. The experimental group was 47% male, with 80% patients between 51 and 75 years. The experimental (n = 30) and control groups (n = 26) were similar. Patients receiving messages were more likely to have a good understanding of health responsibilities (P = .024) and feel that the care team demonstrated shared decision-making (P = .024). Of patients enrolled, 87% felt messages helped them be more prepared for surgery, 100% felt messages kept them better informed, and 97% would participate again.

CONCLUSION

TJA patients who received perioperative communication via automated mobile phone messaging had improved patient satisfaction scores postoperatively. Patients perceived this form of communication was useful and kept them better informed. Automated mobile phone messaging can be an easily integrated, helpful adjunct to surgeons, healthcare systems, and case managers to more effectively communicate with patients undergoing TJA in this era of value-based care.

Perioperative Pain Management in Hip and Knee Arthroplasty

Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.