An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis

Comparison of Patients Based on Their Self-Selected Discharge Pathway after Total Knee Arthroplasty at an Ambulatory Surgical Center

Outpatient total knee arthroplasty (TKA) is being performed more frequently in ambulatory surgical centers (ASCs) to decrease the cost of care. Discharge pathways include 23-hour observation (OBSERVATION) or same-day discharge home (HOME), which differ in postoperative medical supervision. Few studies allow patients to self-select their discharge pathway. This study compared patient variables between self-selected OBSERVATION or HOME discharge after TKA at an ASC. We hypothesized that age, sex, and distance lived from the ASC would differ between discharge pathways. Clinical and patient-reported outcomes were explored.A chart review identified 130 patients with TKA at an ASC between November 2017 and December 2019. Patients self-selected OBSERVATION or HOME during a preoperative physician visit. Patient variables obtained from the electronic medical record were age, sex, race/ethnicity, marital status, body mass index, diabetic status, American Society of Anesthesiologists (ASA) class, distance lived from the ASC, anesthesia type, procedure time, and time in the postanesthesia recovery unit. Clinical outcomes (knee range of motion, infection rate, and reoperation rate) and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS, JR]; Oxford Knee Score [OKS]) were collected at either 6 or 12 weeks postsurgery. Variables were compared between groups.Pathway selection was n = 70 OBSERVATION and n = 60 HOME, and all patients completed their self-selected discharge pathway. Age and proportion of females were significantly higher in OBSERVATION than in HOME (61.3 ± 3.5 vs. 58.5 ± 5.4 years, 85.7 vs. 65.0%, respectively; p < 0.05). Distance lived from the ASC tended to be greater in OBSERVATION than HOME (22.1 ± 24.6 vs. 15.3 ± 10.1 miles, p = 0.056). Across groups, clinical outcomes were favorable (i.e., >88% met the 6-week knee flexion milestone, 1.9% infection rate, and 3.1% manipulation under anesthesia), and the preoperative to 12-week postoperative change in KOOS, JR and OKS scores met the minimal clinically important difference.Older age, female sex, and farther distance lived from the ASC may influence patients to select OBSERVATION over HOME discharge following TKA at an ASC. No robust differences were found in early outcomes.

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.

Short-Term (90 Days) Clinical Outcomes Following the Day of Surgery Conversion of Inpatient to Same-Day Hip and Knee Arthroplasty

BACKGROUND

The incidence of total joint arthroplasty is increasing, with added emphasis on shifting care toward outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion.

METHODS

We identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a 2-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including reoperation, readmission, and emergency room visits within a 90-day postoperative period.

RESULTS

We identified a total of 80 patients who converted from inpatient to outpatient surgery over a 2-year interval. Over the first 90 days postoperatively 4 (5%) patients were readmitted: 2 (2.5%) for medical complications and 2 (2.5%) for reoperation. There were 2 (2.5%) reoperations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were 5 (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of 5 (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission.

CONCLUSIONS

Hospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.

Intraoperative Surgeon-Administered Adductor Canal Block Is a Safe Alternative to Preoperative Anesthesiologist-Administered Adductor Canal Block in Primary Total Knee Arthroplasty

BACKGROUND

The shift toward outpatient total knee arthroplasties (TKAs) has led to a demand for effective perioperative pain control methods. A surgeon-performed "low" adductor canal block ("low-ACB") technique, involving an intraoperative ACB, is gaining popularity due to its efficiency and early pain control potential. This study examined the transition from traditional preoperative anesthesiologist-performed ultrasound-guided adductor canal blocks ("high-ACB") to low-ACB, evaluating pain control, morphine consumption, first physical therapy visit gait distance, hospital length-of-stay, and complications.

METHODS

There were 2,620 patients at a single institution who underwent a primary total knee arthroplasty between January 1, 2019, and December 31, 2022, and received either a low-ACB or high-ACB. Cohorts included 1,248 patients and 1,372 patients in the low-ACB and high-ACB groups, respectively. Demographics and operative times were similar. Patient characteristics and outcomes such as morphine milligram equivalents (MMEs), Visual Analog Scale pain scores, gait distance (feet), length of stay (days), and postoperative complications (30-day readmission and 30-day emergency department visit) were collected.

RESULTS

The low-ACB cohort had higher pain scores over the first 24 hours (5.05 versus 4.86, P < .001) and higher MME at 6 hours (11.49 versus 8.99, P < .001), although this was not clinically significant. There was no difference in pain scores or MME at 12 or 24 hours (20.81 versus 22.07 and 44.67 versus 48.78, respectively). The low-ACB cohort showed longer gait distance at the first physical therapy visit (188.5 versus 165.1 feet, P < .001) and a shorter length of stay (0.88 versus 1.46 days, P < .01), but these were not clinically significant. There were no differences in 30-day complications.

CONCLUSIONS

The low-ACB offers effective pain relief and comparable early recovery without increasing operative time or the complication rate. Low-ACB is an effective, safe, and economical alternative to high-ACB.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective cohort study).

Same Day Discharge Total Knee Arthroplasty: Hospital Demonstrates Similar Outcomes to Ambulatory Surgery Center in a More Complex Patient Population

BACKGROUND

The purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting.

METHODS

A single tertiary academic center's institutional database was reviewed for patients who underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least 1 year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures, emergency department visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria.

RESULTS

Patients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (P < 0.001), Elixhauser comorbidity index (P < 0.001), proportion of patients who had an American Society of Anesthesiologists classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0.422) scores as well as similar rates of achieving minimum clinically important difference for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of emergency department visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years CONCLUSIONS: Although ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California

BACKGROUND

Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic.

METHODS

Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05.

RESULTS

In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA.

CONCLUSIONS

This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly.

LEVEL OF EVIDENCE

Therapeutic Level IV, Retrospective Cohort Study.

Impact of COVID-19 on Pulmonary Embolism Rates in Patients Undergoing Total Joint Arthroplasty

BACKGROUND

The purpose of this study was to evaluate the incidence and severity of pulmonary embolism (PE) in patients undergoing total hip and knee arthroplasties after the onset of the coronavirus disease 2019 (COVID-19) pandemic.

MATERIALS AND METHODS

Patients who underwent a total hip arthroplasty or a total knee arthroplasty between 2017 and 2022 and had a PE within 90 days postoperatively were included. Demographics, medical history, procedural information, and PE outcomes were collected and evaluated.

RESULTS

There were 5933 procedures and 17 PE events (0.27%) before COVID-19 compared with 3273 procedures and 16 PE events (0.49%) after COVID-19 (P=.12). There was an increase in intensive care unit admission after COVID-19 (44% vs 0%, P<.05).

CONCLUSION

This study showed a trend toward an increased incidence of PE events in the post-COVID-19 cohort and a statistically significant increase in the severity. [Orthopedics. 2024;47(4):233-237.].

Trends in Hospital Stay, Complication Rate, and Mortality in Hip Fracture Patients: A Two-Decade Comparison at a National Tertiary Referral Center

Background: Since the turn of the century, the age-adjusted incidence of proximal femoral fractures has caused a plateau or fall. However, it was anticipated that the number of patients with proximal femoral fractures would rise as life expectancy rose and the population over 80 years old expanded. The aim of this study was to compare the length of hospital stay, complication rate, and mortality in patients with proximal femoral fractures between two different time periods: 20 years ago and the present. Methods: We conducted a retrospective review of medical records of patients aged 65 years and above who underwent surgery for proximal femoral fractures between January 2000 and December 2001 and between January 2020 and December 2021. We collected information on age, gender, fracture type, length of hospital stay, and complication rate. Dates of death were obtained from the Ministry of the Interior and Safety. Results: We included 136 patients who were operated on between 2000 and 2001 and 134 patients between 2020 and 2021. The average age increased significantly from 71.6 years to 79.0 years (p < 0.001). The length of hospital stay decreased dramatically from 15.1 days to 6.0 days (p < 0.001). There was no statistically significant difference in delirium, urinary tract infection, or pneumonia. No difference was found in 30-day or 1-year mortality between the two groups. Conclusions: The complication rate and mortality between the two time periods appeared comparable, although the length of hospital stay decreased substantially. Therefore, we recommend considering expedited discharge from the acute care hospital for elderly hip fracture patients while implementing an individualized approach for better outcomes.

Same-Day Total Joint Arthroplasty in the United States From 2016 to 2020: The Impact of the Medicare Inpatient Only List and the COVID-19 Pandemic

BACKGROUND

Same-day total hip arthroplasty (THA) and total knee arthroplasty (TKA) continue to gain popularity in the United States. The present study sought to quantify recent same-day outpatient trends taking into consideration the COVID-19 pandemic as well as the removal of these procedures from the Medicare inpatient only (IPO) list.

METHODS

Patients undergoing primary elective TKA and THA were identified using the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample from January 1, 2016, to December 31, 2020. The same-day cohort included Nationwide Ambulatory Surgery Sample and National Inpatient Sample patients with a length of stay = 0 days. The inpatient cohort included patients with length of stay ≥1 day. National estimates were extrapolated using weight functions.

RESULTS

From January 2016 to December 2020, the proportion of same-day TKA increased from 1.2 (719) to 62.4% (31,293) and the proportion of same-day THA increased from 2.0 (599) to 54.5% (18,252). Following removal from the Medicare IPO list, same-day TKAs increased from 3.2% (1,895) in December 2017 to 13.8% (9,269) in January 2018, and same-day THAs increased from 10.7% (4,295) in December 2019 to 22.5% (8,708) in January 2020. Between February and March 2020, same-day TKAs increased from 42.4 (26,148) to 44.4% (16,972) and same-day THAs increased from 28.5 (10,729) to 30.2% (7,409).

CONCLUSIONS

The proportion of same-day TKA and THA dramatically increased following removal from the Medicare IPO list and in response to the COVID-19 pandemic. By December 2020, same-day TKA and THA accounted for >50% of all cases performed in the United States.

Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy

OBJECTIVE

To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model.

DATA SOURCES AND STUDY SETTING

Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention.

STUDY DESIGN

This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015.

DATA COLLECTION/EXTRACTION METHODS

Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded.

PRINCIPAL FINDINGS

After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function.

CONCLUSIONS

We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.

Scaled TelePhysical Therapy Program a Promising Option for Post-acute Care of Lower-Extremity Arthroplasty Patients

Background

Post-acute care for orthopedic surgery patients continues to evolve with the reduction in hospital length of stay (LOS), shift to ambulatory surgery, increased number of surgeries, and focus on value-based care.

Purpose

We sought to examine outcomes of a cohort of lower-extremity arthroplasty patients receiving telephysical therapy (TelePT) according to hospital LOS, as a means of exploring the viability of TelePT as a value-based discharge option.

Methods

A retrospective review was conducted of patients who participated in our institution's HSS@Home TelePT program after undergoing primary unilateral hip or knee arthroplasty, unicondylar knee replacement, or hip resurfacing. Demographic data and outcomes such as hospital LOS, number of days between discharge and TelePT evaluation, number of TelePT visits, number of re-admissions, Hip dysfunction and Osteoarthritis Outcome (HOOS Jr.) or Knee injury and Osteoarthritis Outcome (KOOS Jr.) scores, and patient satisfaction scores were collected. Patients were divided into categories based on hospital LOS to help determine the versatility of program.

Results

In the 2814 patients included, we observed an average of 4.1 TelePT visits; 1% of patients were readmitted within 90 days, and 97% of patients were satisfied or highly satisfied. There was no difference in HOOS or KOOS Jr. scores at each follow-up time point, except for the 6-month HOOS Jr. scores.

Conclusion

This retrospective study suggests that TelePT may be a viable option for care of lower-extremity arthroplasty patients in the post-acute setting, regardless of hospital LOS. As a discharge option, it may meet the needs of select patients to fill a gap in providing value-based care.

Adapting hip arthroplasty practices during the COVID-19 pandemic: Assessing the impact of outpatient care sudden increase on early complications and clinical outcomes

INTRODUCTION

The COVID-19 pandemic has significantly affected access to timely care for patients with hip osteoarthritis requiring total hip replacement (THR). This study aimed to assess the changes in surgical activity, outpatient treatment, length of stay (LOS), discharge destinations, readmission rates, clinical outcomes, and patient satisfaction before and after the pandemic at our institution.

MATERIALS AND METHODS

This retrospective study encompassed patients undergoing primary THR through the direct anterior approach at a single university hospital. Data on demographic characteristics, surgical technique, perioperative management, LOS, discharge destinations, complications, and clinical outcomes were collected. Furthermore, a comparative analysis between the pre-pandemic (2019) and post-pandemic (2022) periods was conducted.

RESULTS

There was a 14% increase in surgical activity post-pandemic, with 214 patients undergoing surgery in 2019 versus 284 in 2022. The percentage of patients managed as outpatients significantly increased from 0.5% in 2019 to 29.6% in 2022 (p < 0.001). LOS decreased from 2.7 ± 1 [0-8] days to 1.4 ± 1.1 [0-12] days (p < 0.001), and the rate of discharge to rehabilitation centres declined from 21.5% to 8.8% (p < 0.001). No significant increase in the readmission rates was observed (1.4% in both periods). At two months postoperatively, the mean HHS and satisfaction rates were comparable between the two groups (p = 1 and p = 0.73, respectively).

DISCUSSION

Despite the challenges posed by the COVID-19 pandemic, surgical activity at our institution demonstrated an increase compared to the pre-pandemic levels by expanding outpatient care, reducing LOS, and increasing rates of home discharges. Importantly, these changes did not adversely affect rehospitalization rates or early clinical outcomes.

LEVEL OF EVIDENCE

IV.

Did Rapid Expansion of Same Day Discharge Hip and Knee Arthroplasty During the COVID-19 Pandemic Increase Early Complications?

Background

The COVID-19 pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA) including more patients undergoing same day discharge (SDD) following total joint arthroplasty (TJA). The purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipated that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications.

Methods

We retrospectively queried the ACS-NSQIP database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Patients with length of stay greater than 0 were excluded. Primary outcome was any complication at 30 days. Secondary outcomes included readmission and re-operation 30 days.

Results

A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). Combined data to include THA and TKA patients did not find a statistical difference in the rate of complications or readmission but did note a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028).

Conclusion

Rapid expansion of SDD TJA during the COVID-19 pandemic did not increase overall complication, readmission, or re-operation rates. Level of Evidence: IV.