Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016

Failed Same-Calendar-Day Discharges: Understanding the Reasons for an Inpatient Stay Following Intended Outpatient Total Joint Arthroplasty

BACKGROUND

The adoption of Same-Calendar-Day discharge, or outpatient, arthroplasty has driven the evolution of care pathway protocols to optimize success rates of discharging patients home the day of surgery. There are, however, instances where patients are unable to discharge on the same day as intended and require a stay in the hospital. This can lead to a poorer patient and provider care experience as well as incur additional costs. This study, therefore, aimed to determine the incidence of 'failed' Same-Calendar-Day discharge, report the demographics of this patient population, and identify common reasons for failure of Same-Calendar-Day discharge.

METHODS

A retrospective review of a prospectively maintained regional database of 1,002 Same-Calendar-Day discharge hip and knee arthroplasty patients was performed. Patients not discharged on the Same-Calendar-Day were converted to an Enhanced Recovery After Surgery pathway. The Enhanced Recovery After Surgery conversion cohort (n = 59) was identified, and demographics, comorbidities, and reasons for conversion were reported.

RESULTS

Of 1,002 patients in the database, 59 (5.9%) did not achieve Same-Calendar-Day discharge. The most common comorbidities were hypertension (52.5%), arthritis of the spine (22.0%), and depression and anxiety (18.6%). The median length of stay for these patients was one night. The all-cause 90-day readmission rate of this patient group was 5.1%. Difficulty mobilizing (n = 16), nausea and vomiting (n = 14), and social circumstances (n = 11) were the primary causes of patients being converted to Enhanced Recovery After Surgery pathways.

CONCLUSION

Same-Calendar-Day Discharge Arthroplasty can be successfully achieved in the majority of the patient group, provided patients are assessed and treated under standard protocols that are adapted to the individual needs. Common hurdles encountered in Same-Calendar-Day Discharge Arthroplasty are mobilization, nausea and vomiting, and social circumstances.

Initiation of a novel text messaging system in total knee and hip arthroplasty

BACKGROUND

The primary objective of this study was to investigate whether using a novel text messaging system improves patient overall satisfaction compared to standard care. Secondary objectives included assessing the impact of the text messaging system on decreasing narcotic usage, the number of emergency department visits, the range of flexion and extension, and number of telephone calls to the surgeon's office.

METHODS

We enrolled 217 patients to either receive informative text messages (text messaging group, n = 86) or no additional text messages (conventional group, n = 131). Patients self-reported results on a questionnaire at the 6-week follow-up regarding the primary and secondary objectives. The active range of motion of total knee arthroplasty patients was recorded by the surgeon or treating physiotherapist.

RESULTS

There was no significant difference in overall satisfaction (P = 0.644), narcotic cessation (P = 0.185), range of motion (Flexion P = 0.521; Extension P = 0.515), and emergency department visits (P = 0.650) between the two groups. There was a statistically significant decrease in surgeon office calls favoring the text messaging group (P = 0.029). A subgroup analysis revealed that the statistical difference was mainly in the TKA group (P = 0.046).

CONCLUSIONS

A novel text messaging system may help reduce the work burden by decreasing telephone calls to the surgeon's office. While satisfaction, narcotic usage, emergency department visits, and range of motion did not significantly differ, patients endorsed the system for friends/family.

Impact of a Remote Patient Monitoring Platform on Outcomes Following a Total Hip or Knee Arthroplasty

Background

The coronavirus pandemic highlighted the need for remote patient monitoring to deliver and provide access to patient care and education. A mobile-based app providing interactive tools for patient education and monitoring was piloted at Thunder Bay Regional Health Sciences Centre (TBRHSC) in November 2020. We aimed to examine the platform's impact on postoperative length of stay, hospital readmissions, and emergency department (ED) visits 60 days postsurgery in total hip and knee arthroplasty patients in Northwestern Ontario.

Methods

Data were assessed from patients undergoing primary total hip or knee arthroplasties at TBRHSC from March 1, 2020, to February 28, 2022. Patients were divided into 2 cohorts based on enrollment with the mobile-based app (SeamlessMD). Statistical differences in outcomes were determined using Mann-Whitney or χ2 tests. An odds ratio was calculated for ED visits.

Results

Patients enrolled in the mobile-based app had statistically lower length of stay (U = 7779.0, P < .001) and fewer ED visits (χ2 (1,212) = 5.570, P = .018) than patients not enrolled in the program. Patients not enrolled had 2.31 times greater odds of visiting the ED postsurgery (odds ratio = 0.432, 95% confidence interval = 0.213-0.877, P = .022). There were no statistical differences found in readmission rates.

Conclusions

The implementation of the mobile-based app at TBRHSC showed its potential value as a tool to reduce costs in the healthcare system and improve patient outcomes. Consequentially, more formal studies are required to elucidate the magnitude of this effect.

Postoperative Communication Volume Following Total Joint Arthroplasty Can Be a Precursor for Emergency Department Visits

Background

Unplanned calls, messages, and visits to the clinic can occur at a higher rate as newer technologies allow patients more accessibility and connectivity to clinicians. By reviewing postoperative patient phone calls and electronic portal messages, we compared the methods and frequency of communications between conventional and robotic joint arthroplasty cases.

Methods

A retrospective review of total hip, total knee, and unicompartmental knee arthroplasty procedures by fellowship-trained adult reconstruction surgeons at our hospitals between 2017 and 2022 was performed. Any unplanned postoperative communication within 30 days of the postoperative period and unplanned emergency department visits were collected.

Results

There were 12,300 robotic and manual consecutive primary total hip, total knee, and unicompartmental knee arthroplasty procedures performed on 10,908 patients over the study period. A total of 905 (40.4%) patients and 2012 (23.2%) patients sent an electronic text message (ETM) in the robotic and manual arthroplasty cohorts (P < .0001), respectively. Overall, 1942 (86.6%) patients in the robotic arthroplasty group and 6417 (74%) patients in the manual arthroplasty group had at least one phone call within the first month after their joint arthroplasty.

Conclusions

Robotic arthroplasty patients place an increased demand on the orthopaedic surgery department in terms of unplanned patient contacts. Robotic arthroplasty patients had a significantly increased rate of unplanned postoperative ETMs and phone calls when compared to manual arthroplasty patients. An increased number of postoperative phone calls, but not ETMs, can also be indicative of an emergency department visit. These findings can be used in the perioperative setting to counsel and educate patients about expectations.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BACKGROUND

Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement.

METHODS

A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units.

RESULTS

Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts.

CONCLUSIONS

Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

The Effect of QR Code-Supported Patient Training on Total Knee Arthroplasty-Related Problems and Emergency Department Admission Rate

Knee arthroplasty surgery, which is increasingly performed due to increased life expectancy, has positive outcomes, although it can also cause serious health problems following surgery. This study was conducted to evaluate the impact of patient-related education via a QR code on total knee arthroplasty problems and emergency department referral rates. Participants were randomly assigned to intervention (n = 51) and control (n = 51) groups. The intervention group received QR code-supported training. The outcomes were assessed at baseline (preoperative), discharge, and postoperative sixth week. In the intervention group, significantly fewer problems related to total knee arthroplasty occurred at discharge and in week 6, and a higher level of functionality was noted ( P < .05). In week 6, the rate of emergency department admissions was lower, and mean scores for satisfaction with patient training were higher in the intervention group ( P < .05). In conclusion, QR code-supported patient training was effective in reducing the physiological and psychosocial problems related to total knee arthroplasty and the emergency department referral rates. In addition, it provided functional improvement and increased satisfaction with patient training.

Assessing the Ambulatory Surgery Center Volume-Outcome Association

Importance

In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US.

Objective

To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity.

Design, Setting, and Participants

This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019.

Main Outcomes and Measures

Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures).

Results

Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity.

Conclusions and Relevance

In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Predictors of Undergoing Revision Within 5 Years of Total Knee Arthroplasty: A Population-Based Study

BACKGROUND

The objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death.

METHODS

We conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA.

RESULTS

There were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision.

CONCLUSIONS

In our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs.

Analysis of gender differences with traditional posterior stabilized versus kinematic designs in total knee arthroplasty

INTRODUCTION

Total knee arthroplasty (TKA) is a good treatment for end-stage knee osteoarthritis (KOA). Approximately 60% of the patients are females, and 40% are males. This study analyzed pre- and postoperative angle differences in the range of motion (ROM), and the occurrence of complications with traditional posterior stabilization versus kinematic TKA in relation to gender.

METHODS

Data from 434 patients with primary cemented total knee arthroplasty from 2018 to 2021 were collected. Alpha and beta angles were determined pre- and postsurgery. The ROM was collected pre- and postoperatively and during follow-up. Additionally, perioperative complications, revision rate, and blood transfusion management were investigated.

RESULTS

The pre- and postoperative alpha-angle between men and women was significantly different, as was the level of alpha-angle correction between men and women (p = 0.001; p = 0.003). Same-gender differences in pre- to postoperative alpha-angles between traditional and kinematic TKA were shown (women (w): p = 0.001; men (m); p = 0.042). High postoperative alpha angles led to less ROM in traditional TKA for women (p = 0.008). No significant gender differences in ROM, perioperative complications, or revision surgery and transfusion rates were found.

CONCLUSION

Despite high gender differences in pre- and postoperative angles, only female patients with traditional arthroplasty and high postoperative alpha angles showed less ROM in the follow-up. This leads to the assumption that gender-related pre- and postoperative angle differences, and the degree of angle correction, do not influence the ROM or perioperative occurrence of complications. Both designs present safe procedures for both genders with a wide spectrum of axis deformities.

Trends and risk factors for readmissions following press-fit total knee arthroplasty for the treatment of end-stage osteoarthritis of the knee: a five-year analysis

INTRODUCTION

The development of new prostheses with improved osseointegration, bone preservation, and reduced cost has renewed interest in uncemented total knee arthroplasty (UCTKA). In the current study, we aimed to: (1) assess demographic data of patients who were and were not readmitted and (2) identify patient-specific risk factors associated with readmission.

METHODS

A retrospective query from the PearlDiver database was performed from January 1, 2015, to October 31, 2020. International Classification of Disease, Ninth Revision (ICD-9), ICD-10, or Current Procedural Terminology (CPT) coding was used to distinguish cohorts of patients who had osteoarthritis of the knee and underwent UCTKA. Patients readmitted within 90 days were classified as the study population, while those who were not readmitted were classified as control. A linear regression model was utilized to analyze readmission risk factors.

RESULTS

The query yielded 14,575 patients, with 986 (6.8%) being readmitted. Patient demographics such as age (P < 0.0001), sex (P < 0.009), and comorbidity (P < 0.0001) were associated with annual 90-day readmission. Patient-specific risk factors associated with 90-day readmission following press-fit total knee arthroplasty were: arrhythmia (OR: 1.29, 95% CI: 1.11-1.49, P < 0.0005), coagulopathy (OR: 1.36, 95% CI: 1.13-1.63, P < 0.0007), fluid and electrolyte abnormalities (OR: 1.59, 95% CI: 1.38-1.84, P < 0.0001), iron deficiency anemia (OR: 1.49, 95% CI: 1.27-1.73, P < 0.0001), and obesity (OR: 1.37, 95% CI: 1.18-1.60, P < 0.0001).

DISCUSSION

This study demonstrates that patients with comorbidities, such as fluid and electrolyte problems, iron deficiency anemia, and obesity, were at an increased risk of readmission after having an uncemented total knee replacement. The risks of readmission following an uncemented total knee arthroplasty can be discussed with patients who have certain comorbidities by arthroplasty surgeons.

Assessing the Mortality Rate After Primary Total Knee Arthroplasty: An Observational Study to Inform Future Economic Analysis

BACKGROUND

Previous research has focused on the perioperative or short-term (<1 year) mortality rate of total knee arthroplasty (TKA), leaving the long-term (>1 year) mortality rate unresolved. In this study, we calculated the mortality rate up to 15 years after primary TKA.

METHODS

Data from the New Zealand Joint Registry from April 1998 to December 2021 were analyzed. Patients aged 45 years or older who underwent TKA for osteoarthritis were included. Mortality data were linked with national records from births, deaths, and marriages. To determine the expected mortality rates in the general population, age-sex-specific life tables from statistics New Zealand were used. Mortality rate was presented as standardized mortality ratios (SMRs) - a comparison of relative mortality rate between the TKA and general populations. In total, 98,156 patients with a median follow-up of 7.25 years (range, 0.00 to 23.74) were included.

RESULTS

Over the entire follow-up period, 22,938 patients (23.4%) had died. The overall SMR for the TKA cohort was 1.08 (95% confidence interval (CI): 1.06 to 1.09), suggesting that TKA patients have an 8% higher mortality rate compared to the general population. However, a reduction in short-term mortality rate was observed for TKA patients up to 5 years post TKA (SMR 5 years post TKA; 0.59 95% CI: 0.57 to 0.60]). On the contrary, a significantly increased long-term mortality rate was observed in TKA patients with greater than 11 years of follow-up, particularly in men over the age of 75 years (SMR 11 to 15 years post TKA for males ≥ 75 years; 3.13 [95% CI: 2.95 to 3.31]).

CONCLUSION

The results suggest a reduction in short-term mortality rate for patients who undergo primary TKA. However, there is an increased long-term mortality rate particularly in men over the age of 75 years. Importantly, the mortality rates observed in this study cannot be causally attributed to TKA alone.

Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement

BACKGROUND

Total knee arthroplasty (TKA) is commonly considered to address symptomatically limiting knee osteoarthritis. With increasing utilization, understanding the variability and related drivers may help the healthcare system optimize delivery to the large numbers of patient to whom it is offered.

METHODS

A total of 1,066,327 TKA patients who underwent primary TKA were isolated from a 2010 to 2021 PearlDiver national dataset. Exclusion criteria included patients less than 18 years old and traumatic, infectious, or oncologic indications. Overall, 90-day reimbursements and variables associated with the patient, surgical procedure, region, and perioperative period were abstracted. Multivariable linear regressions were performed to determine independent drivers of reimbursement.

RESULTS

The 90-day postoperative reimbursements had an average (standard deviation) of $11,212.99 ($15,000.62), a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. Variables independently associated with the greatest increase in overall 90-day reimbursement were related to admission (in-patient index-procedure [+$5,695.26] or hospital readmission [+$18,495.03]). Further drivers were region (Midwest +$8,826.21, West +$4,578.55, South +$3,709.40; relative to Northeast), insurance (commercial +$4,492.34, Medicaid +$1,187.65; relative to Medicare), postoperative emergency department visits (+$3,574.57), postoperative adverse events (+$1,309.35), (P < .0001 for each).

CONCLUSION

The current study assessed over a million TKA patients and found large variations in reimbursement/cost. The largest increases in reimbursement were associated with admission (readmission or index procedure). This was followed by region, insurance, and other postoperative events. These results underscore the necessity to balance performing out-patient surgeries in appropriate patients versus the risk of readmissions and defined other areas for cost containment strategies.

Temporal trends in the rate of complications and prolonged length of stay relative to body mass index in patients undergoing total knee arthroplasty from 2012 to 2020

BACKGROUND

Elevated body mass index (BMI) is a risk factor for complications following total knee arthroplasty (TKA). Thus, we believe it is important to constantly re-evaluate the relationship between BMI and complication risk following TKA.

METHOD

Patients undergoing primary TKA were identified in a national database from 2012-2020. Rates of major complications, minor complications, and length of stay (LOS) greater than 2 days were calculated. The prevalence of postoperative outcomes were calculated per unit of BMI and then multiplied by a factor of 10^{^2} or 10^{^3} in order to create adjusted-BMI (aBMI). To isolate the effect of aBMI on postoperative outcomes, changes over time were analyzed using linear regression analysis controlling for age, sex, American Society of Anesthesiology (ASA) classification and smoking status.

RESULTS

365,333 patients were included. Mean BMI 33 ± 6.8. 10,616 (2.9%) of patients had a major postoperative complication, 9,345 (2.6%) minor complications, 3,277 (0.9%) had a deep or superficial surgical site infection (SSI). 133,563 (37%) of patients had LOS > 2 days. From 2012-2020, the ratio of major complications to aBMI decreased significantly by an average of -2.7% per year. The ratio of patients with LOS > 2 days to aBMI decreased significantly by -27% per year. The ratio of SSI to aBMI increased significantly by 10.8% per year.

CONCLUSIONS

From 2012 to 2020, the ratio of major complications and extended LOS following TKA as a function of BMI has decreased significantly, while the ratio of SSI as a function of BMI has doubled.

Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

BACKGROUND

To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity.

QUESTIONS/PURPOSES

We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?

METHODS

A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively.

RESULTS

Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles.

CONCLUSION

These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

"I Had Bills to Pay": a Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System

BACKGROUND

Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited.

OBJECTIVE

To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities.

DESIGN

Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial.

PARTICIPANTS

Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals.

MAIN MEASURES

The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted.

KEY RESULTS

Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0-3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health.

CONCLUSIONS

There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Incidence, patterns and risk factors for readmission following knee arthroplasty in China: A national retrospective cohort study

BACKGROUND

Limited data exist on readmission following knee arthroplasty (KA) in countries without well-established referral or extended care systems. This study aimed to investigate the incidence, patterns and risk factors for readmission following KA in China.

MATERIAL AND METHODS

In this national retrospective cohort study, we reviewed 167,265 primary KAs registered in the Hospital Quality Monitoring System in China between 2013 and 2018. Readmissions after KA within 30 and 90 days were evaluated. The causes for readmission were identified and classified as surgical or medical. The potential risk factors of readmission were assessed using multivariable logistic regression.

RESULTS

4017 (2.4%) patients readmitted within 30 days, and 7258 (4.3%) patients readmitted within 90 days. The readmission rate exhibited a downward trend during the period from 2013 to 2018 (2.7%-2.3% for 30-day readmission; 4.5%-4.2% for 90-day readmission). Surgical causes contributed to 54.3% readmissions within 30 days and 47.3% readmissions within 90 days. Wound infection/complication, joint pain, and thromboembolism were the most frequently reported reasons for surgical readmission. Older age, male sex, single marital status, non-osteoarthritis indication, a high comorbidity index, non-provincial hospitals, low hospital volume, and longer length of stay were associated with an increased risk of readmission. The geographic regions of hospitals contributed greatly to the variety of readmissions.

CONCLUSION

The readmission rate following KA decreased from 2013 to 2018. Surgery-related causes, especially wound infection/complication and pain, accounted for a large proportion. Both patient and hospital factors were associated with readmissions. Improved primary care and targeted measures are needed to help further prevent readmissions and optimize resource utilization.

Emergency department visits following total joint arthroplasty: do revisions present a higher burden?

Aims

Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits.

Methods

We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables.

Results

Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001).

Conclusion

ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA.

Cite this article: Bone Jt Open 2022;3(7):543–548.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge

BACKGROUND

Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations.

METHODS

We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables.

RESULTS

Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131).

CONCLUSION

Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Feasibility of a Complex Optimized Process for the Treatment of Patients Receiving Hip and Knee Endoprostheses in Most Different Settings in Germany—Results from the PROMISE Trial

Background: While there is evidence on the effectiveness of optimized treatment processes for patients receiving hip and knee endoprostheses, feasibility in various settings has not been adequately investigated. The multicenter PROMISE Trial (Process optimization by interdisciplinary and cross-sectoral care using the example of patients with hip and knee prostheses) was set up to fill this gap. Methods: A complex optimized process was implemented in three German hospitals offering different levels of care and five cooperating rehabilitation centers. For the feasibility question, data on 19 parameters characterizing the defined process were collected. The extent of cross-sectoral collaboration was a special focus. Results: The data show, for almost all parameters in all facilities, an implementation rate of more than 80% with missing data below 5%, n = 1887 study participants. A total of 96.8% attended a rehabilitation program, and for 29.2% rehabilitation took place in a PROMISE-collaborating facility. Conclusions: Adherence to the defined and well-documented process was very high in all three organizationally very different hospitals, so that feasibility is given and transferability of the concept can be assumed. An exception was the targeted integration of rehabilitation into the treatment process. The goal of cross-sectoral networking could only be partially achieved.

Investigating readmission rates for patients undergoing oncologic resection and endoprosthetic reconstruction for primary sarcomas and tumors involving bone

BACKGROUND

Little is known about the drivers of readmission in patients undergoing Orthopaedic oncologic resection. The goal of this study was to identify factors independently associated with 90-day readmission for patients undergoing oncologic resection and subsequent prosthetic reconstruction for primary tumors involving bone.

METHODS

This was a retrospective comparative cohort study of patients treated from 2008 to 2019 who underwent endoprosthetic reconstruction for a primary bone tumor or soft tissue tumor involving bone, as well as those who underwent a revision endoprosthetic reconstruction if the primary endoprosthetic reconstruction was performed for an oncologic resection. The primary outcome measure was unplanned 90-day readmission.

RESULTS

A total of 149 patients were identified who underwent 191 surgeries were for a primary bone or soft tissue tumor. The 90-day readmission rate was 28.3%. Female gender, depression, higher tumor grade, vascular reconstruction, longer procedure duration, longer length of stay (LOS), multiple surgeries during an admission and disposition to a Skilled Nursing Facility were associated with readmission (p < 0.05). In a multivariate analysis, female sex, higher tumor grade and longer procedure duration were independently associated with risk of readmission (p < 0.05).

CONCLUSIONS

Readmission rates are high following endoprosthetic reconstruction for Orthopaedic oncologic resections. Further work is necessary to help minimize unplanned readmissions.

Characterizing 30-d Postoperative Acute Care Visits: A National Surgical Quality Improvement Program Collaborative Analysis

INTRODUCTION

Many postoperative acute care visits (PACVs) are likely more appropriately addressed in lower acuity settings; however, the frequency and nature of PACVs are not currently tracked by the National Surgical Quality Improvement Program (NSQIP), and the overall burden to emergency departments and urgent care centers is unknown.

METHODS

NSQIP collaborative data were augmented to prospectively capture 30-d PACVs for 1 y starting October 2018 across all NSQIP specialties, including visit reason and disposition. Data were analyzed using binomial logistic regression.

RESULTS

A total of 9933 patients were identified; 12.0% (n = 1193) presented to an acute care setting over 1413 visits, most commonly for surgical pain (15.4%) in the absence of an identified complication. Visits most commonly resulted in discharge (n = 817, 68.5%) or admission (n = 343, 24.3%). Variables independently associated with visits resulting in discharge included age (odds ratio [OR] 0.99 per year, P < 0.001), increasing comorbidities (1-2 [OR 1.55, P < 0.001]; 3-4 [OR 2.51, P < 0.001]; 5+ [OR 2.79 P < 0.001]), operative duration (OR 1.08 per hour, P = 0.001), and nonelective (OR 1.20, P = 0.01) or urologic (OR 1.46, P = 0.01) procedures.

CONCLUSIONS

PACVs are an overlooked burden on emergency medicine providers and healthcare systems; most do not require admission and could be potentially triaged outside of the acute care setting with improved perioperative care infrastructure. Younger patients, those with multiple comorbidities, and those undergoing nonelective procedures deserve special attention when designing initiatives to address postoperative acute care utilization. Data regarding PACVs can be routinely collected with minor modifications to current NSQIP workflows.

The Impact of Pre-Operative Healthcare Utilization on Complications, Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty

BACKGROUND

Identifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized.

METHODS

This is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU.

RESULTS

The 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events.

CONCLUSION

Patients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU.

LEVEL OF EVIDENCE

Level III.

Why Do Patients Undergoing Extremity Prosthetic Reconstruction for Metastatic Disease Get Readmitted?

BACKGROUND

Orthopedic oncology patients are particularly susceptible to increased readmission rates and poor surgical outcomes, yet little is known about readmission rates. The goal of this study is to identify factors independently associated with 90-day readmission for patients undergoing oncologic resection and subsequent prosthetic reconstruction for metastatic disease of the hip and knee.

METHODS

This is a retrospective comparative cohort study of all patients treated from 2013 to 2019 at a single tertiary care referral institution who underwent endoprosthetic reconstruction by an orthopedic oncologist for metastatic disease of the extremities. The primary outcome measure was unplanned 90-day readmission.

RESULTS

We identified 112 patients undergoing 127 endoprosthetic reconstruction surgeries. Metastatic disease was most commonly from renal (26.8%), lung (23.6%), and breast (13.4%) cancer. The most common type of skeletal reconstruction performed was simple arthroplasty (54%). There were 43 readmissions overall (33.9%). When controlling for confounding factors, body mass index >40, insurance status, peripheral vascular disease, and longer hospital length of stay were independently associated with risk of readmission (P ≤ .05).

CONCLUSION

Readmission rates for endoprosthetic reconstructions for metastatic disease are high. Although predicting readmission remains challenging, risk stratification presents a viable option for helping minimize unplanned readmissions.

LEVEL OF EVIDENCE

III.

Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study

Background

With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies.

Methods

This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA.

Results

TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%).

Conclusions

Screening and RM can reduce 90-day complications in patients undergoing TKA.

Comparison of Area Deprivation Index, Socioeconomic Parameters, and Preoperative Demographics With Postoperative Emergency Department Visits After Total Knee Arthroplasty

BACKGROUND

This study aims to determine if socioeconomic (SE) parameters, primarily area deprivation index (ADI), relate to postoperative emergency department (ED) visits after total knee arthroplasty (TKA).

METHODS

We retrospectively reviewed 2655 patients who underwent TKA in a health system of 4 hospitals. The primary outcome was an ED visit within 90 days, which was divided into those with and without readmission. SE parameters including ADI as well as preoperative demographics were analyzed. Univariable and multiple logistic regressions were performed determining risk of 90-day postoperative ED visits, as well as once in the ED, risks for readmission.

RESULTS

436 patients (16.4%) presented to the ED within 90 days. ADI was not a risk factor. The multiple logistic regression demonstrated men, Medicare or Medicaid, and preoperative ED visits were consistently risk factors for a postoperative ED visit with and without readmission. Preoperative anticoagulation was only a risk factor for ED visits with readmission. Among patients who visited the ED, if the patient was Caucasian, a lower BMI, or higher American Society of Anesthesiologists score, they were likely to be readmitted.

CONCLUSION

The study demonstrated that the percentage of early ED returns after TKA was high and that ADI was not a predictor for 90-day postoperative ED visit. The only SE factor that may contribute to this phenomenon was insurance type. Once in the ED, race, preoperative ED visits, preoperative anticoagulation, BMI, gender, and preoperative American Society of Anesthesiologists score contributed to a risk of readmission. The study supports hospitals' mission to provide equal access health care.

Implementation of the Management of Anticoagulation in the Periprocedural Period App Into an Electronic Health Record: A Prospective Cohort Study

Appropriate perioperative management of patients on chronic oral anticoagulation (OAC)—including warfarin and the direct oral anticoagulants—is a poorly defined yet important clinical issue with potentially severe consequences in the postoperative period. We sought to prospectively evaluate the effect of the Management of Anticoagulation in the Periprocedural Period (MAPPP) mobile app as a clinical decision tool in the management of patients on chronic OAC undergoing elective procedures or surgeries. Between January 1, 2018, and January 31, 2019, 642 patients treated in our health system were included. Eligible patients met the following criteria: age >18 years old, creatinine clearance ≥15 mL/min, and on chronic OAC with adequate information regarding baseline characteristics. Our study outcome was patient’s emergency department (ED) visits within 30 days postprocedure. The MAPPP app was integrated into the electronic health record (EHR), and the end user was free to accept or decline recommended evidence-based perioperative anticoagulation management guidance. Analysis revealed that acceptance was more common in younger patients (P = .0137), patients on oral anticoagulants other than warfarin (P < .0001), and patients undergoing increased bleeding risk procedures (P = .0068). Acceptance of the MAPPP app recommendation was significantly associated with fewer ED visits (acceptance group: 4.0% vs rejection group: 8.3%, P = .0205). Logistic regression showed that intervention acceptance and female gender were significantly associated with fewer—while age ≥80 with more—30-day ED visits. Our findings indicate that newer technologies, such as the MAPPP app, integrated into clinical EHR workflow, can significantly augment evidence-based perioperative anticoagulation management and potentially result in a reduction of adverse outcomes.

Influence of day of surgery and prediction of LOS > 2 days after fast-track hip and knee replacement

Background and purpose - Enhanced recovery programs have reduced length of stay (LOS) after hip and knee arthroplasty (THA/TKA). Although risk factors disposing to prolonged LOS are well documented, there is limited information on the role of weekday of surgery. This study analyzed the role of weekday of surgery and other potential risk factors for LOS > 2 days.Patients and methods - We included 10,576 unselected consecutive procedures between January 2016 and August 2017 within a multicenter fast-track THA/TKA collaboration with prospective collection of preoperative characteristics. We used multiple regression analysis of potential risk factors for LOS > 2 days followed by construction of a simple risk score from 0 to 15 points based on the calculated odds ratios.Results - Mean LOS was 1.9 (SD 1.8) days, with 80% of patients having surgery from Monday to Wednesday. Of these, 17% (95% CI 16-18) had a LOS > 2 days vs. 19% (CI 17-21) in those operated on Thursday and Friday. Patients were scheduled evenly throughout the week regardless of risk of LOS > 2 days and despite the fact that 38% (CI 35-40) of patients with ≥ 6 points (16% of the total population) had a LOS > 2 days compared with 14% (CI 13-14) in those with < 6 points. In these "high-risk" patients, the fraction with LOS > 2 days increased when having surgery on Thursdays or Fridays (43% CI 38-49) compared with Monday to Wednesday (37% CI 34-39).Interpretation - A detailed preoperative risk assessment may be helpful to plan the weekday of surgery in order to decrease LOS and weekend hospitalization.

Serious adverse events and 30-day hospital readmission rate following elective total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Elective total knee arthroplasty (TKA) is a common surgery which has evolved rapidly. However, there are no recent large systematic reviews of serious adverse event (SAE) rate and 30-day readmission rate (30-dRR) or an indication of whether surgical methods have improved.

METHODS

To obtain a pooled estimate of SAE rate and 30-dRR following TKA, we searched Medline, Web of Science, Cochrane Library, and Google Scholar databases. Data were extracted by two authors following PRISMA guidelines. Eligibility criteria were defined prior to a comprehensive search. Studies were eligible if they were published in 2007 or later, described sequelae of TKA with patient N > 1000, and the SAE or 30-dRR rate could be calculated. SAEs included return to operating room, death or coma, venous thromboembolism (VTE), deep infection or sepsis, myocardial infarction, heart failure or cardiac arrest, stroke or cerebrovascular accident, or pneumonia.

RESULTS

Of 248 references reviewed, 28 are included, involving 10,153,503 patients; this includes 9,483,387 patients with primary TKA (pTKA), and 670,116 patients with revision TKA (rTKA). For pTKA, the SAE rate was 5.7% (95% CI 4.4-7.2%, I2 = 100%), and the 30-dRR was 4.8% (95% CI 4.3-5.4%, I2 = 100%). For rTKA, the SAE rate was 8.5% (95% CI 8.3-8.7%, I2 = 77%), while the 30-dRR was 7.2% (95% CI 6.4-8.0%, I2 = 81%). Odds of 30-dRR following pTKA were about half that of rTKA (OR 0.57, 95% CI 0.53-0.62%, p < 0.001, I2 = 45%). Of patients who received pTKA, the commonest SAEs were VTE (1.22%; 95% CI 0.83-1.70%) and genitourinary complications including renal insufficiency or renal failure (1.22%; 95% CI 0.83-1.67%). There has been significant improvement in SAE rate and 30-dRR since 2010 (χ2 test < 0.001).

CONCLUSIONS

TKA procedures have a relatively low complication rate, and there has been a significant improvement in SAE rate and 30-dRR over the past decade.

Same-Day vs One-Day Discharge: Rates and Reasons for Emergency Department Return After Hospital-Based Total Joint Arthroplasty

BACKGROUND

As short stay and outpatient total joint arthroplasties (TJAs) are more widely adopted, it is important to assess whether reducing length of stay leads to increased emergency department (ED) visits or readmissions.

METHODS

This is a retrospective review of 1743 primary TJA patients with same-day discharge (SDD) or 1-day length of stay between January and December 2019. Patients who returned to the ED or were readmitted within 30 days of TJA were identified, and chart review was performed to identify their primary reason for revisit.

RESULTS

Patients discharged on the day of surgery (n = 203, 11.6%) were more likely to be younger (P < .001) and have a lower body mass index (total hip arthroplasty, P = .018; total knee arthroplasty, P < .001) and American Society of Anesthesiologists score (P < .001). The overall rate of return was 6.3%, and 1.3% of patients were readmitted. Controlling for age, gender, body mass index, surgery type, and American Society of Anesthesiologists, patients selected for SDD were not found to be at higher risk of return to the ED compared to 1-day length of stay patients (4.9% vs 6.4%, odds ratio 0.980, 95% confidence interval 0.484-1.984, P = .956).

CONCLUSION

SDD of eligible patients does not increase the risk of 30-day return to the ED. Continued analysis of risk factors for return and readmission will improve prospective identification of patients who can safely be discharged on the day of surgery, and future quality improvement initiatives should target the most common reasons for ED return.

Patient-Related Risk Factors for Unplanned 30-Day Hospital Readmission Following Primary and Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Total knee arthroplasty (TKA) is a highly effective procedure for advanced osteoarthritis of the knee. Thirty-day hospital readmission is an adverse outcome related to complications, which can be mitigated by identifying associated risk factors. We aimed to identify patient-related characteristics associated with unplanned 30-day readmission following TKA, and to determine the effect size of the association between these risk factors and unplanned 30-day readmission. We searched MEDLINE and EMBASE from inception to 8 September 2020 for English language articles. Reference lists of included articles were searched for additional literature. Patients of interest were TKA recipients (primary and revision) compared for 30-day readmission to any institution, due to any cause, based on patient risk factors; case series were excluded. Two reviewers independently extracted data and carried out critical appraisal. In-hospital complications during the index admission were the strongest risk factors for 30-day readmission in both primary and revision TKA patients, suggesting discharge planning to include closer post-discharge monitoring to prevent avoidable readmission may be warranted. Further research could determine whether closer monitoring post-discharge would prevent unplanned but avoidable readmissions. Increased comorbidity burden correlated with increased risk, as did specific comorbidities. Body mass index was not strongly correlated with readmission risk. Demographic risk factors included low socioeconomic status, but the impact of age on readmission risk was less clear. These risk factors can also be included in predictive models for 30-day readmission in TKA patients to identify high-risk patients as part of risk reduction programs.

Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017

“Fast-track” protocols has improved surgical care with a reduction in length of hospital stay (LOS) in total hip (THA) and knee arthroplasty (TKA). However, the effects of continuous refinement of perioperative care lack detailed assessment. We studied time-related changes in LOS and morbidity after THA and TKA within a collaboration with continuous scientific refinement of perioperative care. Prospective multicentre consecutive cohort study between 2010 and 2017 from nine high-volume orthopaedic centres with established fast-track THA and TKA protocols. Prospective collection of comorbidities and complete 90-day follow-up from the Danish National Patient Registry and medical records. Of 36,935 procedures median age was 69 [62 to 75] years and 58% women. LOS declined from three [two to three] days in 2010 to one [one to two] day in 2017. LOS > 4 days due to “medical” or “surgical” complications, and “with no recorded morbidity” declined from 4.4 to 2.7%, 1.5 to 0.6%, and 3.8 to 1.3%, respectively. 90-days readmission rate declined from 8.6 to 7.7%. Our multicentre study in a socialized healthcare setting was associated with a continuous reduction in LOS and morbidity after THA and TKA.

Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty

BACKGROUND

The Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature.

METHODS

We prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff.

RESULTS

Although the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes.

CONCLUSION

Surgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.