Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Knee Arthroplasty

BACKGROUND

Frailty can predict adverse outcomes after various orthopaedic procedures, but is not well-studied in revision total knee arthroplasty (rTKA). We investigated the correlation between the Hospital Frailty Risk Score (HFRS) and post-rTKA outcomes.

METHODS

Using the Nationwide Readmissions Database, we identified rTKA patients discharged from January 2017 to November 2019 for the most common diagnoses (mechanical loosening, infection, and instability). Using HFRS, we compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients with multivariate and binomial regressions. The 30-day complication and reoperation rates were compared using univariate analyses. We identified 25,177 mechanical loosening patients, 12,712 infection patients, and 9,458 instability patients.

RESULTS

Frail patients had higher rates of 30-day readmission (7.8 versus 3.7% for loosening, 13.5 versus 8.1% for infection, 8.7 versus 3.9% for instability; P < .01), longer length of stay (4.1 versus 2.4 days for loosening, 8.1 versus 4.4 days for infection, 4.9 versus 2.4 days for instability; P < .01), and greater cost ($32,082 versus $27,582 for loosening, $32,898 versus $28,115 for infection, $29,790 versus $24,164 for instability; P < .01). Frail loosening patients had higher 30-day complication (6.8 versus 2.9%, P < .01) and reoperation rates (1.8 versus 1.2%, P = .01). Frail infection patients had higher 30-day complication rates (14.0 versus 8.3%, P < .01). Frail instability patients had higher 30-day complication (8.0 versus 3.5%, P < .01) and reoperation rates (3.2 versus 1.6%, P < .01).

CONCLUSIONS

The HFRS may identify patients at risk for adverse events and increased costs after rTKA. Further research is needed to determine causation and mitigate complications and costs.

Initiation of a Comprehensive Early Discharge Program at a Veterans Affairs Hospital

INTRODUCTION

Early discharge protocols have become a major surgical paradigm, but this protocol is not routinely used in the Veteran Affairs (VA) system. The primary objective was to demonstrate the feasibility of a comprehensive joint program (CJP) protocol, including same-day discharge, at a VA hospital. Secondary objectives are to determine whether an increase in postoperative complications, increased readmissions, and increased ER visits compared with previous management protocols occur.

METHODS

A retrospective review of patients undergoing primary total joint arthroplasty conducted before the initiation of CJP was compared with patients undergoing primary total joint arthroplasty conducted after the initiation of CJP. The two cohorts were subdivided further into total knee arthroplasty (TKA) and total hip arthroplasty (THA). Patients' demographics, medical comorbidities, discharge disposition, length of stay (LOS), surgery information, 30-day and 90-day postoperative complications, surgical site infections, and emergency room visits were collected and assessed with paired t -tests.

RESULTS

A total of 200 control cases (101 TKA, 99 THA) were compared with 260 cases (165 TKA, 95 THA) in the CJP group. The mean LOS reduced from 4.38 days in the control group to 0.75 days in the CJP group ( P < 0.001), with 890 total inpatient days in the control group compared with just 200 total inpatient days with the CJP group. A total of 92 patients (34.5%) in the CJP group were discharged the same day compared with 0 in the control group ( P < 0.001). In the control group, 47.8% were discharged to rehabilitation centers compared with only 4.5% in the CJP group ( P < 0.001). The 30-day complication rate was reduced with CJP (5.6% vs. 10.3% control) ( P = 0.028). ER visits did not significantly change (8.9% control vs. 9.3% CJP; P = 0.77).

CONCLUSION

Overall LOS and complication rates were reduced with the CJP, exemplifying the viability of such a protocol in the VA system. In addition, we demonstrated no increased risks accompanied with early discharge to home. This initiative can be used to reduce healthcare dollars in VA healthcare system nationally.

Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA.

METHODS

Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests.

RESULTS

Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01).

CONCLUSIONS

Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA.

TYPE OF STUDY

Level III retrospective cohort study.