Allergies, Preoperative Narcotic Use, and Increased Age Predict Failed Same-Day Discharge After Joint Replacement

Causes and risk factors for same-day discharge failure after total hip and knee arthroplasty: a meta-analysis

In recent decades, the trend toward early same-day discharge (SDD) after surgery has dramatically increased. Efforts to develop adequate risk stratification tools to guide decision-making regarding SDD versus prolonged hospitalization after total hip arthroplasty (THA) remain largely incomplete. The purpose of this report is to identify the most frequent causes and risk factors associated with SDD failure in patients undergoing THA and total knee arthroplasty (TKA). A systematic search following PRISMA guidelines of four bibliographic databases was conducted for comparative studies between patients who were successfully discharged on the same day and those who failed. Outcomes of interests were causes and risk factors associated with same-day discharge failure. Odds ratios (OR) were calculated for dichotomous variables, whereas mean differences (MD) were calculated for continuous variables. Meta-analysis was performed using RevMan software. Random effects were used if there was evidence of heterogeneity. Eight studies with 3492 patients were included. The most common cause of SDD failure was orthostatic hypotension, followed by inadequate physical condition, nausea/vomiting, pain, and urinary retention. Female sex was a risk factor for failure (OR 0.77, 95% CI 0.63-0.93), especially in the THA subgroup. ASA score IV (OR 0.33, 95% CI 0.14-0.76) and III (OR 0.72, 95% CI 0.52-0.99) were risk factors, as were having > 2 allergies and smoking patients. General anesthesia increased failure risk (OR 0.58, 95% CI 0.42-0.80), while spinal anesthesia was protective (OR 1.62, 95% CI 1.17-2.24). The direct anterior and posterior approaches showed no significant differences. In conclusion, orthostatic hypotension was the primary cause of SDD failure. Risk factors identified for SDD failure in orthopedic surgery include female sex, ASA III and IV classifications, a higher number of allergies, smoking patients and the use of general anesthesia. These factors can be addressed to enhance SDD outcomes.

Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty

BACKGROUND

A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD.

METHODS

A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression.

RESULTS

Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older.

CONCLUSIONS

The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates.

LEVEL OF EVIDENCE

III.

Predictors of Failure to Achieve Planned Same-Day Discharge after Primary Total Joint Arthroplasty: a Multivariable Analysis of Perioperative Risk Factors

INTRODUCTION

Failure to achieve planned same-day discharge (SDD) primary total joint arthroplasty (TJA) occurs in as many as 7% to 49% of patients in the United States. This study evaluated the association between 43 perioperative risk factors and SDD failure rates.

METHODS

A retrospective analysis of prospectively collected data from 466 primary TJAs with planned SDD to home was performed. Surgeries were performed at an academic tertiary care center comprising a hospital facility and a stand-alone ambulatory surgery center (ASC) on the same campus. Factors associated with failed SDD were identified using a multivariable analysis.

RESULTS

Only one of 316 (0.3%) patients who underwent surgery in the ASC failed planned SDD ( P < 0.001) compared with 33.3% of 150 patients who underwent surgery in the hospital. The ASC failure was because of pain that interfered with physical therapy. Sixty-two percent (n = 31) of hospital failures were attributed to medical complications, 24% (n = 12) to physical therapy clearance, 8% (n = 4) to not being seen by internal medicine or therapy on the day of surgery, and 6% (n = 3) to unknown causes. Failure was increased in patients with preoperative anemia ( P = 0.003), nonwhite patients ( P = 0.002), patients taking depression/anxiety medication ( P = 0.015), and for every 10-morphine milligram equivalent increase in opioids consumed per hour in the postacute care unit ( P = 0.030).

DISCUSSION

Risk stratification methods used to allocate patients to ASC versus hospital outpatient TJA surgery predicted SDD success. Most failures were secondary to medical causes. The findings of this study may be used to improve perioperative protocols enabling the safe planning and selection of patients for SDD pathways.

Establishing the Minimally Important Difference for the KOOS-Joint Replacement and PROMIS Global-10 in Patients After Total Knee Arthroplasty

Background

Despite the overall prevalence and success of total knee arthroplasty (TKA), a significant portion of patients are dissatisfied with their outcomes.

Purpose

To assess the responsiveness and determine the minimally important difference (MID) of 2 patient-reported outcome measures (PROMs)-the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) and the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS 10)-in patients after TKA.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Included were patients who underwent TKA from August 2015 through August 2019 and completed baseline and postoperative KOOS-JR and PROMIS 10 surveys. The PROMIS 10 consists of 2 domains: physical health and mental health. Estimates for the reliable change index (RCI) and MID, using anchor-based and distribution-based methods, were calculated for each PROM. Regression modeling was used to determine whether patient and clinical factors predicted MID thresholds or MID achievement.

Results

A total of 1315 patients were included. Distribution-based MIDs, calculated using various methods from baseline scores, ranged from 19.3 to 31 for the KOOS-JR, and the RCI was 4.38. Of these patients, 293 (22.3%) demonstrated small or moderate improvement, and this cohort was included in the calculation of anchor-based MIDs. The anchor-based MIDs were 16.9 and 24.3 at 3-month and 1-year follow-up, respectively, and 66% of patients achieved the MID at 12 months. Higher preoperative PROM score, male sex, non-White race, and current smoker status were predictive of failing to achieve the anchor-based MID for KOOS-JR at 1 year postoperatively (P < .05). Higher preoperative PROM score and any 90-day adverse event predicted lower thresholds of important change in anchor-based MIDs. Higher baseline PROM scores, younger age, male sex, non-White ethnicity, higher American Society of Anesthesiologists classification, preoperative narcotics use, not smoking, and longer hospital stay were all associated with lower odds of achieving the MID on the KOOS-JR or either of the PROMIS 10 subscales.

Conclusion

The study results demonstrated relevant values for interpretation of the KOOS-JR and PROMIS 10. While patient demographics did not accurately predict which patients would achieve the MID, some potential factors predicting successful patient-reported outcomes after TKA were identified.

Does Surgical Approach to the Hip Play a Role in Same-Day Discharge Outcomes?

BACKGROUND

Different approaches for total hip arthroplasty (THA) may offer advantages in regard to achieving same-day-discharge (SDD) success.

METHODS

We retrospectively identified patients aged ≥ 18 years who underwent elective primary THA from 2015 to 2020 who were formally enrolled in a single institution's SDD program. A total of 1,127 and 207 patients underwent THA via direct anterior approach and posterior approach, respectively, were included. Cohorts were assigned based on approach. The primary outcome was failure-to-launch, defined as hospital stay extending past 1 midnight. Secondary outcomes included Forgotten Joint Score-12, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, 90-day readmission and revision rate, and surgical time. Patient-reported outcomes were collected at 3 and 12 months.

RESULTS

After controlling for demographic differences, posterior approach patients had higher rates of failure-to-launch (12.1% versus 5.9%, P = .002) and longer surgical times (99 versus 80 minutes; P < .001) compared to direct anterior approach patients. The cohorts had similar readmission (1.7% versus 1.4%; P = .64) and revision rates (1% versus 1%; P = .88). The magnitude of improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores from preoperative to 12 months was similar between cohorts (35.3 versus 34.5; P = .42). The differences in outcome scores between cohorts at each time point were not considered clinically significant.

CONCLUSION

Our analysis suggests that patient selection and surgical approach may be important for achieving SDD. Surgical approach did not significantly impact readmission or revision rates nor did it have a meaningful impact on patient-reported outcomes in the first year after surgery.

A Formal Same-Day Discharge Total Joint Arthroplasty Program May Not Be Necessary: A Propensity-Matched Cohort Study

BACKGROUND

Same-day discharge (SDD) total joint arthroplasty (TJA) programs often have stringent selection criteria. Some patients deemed ineligible may nonetheless be discharged on the day of surgery. This study compares the outcomes between patients enrolled in our SDD TJA program who were SDD to those who did not participate in the program but were also SDD.

METHODS

We retrospectively reviewed all patients who were SDD following TJA from 2015 to 2020. Patients were stratified into two cohorts based on whether they were formally enrolled in our institution's SDD TJA program. Propensity-score matching was performed to limit confounding and independent sample t-tests or Pearson's chi-squared tests were used to compare outcomes of interest between the matched groups.

RESULTS

Of the 1778 patients included, 1384 (78%) completed the SDD TJA program and 394 (22%) were SDD but did not participate in the SDD TJA program. Upon 1:1 propensity-score matching, a total of 550 patients were matched for comparison. The surgical time was significantly longer for patients who did not participate in the SDD TJA program compared to those who participated in the program (109.39 vs 87.29 minutes; P < .001). Discharge disposition (P = .999), 90-day emergency department visits (P = .476), 90-day all-cause readmissions (P = .999), 90-day all-cause revisions (P = .563), and Hip disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) and Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement at all time points did not significantly differ.

CONCLUSION

Enrollment in a formal SDD TJA program may not be a necessary precursor to achieving similar outcomes following TJA for patients who are SDD without formally enrolling. Therefore, a formal program may no longer be needed at an institution with well-established evidence-based protocols with strong success and an experience with value-based care.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Causes and predictors of failed same-day home discharge following primary hip and knee total joint arthroplasty: a Canadian perspective

PURPOSE

Same-day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients.

METHODS

A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between 01 April 2019 and 31 March 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge.

RESULTS

The cohort consisted of 527 consecutive patients. 101 (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). 2 individual surgeons, later operative start time (OR 1.3; 95% CI, 1.15-1.55; p = 0.001), ASA class IV (OR 3.4; 95% CI, 1.4-8.2; p = 0.006) and undergoing a THA (OR 2.0; 95% CI, 1.2-3.1, p = 0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anaesthetic were found (p > 0.05). The 30-day readmission or 6-month reoperation were similar between groups (p > 0.05).

CONCLUSIONS

Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes

INTRODUCTION

As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay.

MATERIALS AND METHODS

We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences.

RESULTS

A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts.

CONCLUSION

Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery.

LEVEL III EVIDENCE

Retrospective Cohort Study.