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Delfosse G, Mesnard G, Ecki M, Batailler C, Servien E, Lustig S. Is outpatient joint arthroplasty safe in a high volume academic centre? A retrospective monocentric study using an institutional pathway. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06333-y. [PMID: 39325179 DOI: 10.1007/s00264-024-06333-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 09/17/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice. METHODS We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied. RESULTS 498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59 years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters. CONCLUSION Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.
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Affiliation(s)
- Gérald Delfosse
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.
| | - Guillaume Mesnard
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Martin Ecki
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- IFSTTAR, Univ Lyon, Claude Bernard Lyon 1 University, LBMC UMR-T9406, 69622, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- Interuniversity Laboratory of Biology of Mobility, LIBM-EA 7424, Claude Bernard Lyon 1 University, Lyon, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
- IFSTTAR, Univ Lyon, Claude Bernard Lyon 1 University, LBMC UMR-T9406, 69622, Lyon, France
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Lee GC, Illescas A, Fowler M, Poeran J, Memtsoudis S, Liu J. Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty? J Arthroplasty 2024; 39:S179-S184. [PMID: 38640964 DOI: 10.1016/j.arth.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. METHODS Using an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. RESULTS The risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B]. CONCLUSIONS Chronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.
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Affiliation(s)
- Gwo-Chin Lee
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Alex Illescas
- Department of Anesthesiology and Critical Care, Hospital for Special Surgery, New York, New York
| | - Mia Fowler
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stavros Memtsoudis
- Department of Anesthesiology and Critical Care, Hospital for Special Surgery, New York, New York
| | - Jiabin Liu
- Department of Anesthesiology and Critical Care, Hospital for Special Surgery, New York, New York
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Lum ZC. The Impact of Bundled Payment Initiatives in Orthopedic Surgery Access to Care: Cherry Picking and Lemon Dropping. Cureus 2024; 16:e57205. [PMID: 38681265 PMCID: PMC11056226 DOI: 10.7759/cureus.57205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
This editorial explores the impact of bundled payment initiatives, specifically in the context of orthopedic surgery, on access to care. We examine the phenomenon of "cherry picking" healthier patients and "lemon dropping" higher-risk patients, potentially leading to disparities in access and healthcare outcomes. We discuss recent studies investigating these concerns and highlight the need for more in-depth research to better understand the groups these policies may marginalize. Policymakers are urged to consider measures to protect disadvantaged patients and ensure equitable access to care, aligning with the principles of equality and diversity in healthcare.
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Affiliation(s)
- Zachary C Lum
- Orthopedic Surgery, Nova Southeastern University, Fort Lauderdale, USA
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Harper KD, Sullivan TC, Wininger A, Incavo SJ, Lambert BS. Health Status of Total Hip Versus Total Knee Arthroplasty Patients and Possible Effects on Decisions Regarding Surgical Location, Cost, and Access to Care. HSS J 2024; 20:57-62. [PMID: 38356748 PMCID: PMC10863601 DOI: 10.1177/15563316231209308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 02/16/2024]
Abstract
Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are no longer considered inpatient-only procedures. Qualifying for inpatient status reimbursement requires additional, unreimbursed administrative effort, and may limit care to these patients. Purpose: We sought to evaluate and compare the overall health status of patients receiving THA and TKA. Methods: We conducted a retrospective review evaluating 2207 patients undergoing primary THA and TKA from 2015 to 2018 at a single institution. Clinical parameters, surgical procedure, medical history, laboratory values, length of stay (LOS), and discharge location were recorded and compared between the 2 groups. Results: In 2202 patients, we observed differences for body mass index (THA = 29.4 ± 0.4, TKA = 32.1 ± 0.3), low-density lipoprotein cholesterol levels (THA = 105.8 ± 13.5 mg/dL; TKA = 128.6 ± 13.7 mg/dL), and blood glucose levels (THA = 98.2 ± 1.7 mg/dL; TKA = 101.4 ± 1.3 mg/dL), indicating that TKA patients were more likely than THA patients to be classified as obese, hypercholesterolemic, and hyperglycemic. We observed longer LOS in THA patients (51.25 hours, 95% CI ± 3.87 hours) than in TKA patients (36.93 hours, 95% CI ± 1.17 hours). A greater proportion of TKA patients were discharged home (81.97%, N = 1155) rather than to additional care facilities compared with THA patients (71.84%, N = 539). Conclusion: In this retrospective study, we observed that TKA patients had higher rates of comorbidities than did THA patients, but TKA patients spent less time in the hospital and were more likely to be discharged home. Future studies should evaluate reasons for poor clinical outcomes for patients undergoing total joint arthroplasty with an outpatient designation.
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Affiliation(s)
- Katharine D Harper
- Department of Orthopedic Surgery, Washington DC VA Medical Center, Washington, DC, USA
| | - Thomas C Sullivan
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Austin Wininger
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Stephen J Incavo
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Bradley S Lambert
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
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Habbous S, Waddell J, Hellsten E. The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic. PLoS One 2023; 18:e0290135. [PMID: 38011077 PMCID: PMC10681212 DOI: 10.1371/journal.pone.0290135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. METHODS This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. RESULTS 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)]. CONCLUSION Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.
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Affiliation(s)
- Steven Habbous
- Ontario Health (Strategic Analytics), Toronto, Ontario, Canada
- Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - James Waddell
- Division of Orthopedic Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Erik Hellsten
- Ontario Health (Strategic Analytics), Toronto, Ontario, Canada
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Taunton MJ, Liu SS, Mont MA. Deep Learning: Orthopaedic Research Evolves for the Future. J Arthroplasty 2023; 38:1919-1920. [PMID: 37734830 DOI: 10.1016/j.arth.2023.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
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Burnett RA, Serino J, Hur ES, Higgins JDD, Courtney PM, Della Valle CJ. Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020. J Arthroplasty 2023; 38:1718-1725. [PMID: 36963527 DOI: 10.1016/j.arth.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/12/2023] [Accepted: 03/16/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND The number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA. METHODS Patients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients. RESULTS The incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84). CONCLUSIONS Complications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Joseph Serino
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Edward S Hur
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - John D D Higgins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson Univeristy, Philadelphia, Pennsylvania
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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