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Zhang Q, Chen Y, Li Y, Liu R, Rai S, Li J, Hong P. Enhanced recovery after surgery in patients after hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J 2024; 100:159-173. [PMID: 38134323 DOI: 10.1093/postmj/qgad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) was characterized as patient-centered, evidence-based, multidisciplinary team-developed routes for a surgical speciality and institution to improve postoperative recovery and attenuate the surgical stress response. However, evidence of their effectiveness in osteoarthroplasty remains sparse. This study aimed to develop an ERAS standard and evaluate the significance of ERAS interventions for postoperative outcomes after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We searched Medline, Embase, Cochrane databases, and Clinicaltrials.gov for randomized controlled trials, cohort studies, and case-control studies until 24 February 2023. All relevant data were collected from studies meeting the inclusion criteria. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was the length of stay (LOS), postoperative complications, and readmission rate. The secondary outcomes included transfusion rate, mortality rate, visual analog score (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form 36 (SF-36) bodily pain (SF-36 BP), SF-36 physical function (SF-36 PF), oxford knee score, and range of motion (ROM). RESULTS A total of 47 studies involving 76 971 patients (ERAS group: 29 702, control group: 47 269) met the inclusion criteria and were included in the meta-analysis. The result showed that ERAS could significantly shorten the LOS (WMD = -2.65, P < .001), reduce transfusion rate (OR = 0.40, P < .001), and lower 30-day postoperative mortality (OR = 0.46, P = .01) without increasing postoperative complications or readmission rate. Apart from that, ERAS may decrease patients' VAS (WMD = -0.88, P = .01) while improving their ROM (WMD = 6.65, P = .004), SF-36 BP (WMD = 4.49, P < .001), and SF-36 PF (WMD = 3.64, P < .001) scores. However, there was no significant difference in WOMAC, oxford knee score between the ERAS and control groups.Furthermore, we determined that the following seven components of the ERAS program are highly advised: avoid bowel preparation, PONV prophylaxis, standardized anesthesia, use of local anesthetics for infiltration analgesia and nerve blocks, tranexamic acid, prevent hypothermia, and early mobilization. CONCLUSION Our meta-analysis suggested that the ERAS could significantly shorten the LOS, reduce transfusion rate, and lower 30-day postoperative mortality without increasing postoperative complications or readmission rate after THA and TKA. Meanwhile, ERAS could decrease the VAS of patients while improving their ROM, SF-36 BP, and SF-36 PF scores. Finally, we expect future studies to utilize the seven ERAS elements proposed in our meta-analysis to prevent increased readmission rate for patients with THA or TKA.
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Affiliation(s)
- Qingqing Zhang
- Department of Gastroenterology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
| | - Yuzhang Chen
- Department of Endocrinology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital,, Wuhan 430022, China
| | - Yi Li
- First Clinical School, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ruikang Liu
- Department of Endocrinology, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, , Wuhan 430022, China
| | - Saroj Rai
- Department of Orthopedics, Al Ahalia Hospital Mussafah, Abu Dhabi 00000, United Arab Emirates
| | - Jin Li
- Department of Orthopaedic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Union Hospital, Wuhan 430022, China
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2
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Berkovic D, Vallance P, Harris IA, Naylor JM, Lewis PL, de Steiger R, Buchbinder R, Ademi Z, Soh SE, Ackerman IN. A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection. BMC Med 2023; 21:511. [PMID: 38129857 PMCID: PMC10740291 DOI: 10.1186/s12916-023-03219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection. METHODS A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed. RESULTS Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814). CONCLUSIONS There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.
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Affiliation(s)
- Danielle Berkovic
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Patrick Vallance
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia and Faculty of Medicine, University of Adelaide, Adelaide, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth HealthCare, University of Melbourne, Melbourne, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Health Economics and Policy Evaluation Research (HEPER), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Sze-Ee Soh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
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Costa-Pinto R, Yanase F, Kennedy LM, Talbot LJ, Flanagan JP, Opdam HI, Ellard LM, Bellomo R, Jones DA. Characteristics and outcomes of surgical patients admitted to an overnight intensive recovery unit: A retrospective observational study. Anaesth Intensive Care 2023; 51:29-37. [PMID: 36217293 DOI: 10.1177/0310057x221105299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Postoperative 'enhanced care' models that sit between critical care and ward-based care may allow for more cost-effective and efficient utilisation of resources for high-risk surgical patients. In this retrospective observational study, we describe an overnight intensive recovery model in a tertiary hospital, termed 'recovery high dependency unit', and the characteristics, treatment, disposition at discharge and in-hospital outcomes of patients admitted to this unit. We included all adult patients (≥18 years) admitted to the recovery high dependency unit for at least one hour between July 2017 and June 2020. Over this three-year period, 1257 patients were included in the study. The median length of stay in the recovery high dependency unit was 12.6 (interquartile range 9.1-15.9) hours and the median length of hospital stay was 8.3 (interquartile range 5.0-17.3) days. Hospital discharge data showed that 1027 (81.7%) patients were discharged home and that 37 (2.9%) patients died. Non-invasive ventilation was delivered to 59 (4.7%) patients and 290 (23.1%) required vasopressor support. A total of 164 patients (13.0%) were admitted to the intensive care unit following their recovery high dependency unit admission. Of the 1093 patients who were discharged to the ward, 70 patients (6.4%) had a medical emergency team call within 24 hours of discharge from the recovery high dependency unit. In this study of a recovery high dependency unit patient cohort, there was a relatively low need for intensive care unit admission postoperatively and a very low incidence of medical emergency team calls post-discharge to the ward. Other institutions may consider the introduction and evaluation of this model in the care of their higher risk surgical patients.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lucy M Kennedy
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Lachie J Talbot
- Melbourne Medical School, University of Melbourne, Parkville, Australia
| | | | - Helen I Opdam
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Louise M Ellard
- Department of Anaesthesia, 96043Austin Hospital, Heidelberg, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Daryl A Jones
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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5
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta J, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery. JOURNAL OF SPINE SURGERY 2021; 7:19-25. [PMID: 33834124 DOI: 10.21037/jss-20-626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. Methods This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. Results A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Conclusions Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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6
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta JL, Davis E, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption. JOURNAL OF SPINE SURGERY 2020; 6:681-687. [PMID: 33447670 DOI: 10.21037/jss-20-629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). Methods This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). Results In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs. Conclusions The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - Eric Davis
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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Pritchard MG, Murphy J, Cheng L, Janarthanan R, Judge A, Leal J. Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence. BMJ Open 2020; 10:e032204. [PMID: 31948987 PMCID: PMC7044879 DOI: 10.1136/bmjopen-2019-032204] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work. DESIGN Systematic review of cost-utility analyses. DATA SOURCES Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019. ELIGIBILITY CRITERIA English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis. DATA EXTRACTION AND SYNTHESIS Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken. RESULTS We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation. CONCLUSIONS Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies. PROSPERO REGISTRATION NUMBER CRD42017059473.
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Affiliation(s)
- Mark G Pritchard
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jacqueline Murphy
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- Wolfson Institute of Preventive Medicine - Barts and the London, Queen Mary University of London, London, UK
| | - Lok Cheng
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Roshni Janarthanan
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Jose Leal
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
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Khan RM, Albutt K, Qureshi MA, Ansari Z, Drevin G, Mukhopadhyay S, Khan MA, Chinoy MA, Meara J, Hussain H. Time-driven activity-based costing of total knee replacements in Karachi, Pakistan. BMJ Open 2019; 9:e025258. [PMID: 31142520 PMCID: PMC6549678 DOI: 10.1136/bmjopen-2018-025258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Osteoarthritis of the knee has been identified as the most common disability in Pakistan. Total knee replacement (TKR) surgery is the curative treatment for advanced osteoarthritis of the knee; however, cost remains one of the barriers to effective and timely service delivery. OBJECTIVE We conducted a time-driven activity-based costing (TDABC) analysis of TKR to identify major cost drivers and areas for process improvement. METHODS AND ANALYSIS We performed a prospective TDABC analysis of patients who underwent bilateral TKR at The Indus Hospital (TIH) during a 14-month period from October 2015 to December 2016. Detailed process maps were developed for each phase of the care cycle. Time durations and costs were allocated to each resource utilised and aggregated across the care cycle, including personnel, direct and indirect costs. RESULTS We identified seven care phases for a complete TKR care cycle and created their detailed process maps. Major time contributors were ward stay and discharge (20 160 min), TKR surgery (563 min) and surgical admission (333 min). Overall, 92.10% of time is spent during the ward stay and discharge phase of care. Patients remain hospitalised for an average of 14 days postoperatively. Overall institutional cost of a TKR at TIH was US$4360.51 (Pakistani rupees 456 981.17) per bilateral TKR surgery. The overall primary cost drivers for the full bundle of care were consumables used during TKR surgery itself, consumables utilised in the wards and personnel costs contributing 57.64%, 27.45% and 12.03% of total costs, respectively. CONCLUSION Utilising TDABC allowed us to obtain a granular analysis of time and cost that was subsequently used to inform quality process improvement initiatives. In low-resource settings, such as Pakistan, TDABC has the potential to be a useful tool to guide resource allocation and process improvement.
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Affiliation(s)
| | - Katherine Albutt
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- General Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Zara Ansari
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Gustaf Drevin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department for Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Mansoor Ali Khan
- Department of Orthopedics, The Indus Hospital, Karachi, Pakistan
| | | | - John Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Hamidah Hussain
- Global Health, Interactive Research and Development (IRD), Global, Singapore
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Jayakumar P, Di J, Fu J, Craig J, Joughin V, Nadarajah V, Cope J, Bankes M, Earnshaw P, Shah Z. A Patient-Focused Technology-Enabled Program Improves Outcomes in Primary Total Hip and Knee Replacement Surgery. JB JS Open Access 2017; 2:e0023. [PMID: 30229224 PMCID: PMC6133096 DOI: 10.2106/jbjs.oa.16.00023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: A patient-engagement and pathway-management program for patients undergoing primary total hip and knee replacement was evaluated. Health-service and multimedia features supported by technology were integrated with existing enhanced recovery after surgery (ERAS) practices. The primary objective was to demonstrate the impact on length of stay. The secondary objective was to assess the impact on clinical, patient-focused, and financial outcomes. Methods: Two thousand and eighty consecutive patients undergoing primary total hip replacement (n = 1,034) and total knee replacement (n = 1,046) were classified into “pre-program” (retrospectively assessed [n = 1,038]) and “program” (prospectively assessed [n = 1,042]) cohorts. Patients in the program cohort were subdivided according to those who were eligible for criteria-based outreach support (OS) (n = 401) and those who were ineligible for this service (NOS) (n = 641). Clinical outcomes were assessed for all patients, and patient-focused outcomes were assessed for a subset (n = 223). Results: The mean reduction in length of stay ranged from 20% (1.2 days) to 42% (2.5 days) following total hip replacement and from 9% (0.6 day) to 31% (2 days) following total knee replacement (p < 0.001). Clinical outcomes (readmissions, complications, emergency department re-attendance rates) were not significantly negatively impacted. The Oxford Hip Score had numerically larger improvement after total hip replacement in the OS group than in the pre-program group (4.1-point increase), and the Oxford Knee Score had numerically larger improvement after total knee replacement in the NOS group than in the pre-program group (0.8-point increase). The patients in the program cohort (either OS or NOS) rated overall health gain as higher than those in the pre-program cohort (gain in numerical rating scale, 1.4 points for patients managed with total hip replacement, 0.6 points for patients managed with total knee replacement). Older patients and those with higher comorbidity indices benefited most with respect to length of stay and multiple clinical outcomes. Patient experience was significantly improved across domains (p < 0.001 to p = 0.003). Potential savings for patients managed with total hip replacement (£401.64 [$267.76] per patient) exceeded estimated program charges of £50 [$33.33] to £60 [$40] per patient, whereas the potential savings for patients managed with total knee replacement (£76.67 [$51.11] per patient) were sufficient to achieve a reduction of total system costs. Conclusions: Technology-enabled programs may deliver enhanced care at lower costs for patients undergoing lower-limb arthroplasty. Shorter durations of inpatient stay without a negative impact on clinical outcomes and improved patient-focused outcomes and experience can deliver substantial value that can be especially beneficial for older patients and those with greater medical complexity. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Prakash Jayakumar
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Jianing Di
- Janssen Healthcare Innovation, a Division of Janssen Cilag Ltd., High Wycombe, United Kingdom
| | - Jiayu Fu
- Janssen Healthcare Innovation, a Division of Janssen Cilag Ltd., High Wycombe, United Kingdom
| | - Joyce Craig
- York Health Economics Consortium, Heslington, York, United Kingdom
| | - Vicki Joughin
- Johnson & Johnson Medical Devices, Beeston, Leeds, United Kingdom
| | - Victoria Nadarajah
- Department of Trauma and Orthopaedics, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Jade Cope
- Department of Trauma and Orthopaedics, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Marcus Bankes
- Department of Trauma and Orthopaedics, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Peter Earnshaw
- Department of Trauma and Orthopaedics, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Zameer Shah
- Department of Trauma and Orthopaedics, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
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Fast-track recovery technique applied to primary total hip and knee replacement surgery. Analysis of costs and complications. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Fast-track recovery technique applied to primary total hip and knee replacement surgery. Analysis of costs and complications. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:111-116. [PMID: 28073671 DOI: 10.1016/j.recot.2016.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 02/05/2016] [Accepted: 10/12/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To determine the cost reduction and complication rates of using an enhanced recovery pathway (Fast-track) when compared to traditional recovery in primary total hip replacement (THR) and total knee replacement (TKR), as well as to determine if there were significant differences in complication rates. MATERIAL AND METHODS Retrospective review of 100 primary total arthroplasties using the Fast-track recovery system and another 100 using conventional recovery. Gender, Charlston comorbidity index, ASA score, length of stay and early complications were measured, as well in-hospital complications and those in the first six months, re-admissions and transfusion rates. The total and daily cost of stay was determined and the cost reduction was calculated based on the reduction in the length of stay found between the groups. RESULTS Both groups where comparable as regards age, gender, ASA score, and Charlston index. The mean reduction in length of stay was 4.5 days for TKR and 2.1 days for THR. The calculated cost reduction was 1266 euros for TKR and 583 euros for THR. There were no statistically significant differences between groups regarding in-hospital complications, transfusion requirements, re-admissions and complication rates in the first six months. DISCUSSION There are few publications in the literature reviewed that analyse the cost implications of using fast-track recovery protocols in arthroplasty. Several published series comparing recovery protocols found no significant differences in complication rates either. The use of a fast-track recovery protocol resulted in a significant cost reduction of 1266 euros for the TKR group and 583 for the THR group, without affecting complication rates.
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Okamoto T, Ridley RJ, Edmondston SJ, Visser M, Headford J, Yates PJ. Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty. J Arthroplasty 2016; 31:2227-30. [PMID: 27209333 DOI: 10.1016/j.arth.2016.03.066] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/07/2016] [Accepted: 03/28/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To determine the effect of mobilization on the day of surgery on the readiness for discharge and length of stay after elective total hip arthroplasty (THA). METHODS We devised a randomized control trial with concealed allocation and intention-to-treat analysis. Overall, 126 patients who underwent THA and met the criteria for mobilization on the day of surgery were randomly allocated into 2 groups; the intervention group was mobilized on the day of surgery, n = 58 and the control group was mobilized on the day after surgery, n = 68. Apart from timing of mobilization, both groups received the same postoperative management. The primary outcome measures were length of hospital stay and time to readiness for discharge. RESULTS The early mobilization group was ready for discharge 63 hours (standard deviation [SD] = 15 hours) after surgery, compared to 70 hours (SD = 18 hours) for the control group (P = .03, 95% CI, 0.7-12.8). There was no significant difference in hospital stay in the early mobilization group (77 hours [SD = 30 hours]), compared to the control group (87 hours [SD = 35 hours]; P = .11, 95% CI, -2.1 to 21.6). Despite this at any point in time after the surgery, the intervention group was 1.8 times (P = .003, 95% CI, = 1.2-2.7) more likely to have been discharged. CONCLUSION Mobilization on the day of THA surgery significantly increases the probability of discharge at any singular point in time compared with mobilization on the day after surgery and decreases the time to readiness for discharge.
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Affiliation(s)
- Taro Okamoto
- Department of Orthopaedic Surgery, Fremantle Hospital, Fremantle, WA, Australia
| | - Ryan J Ridley
- Physiotherapy Department, Osborne Park Hospital, Stirling, WA, Australia
| | | | - Mariet Visser
- Physiotherapy Department, Osborne Park Hospital, Stirling, WA, Australia
| | - Julie Headford
- Department of Orthopaedic Surgery, Fremantle Hospital, Fremantle, WA, Australia
| | - Piers J Yates
- Department of Orthopaedic Surgery, Fremantle Hospital, Fremantle, WA, Australia
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Chen A, Sabharwal S, Akhtar K, Makaram N, Gupte CM. Time-driven activity based costing of total knee replacement surgery at a London teaching hospital. Knee 2015; 22:640-5. [PMID: 26234746 DOI: 10.1016/j.knee.2015.07.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 05/05/2015] [Accepted: 07/13/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to conduct a time-driven activity based costing (TDABC) analysis of the clinical pathway for total knee replacement (TKR) and to determine where the major cost drivers lay. METHODS The in-patient pathway was prospectively mapped utilising a TDABC model, following 20 TKRs. The mean age for these patients was 73.4 years. All patients were ASA grade I or II and their mean BMI was 30.4. The 14 varus knees had a mean deformity of 5.32° and the six valgus knee had a mean deformity of 10.83°. Timings were prospectively collected as each patient was followed through the TKR pathway. RESULTS Pre-operative costs including pre-assessment and joint school were £ 163. Total staff costs for admission and the operating theatre were £ 658. Consumables cost for the operating theatre were £ 1862. The average length of stay was 5.25 days at a total cost of £ 910. Trust overheads contributed £ 1651. The overall institutional cost of a 'noncomplex' TKR in patients without substantial medical co-morbidities was estimated to be £ 5422, representing a profit of £ 1065 based on a best practice tariff of £ 6487. CONCLUSIONS The major cost drivers in the TKR pathway were determined to be theatre consumables, corporate overheads, overall ward cost and operating theatre staffing costs. Appropriate discounting of implant costs, reduction in length of stay by adopting an enhanced recovery programme and control of corporate overheads through the use of elective orthopaedic treatment centres are proposed approaches for reducing the overall cost of treatment.
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Affiliation(s)
- Alvin Chen
- Imperial College NHS Trust, United Kingdom
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Enhanced recovery programme reduces opiate consumption in hip hemiarthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 26:177-81. [DOI: 10.1007/s00590-015-1722-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/01/2015] [Indexed: 11/26/2022]
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