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Changing Patient Expectations Decreases Length of Stay in an Enhanced Recovery Program for THA

Tanzer, Dylan BSc; Smith CRA, Karen; Tanzer, Michael MD

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Clinical Orthopaedics and Related Research: February 2018 - Volume 476 - Issue 2 - p 372-378
doi: 10.1007/s11999.0000000000000043
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Enhanced recovery after surgery (ERAS) has become a well-established program in patients undergoing THA to provide cost-efficient and high-quality patient care [7, 10]. The key components of ERAS include the management of medical comorbidities, effective preoperative patient education, evidence-based perioperative care within a multidisciplinary team, early mobilization, and discharge [6]. Implicit in an ERAS program is extensive patient education and counseling so that the patient is an active participant in his or her own recovery and rehabilitation. The information patients receive before their surgery is extremely important because it establishes their expectations and encourages adherence to the clinical care pathway [1, 5]. Specific tasks and targets such as the day of discharge are given to the patient at this juncture in the pathway.

Overall, the implementation of care pathways in hip arthroplasty ERAS programs has been shown to result in earlier mobilization and a decrease in length of stay (LOS) without leading to increased rates of complication, mortality, or morbidity [2, 3, 8, 11, 12]. However, in most studies [3, 9], multiple elements of the care pathway may be implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient’s prepathway care. Patient LOS after THA is multifactorial and can be reduced by standardizing the patient’s care pathway to affect incremental changes that bear on LOS [10]. In a review of 200 patients undergoing hip arthroplasty at two time intervals, Pantelli et al. [10] found that managing patient expectations and better preparation of the patients for hip arthroplasty was an important factor in reducing LOS. Unlike previous studies that included multiple care pathway changes, Jones et al. [4] evaluated the role of preoperative education on LOS after TKA. They found that the LOS was substantially decreased in the 322 patients who had a preoperative education group compared with the 150 control patients. However, care pathways have been found to have a greater effect on the LOS after TKA than THA and the isolated effect of education on LOS after THA has not previously been specifically addressed [9].

Therefore, we undertook a study to evaluate the following: (1) Does changing the patient’s expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient’s LOS after primary THA? (2) Is the resultant LOS associated with the patient’s age, gender, or day of the week the surgery was performed?

Patients and Methods

Beginning on September 30, 2013, an enhanced recovery care pathway for primary THA with a 4-day LOS was initiated at the surgeon’s (MT) institution. The enhanced recovery pathway standardized the preoperative education, postoperative rehabilitation, medications, and time of discharge for all patients undergoing primary THA. As part of the pathway, all patients were seen in the preoperative clinic within 1 month of their planned surgery where the nursing staff and physiotherapists specifically addressed the discharge planning with the patient. The date of discharge was clearly indicated in the care pathway booklet that each patient received. All patients were then seen in the surgeon’s office 1 to 2 weeks afterward to review the surgery and the discharge plans. Between September 30, 2013, and January 23, 2015, patients undergoing THA were on a 4-day pathway to discharge; 123 patients underwent THA during this period. For the first 100 consecutive patients who underwent THA after the initiation of the 4-day pathway, the surgeon confirmed the 4-day LOS at this visit (4-day Group). After January 23, 2015, it was explicitly communicated by the surgeon to the patient in the preoperative visit that the LOS would only be 2 days. The first 100 consecutive patients operated on after January 23, 2015, comprised the 2-day Group. For patients in the 2-day Group, there was no other intentional change in the pathway, no other health professionals were informed of the change in the planned discharge date, and the patient was informed that the discharge date would be determined by the surgeon when the patient was medically stable, had sufficient pain control, and was able to ambulate and do stairs. However, all postoperative patients were cleared by the physiotherapist and nursing staff before discharge. It was possible to maintain the 4-day pathway and discharge the patient as early as 2 days postoperatively, without changing the protocols, because days 2, 3, and 4 of the pathway were identical with respect to the nursing and physiotherapy goals. The only exception was that the patient was required to walk up and down stairs on their discharge day. This was communicated to the physiotherapist on the morning of the planned discharge. In addition, discharge support was arranged preoperatively and only required 1-day notification to activate. This design of the 4-day pathway minimized the risk of the support staff treating these patients differently as if they were on a 2-day pathway, especially because the other surgeons in the institution continued to use the 4-day pathway. No patients during these time periods were excluded from the analysis.

After receiving institutional ethics approval, the first 100 consecutive patients undergoing primary THA in the 4-day Group were compared with the first 100 consecutive patients in the 2-day Group to determine their LOS. No patients were excluded or lost to followup. All patients underwent primary THA by a single surgeon (MT) through a miniposterior approach under spinal anesthesia. All patients were encouraged to bear full weight on the hip on the day of surgery. Aside from the planned date of discharge, there was no difference in the enhanced care pathway in the two groups of patients.

Information regarding American Society of Anesthesiologists physical status classification (ASA), LOS, discharge disposition, and 90-day readmission events was collected retrospectively from the hospital electronic medical records. Demographic data including age, gender, and diagnosis were obtained from our longitudinally maintained hip replacement database. LOS between the two groups was further evaluated based on the patient’s age and gender as well as the day of the week the surgery was performed.

SPSS (Version 22.0; IBM Corporation, Armonk, NY, USA) was used for all statistical analyses. Chi-square and Fisher’s exact tests were used to examine differences between the groups. A p value < 0.05 was considered statistically significant.

There were no differences in the preoperative characteristics of the 100 patients with the planned 4-day LOS (4-day Group) and the 100 patients with the planned 2-day LOS (2-day Group). The mean age was 66 years old in both the 4- and 2-day Groups with a similar age distribution (Fig. 1). Sixty-two percent of the patients in the 4-day Group and 53% of the patients in the 2-day Group were women. In the 4-day Group, 7% of the patients were classified as ASA 1, 71% ASA 2, 21% ASA 3, and 1% ASA. In the 2-day Group, 9% of the patients were classified as ASA 1, 77% ASA 2, and 14% ASA 3. The underlying diagnosis was osteoarthritis in 83 hips, inflammatory arthritis in 11 hips, avascular necrosis in five hips, and traumatic arthritis in one hip in the 4-day Group. In the 2-day Group, the diagnosis was osteoarthritis in 85 hips, avascular necrosis in 11 hips, and inflammatory arthritis in four hips. All patients in both groups were discharged home and no patients were readmitted to the hospital.

Fig. 1
Fig. 1:
Bar graph comparing the age distribution of the patients in the 4-day Group (gray) and the 2-day Group (black) by decade.


Overall, patients in the 2-day Group had a shorter LOS than did those on the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). Thirty-two percent (32 of 100) of the patients in the 2-day Group were discharged on postoperative day (POD) 2 compared with 8% (eight of 100) in the 4-day Group (odds ratio [OR], 4.0; 95% CI, 1.76-9.11; p < 0.001) (Fig. 2). Eighteen percent (18 of 100) of the patients in the 4-day Group compared with 6% (six of 100) of the patients in 2-day Group remained in the hospital for ≥ 5 days (OR, 3.0; 95% CI, 1.14-7.87; p < 0.03).

Fig. 2
Fig. 2:
Bar graph comparing the postoperative day of discharge. The percent of patients discharged on each postoperative day is indicated for patients in the 4-day Group (gray) and the 2-day Group (black).

For all patients > 40 and < 90 years of age, a greater percentage of patients in the 2-day Group went home by POD 2 than those in the 4-day Group (32% compared with 7%; OR, 4.6; 95% CI, 1.93-10.84; p < 0.001) (Fig. 3). This was most apparent for patients in their fifth and seventh decades of life. In the 2-day Group, 63% of patients in their 40s and 41% of the patients in their 60s went home on POD 2 compared with 18% and 3%, respectively, of the patients in the 4-day Group (40s: OR, 3.50; 95% CI, 1.94-6.33; p < 0.001; 60s: OR, 13.67; 95% CI, 4.10-45.58; p < 0.001). Overall, patients ≥ 80 years of age in the 2-day Group (N = 16) had a shorter LOS than did those in the 4-day Group (N = 12) (3.3 ± 0.78 days versus 4.9 ± 0.96 days; mean difference 1.6 days; 95% CI, 0.92-1.41; p = 0.001; Fig. 4). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; mean difference 0.36 days; 95% CI, -2.00 to 1.00; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; mean difference 0.2 days; 95% CI, -0.41 to 0.74; p = 0.547).

Fig. 3
Fig. 3:
Bar graph comparing the percent of patients in the 4-day Group (gray) and the 2-day Group (black) who were discharged on POD 2.
Fig. 4
Fig. 4:
Bar graph comparing the POD of discharge in patients ≥ 80 years of age. The percent of patients discharged on each POD is indicated for patients in the 4-day Group (gray) and the 2-day Group (black).


A successful ERAS program incorporates many factors with the combined effect of reducing LOS and providing high-quality patient care. Most prior studies on care pathways evaluated a number of changes implemented at once, which makes it impossible to evaluate the influence of a single factor such as a surgeon’s intervention in terms of trying to set patients’ expectations about LOS [3, 9]. It has been established that preoperative patient education and counseling are extremely important to establish expectations and encourage adherence to the clinical care pathway [4, 9, 11, 12]. However, the role of the patient’s preoperative expectation alone, in the context of a care pathway, on LOS after THA has not to our knowledge been carefully evaluated. We found that a surgeon who took the time to set a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in a retrospective study whether other caregivers adjusted the pathway in response to the surgeon’s preferences, and we suspect this probably did occur, it still points to an opportunity on the topic of expectations setting that future studies should explore.

There are several limitations to this study. First, a 4-day LOS care map is now considered quite long and an improvement in this LOS may not be reflective of a shorter care map. However, the intent of the study was to determine the effect of patient expectations alone, in the context of a care pathway, on patients’ LOS. Although the absolute decrease in LOS would likely be less in a pathway with a shorter LOS, the importance of patients’ expectations on their LOS probably remains valid. Second, with the second group of patients routinely going home earlier than the first group, the healthcare workers involved in patient care would have likely started to expect this outcome. However, the treatment of the patient, including physiotherapy regime, medications, and nursing care, was not altered and followed the 4-day care map. In this study, it was possible to maintain the 4-day pathway and discharge the patient as early as 2 days postoperatively, without changing the protocols, because days 2, 3, and 4 of the pathway were identical with respect to the nursing and physiotherapy goals. Presently, as a result of this study, the institution has adopted a 2-day care pathway for primary THA. In addition, this study does not address the support the patients had at home and whether this affected their discharge timing. Finally, the surgeon was not blinded to the discharge date. The timing of the discharge was subjective and based on the surgeon’s evaluation of the patient. However, all patients were cleared by the physiotherapist and nursing staff before discharge. The patients in both the 4-day Group and 2-day Group were encouraged by the surgeon to go home as soon as they could both preoperatively and in the hospital. Finally, the number of patients in each age group and day of the week that surgery was performed were limited. As a result, some of the findings such as the effect of operating on Friday may be underpowered. In addition, other confounders affecting LOS, especially comorbidities in the elderly, could not be addressed.

Previous studies have documented the ability of an ERAS program to decrease the LOS after primary THA [2, 8, 10, 12]. However, the relative importance and contribution of each component of the care pathway in reducing the LOS are uncertain. Similar to the study in patients undergoing TKA, this study showed that even in a well-defined ERAS care pathway, patients’ expectations on LOS can affect LOS after THA [4]. These findings contradict the Cochrane review of 13 THA trials, concluding preoperative education may not offer additional benefits over usual care [9]. As explained by Jones et al. [4], the findings in this study that patient expectations affect LOS may be a reflection on the type of interaction between the patient and the surgeon. In both studies, there was direct contact between the patient and the surgeon preoperatively to clearly outline the discharge plans, answer any questions, and alleviate any fears or concerns regarding the planned discharge. In this study, the discharge plans were reinforced by the surgeon while the patient was in the hospital and any concerns of the patient regarding his or her discharge were alleviated by the surgeon before discharge.

This study specifically addressed the resultant LOS associated with the patient’s age, gender, or the day of the week the surgery was performed. Changing the patients’ expectations was effective in all age groups, even among older patients, as observed by others [12]. Even so, on balance, older patients in this cohort stayed longer, a finding that mirrors that of others [2, 10, 12]. In this study, changing the anticipated LOS in men resulted in a shorter LOS in the 4-day Group, but there was no difference in the shorter 2-day Group. This improvement in men compared with women is similar to the findings previously reported in ERAS studies in which the mean LOS was 5 days [3, 8]. This study could not identify a disadvantage of having surgery before the weekend, a variable that has not been previously reported. There was no difference in the LOS if surgery was done on Friday compared with any other day of the week.

This study suggests that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Direct discussions with the patient and the surgeon can establish the expected discharge goal and help reassure the patient that the plan is reasonable. This may help motivate the patient as well as allowed him or her to prepare psychologically and have the appropriate support at home after discharge. This study highlights the influence patient education and expectations have on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital. To eliminate possible confounding factors, future studies should look at the effect of changing the expectations on the anticipated LOS on the percentage of patients meeting the discharge objective in a modern care pathway of short duration. In addition, these studies should address the results from the perspective of the patient, not simply on whether reduced LOS can be achieved by changing patient expectations, but also, whether this is good for the patient.


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