Length of Stay and Disposition
Length of stay in the protocol group dropped from 3.4 (SD = 1.6) to 1.6 (SD = 1.1) days for all TJA (P < 0.001) (Table 4). For THA specifically, LOS dropped from 3.4 to 1.4 days and for TKA from 3.4 to 1.7 days (both P < 0.001). Seven outpatient (same day) TJA (five THA and two TKA) home discharges, all in the protocol group, were found. Significantly more patients in the protocol group were discharged home (versus SNF or rehab) than patients in the preprotocol group (92% versus 72%, P < 0.001).
90-Day Readmissions and Complications
Protocol patients experienced significantly fewer complications overall compared with preprotocol patients (7% versus 21%, P = 0.007), specifically with fewer acute medical complications (4% versus 12%, P = 0.040) (Table 5). Superficial wound complications, deep wound complications, acute surgical complications, unplanned 90-day readmission, and return to OR within 90 days did not differ between groups.
Twenty-six total complications in the preprotocol group, with three unplanned readmissions (one medical and two surgical) and five returns to the OR within 90 days, were found (Table 4). Seven of the complications were acute surgical complications including intraoperative acetabular fracture, intraoperative patella fracture (medial facet fracture during patella preparation that did not involve extensor mechanism, the fragment was excised, the patella was not resurfaced, and ROM was restricted to <45° of flexion for 1 month), two knee arthrofibrosis requiring manipulation under anesthesia (POD 35 and POD 60), intraoperative MCL injury requiring acute repair, postoperative TKA hemarthrosis that was aspirated on the floor POD 1 and resolved without additional intervention, and one postoperative transient quadriceps paresis believed to be related to the nerve block or tourniquet that required transfer to PMR service before discharge, with eventual resolution. Six superficial wound complications were found; three were treated with wound care and close clinic follow-up (including one with an incisional wound vac), and three returned to the OR for superficial irrigation and débridement (two on POD 7 and one on POD 56). No reported deep infections were found. Thirteen acute medical complications including five patients with acute postoperative anemia requiring blood transfusion, three with DVT picked up on ultrasounds ordered for symptomatic examination, one with pulmonary embolism, one urinary retention requiring foley catheter reinsertion, one with postoperative hyponatremia requiring an additional day in the hospital, one with syncope POD 1 requiring transfer to the medical intensive care unit, and one with new dysphagia POD 5 requiring readmission to the medicine service were found.
In the protocol group, seven total complications, with three unplanned readmissions (one surgical and two medical) and two returns to the OR, were found. Two surgical complications, including one intraoperative patella fracture (small superior pole fragment that was excised without change in postop care or recovery) and one knee arthrofibrosis requiring manipulation under anesthesia (POD 89), were found. One superficial wound complication that was a suture reaction requiring no intervention was found. One deep infection in a THA patient who contracted an acute periprosthetic joint infection after electing to serve jail time 3 weeks postop and being roomed with an inmate with an active staph hand infection was found. Four medical complications, including one pulmonary embolism, one acute postoperative anemia requiring blood transfusion, one hyponatremia requiring extended hospital stay, and one patient with syncope on POD 40 requiring readmission to the medicine service and workup attributed to patient's known pre-existing vertebrobasilar insufficiency, were found.
The average total hospitalization cost for TJA (adjusted to $2018) in the protocol group dropped 24.7% from $100,749 (SD = 19,211) to $75,911 (SD = 15,334) (P < 0.001) (Table 6). For THA specifically, total hospitalization cost dropped 26.1% from $101,057 to $74,680 and for TKA dropped 23.9% from $100,685 to $76,758 (both P < 0.001). The average procedure cost for TJA dropped 22.1% from $10,206 (SD = 2,675) to $7,950.23 (SD = 140.61) (P < 0.001). For THA specifically, average procedure cost dropped 19.1% from $9,675 to $7,943 and for TKA dropped 23.6% from $10,400 to $7,955 (both P < 0.001). In addition to the overall decrease in mean cost, a notable decrease in the SD of procedure costs across TJA was found.
For the eight patients who had a TJA in both preprotocol and protocol groups, the results were similar to the overall group data. The average LOS dropped from 3.8 to 1.0 day (P = 0.004) (Table 7). In the preprotocol group, six patients discharged home and two to SNF, and two complications were found, both acute medical complications (Table 8). In the protocol group, all patients discharged home, and no complications were found. Average procedure and overall hospitalization cost were also less, but only the difference in overall cost was statistically significant (P = 0.134 and P = 0.010, respectively) (Table 9).
Numerous studies have shown the safety, efficiency, and cost-saving potential of accelerated and outpatient TJA in select cohorts.1-5 Although a County Hospital patient cohort tends to have a higher rate of psychosocial and medical risk factors than traditionally studied TJA cohorts, our results suggest that an accelerated recovery and outpatient TJA protocol can be implemented safely and with notable cost-saving potential.
The demographics of the patients between groups were mostly similar except for the lower rate of ASA 3 classification in the protocol group. Although ASA is not a perfect surrogate for health status, it does give a general sense of a patient's overall health. The difference in ASA between the protocol and preprotocol group could be seen as a limitation of the study or, alternatively, could be a reflection of the use of more standardized patient selection protocol and close work with primary care providers on preoperative medical optimization.22 The same county hospital population was treated in both groups, so there is no reason to believe there is a difference in the overall health status of patients presenting to the orthopedic clinic between groups would be present. In addition, although ASA been shown to be an accurate predictor of postoperative discharge location and readmission rate,27,28 the literature is not clear on the association between ASA and LOS,28,29 making our results relevant regardless of the difference in ASA status. With regard to the increased proportion of THA done in the protocol group, this is likely a reflection of the increased comfort of the arthroplasty fellowship-trained surgeon in doing THA compared with nonarthroplasty-trained surgeons. A national trend for primary THA to be done by fellowship-trained arthroplasty surgeons, which is reflected in this trend at our institution, is found.30 A multivariable linear regression analysis was run, concluding that the increase in the percentage of THA from the pr-protocol to the protocol group did not markedly affect any of the length of stay or cost outcomes (all P < 0.001) (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JG9/A57).
The decrease in average LOS from 3.4 to 1.6 days in the protocol group brought our hospital below the national average of 3 days30-33 and is similar improvement compared with other accelerated recovery TJA programs.7,21,22,34 The following implies that an accelerated recovery program can be as effective at County Hospital as they are in other high-volume joint centers. The seven same-day TJA cases (6.48%) represents an area of growing improvement in the new TJA protocol, and this rate continued to increase after the formal study period. Successful outpatient TJA relies on a strong coordinated social support system,35 which remains an ongoing challenge in our County Hospital cohort.
The markedly lower overall complication and acute medical complication rates demonstrate a notable improvement in the quality of TJA care delivered. The etiology of these results is likely multifactorial, but is undoubtedly related to the focus on extensive preoperative medical and psychosocial optimization, coordination of care, patient education, and the standardization of perioperative and postoperative care protocols. The fact that no difference was found in the surgical or wound complications, 90-day readmissions, or return to OR again demonstrates the safety of our accelerated recovery TJA protocol.
Decreasing complications and LOS represent a tremendous cost-saving opportunity for our County Hospital,34,36-38 which was shown in the 24.7% change in average hospital cost per patient. The average cost per procedure also decreased 22.1%, with a very small SD, which is likely the result of standardization of surgical room equipment, implants, and protocols. Our study likely underestimates the total cost savings because we did not include readmission costs, which can be extremely expensive, especially if they require subsequent surgery.39 In addition, we did not include any potential savings incurred from the notable decrease in discharge SNFs. Postacute care has been shown to account for 36% to 55% of total costs associated with an episode of TJA care.40,41 Keeping in mind that Medicare patients, which make up a large percentage of our County Hospital cohort, have markedly longer stays in SNFs after TJA than patients covered by Health Maintenance Organizations or Preferred Provider Organizations,42 increasing discharges to home instead of SNFs represents another potential area of notable cost savings that was not accounted for in our data.
The strengths of our study include that it is as large, comprehensive review of a homogenous, consecutive patient cohort was found. As with all retrospective studies that are dependent on the accuracy of chart review, potential for missing postoperative complications is found. However, our chart review, specifically in the protocol group, was checked against the operating surgeon's personal notes to ensure accuracy. Readmissions to other hospitals in the preprotocol group could have been missed since we only had access to the records at our County Hospital. However, since a large percentage of our patients rely on care at our institution secondary to insurance limitations, they are more likely to represent to our hospital by default if any complications are found.
A potential limitation of our study is that the new TJA protocol was implemented by a single surgeon, and although this ensured the standardization of intraop techniques and periop care, the following may not have the same generalizability if implemented by nonarthroplasty-trained surgeons. Higher surgeon volume is known to be correlated with decreased infection, readmission rates, and LOS and increased likelihood of being discharged home.43 Before the protocol, TJA was done by five different low-volume TJA surgeons, compared with after the protocol where all TJA were done by a single high-volume TJA surgeon. Using high-volume surgeons to help standardize the procedure is a common component of implementing accelerated recovery TJA programs; so, although readers should be aware of this difference, it does not invalidate the results. Because the protocol implements many perioperative changes (eg, preoperative optimization protocols, pain management, and early postoperative therapy.), it is difficult to identify confounding variables. As the program continues to evolve, a future area of study will be found. Another limitation is our relatively short-term follow-up. To include as many patients as possible in this newly implemented protocol, complication data were only reviewed up to 90 days postoperatively for the latest patients in the protocol group. Longer follow-up will be necessary to ensure that no increased mid-term or long-term complications rates among this cohort are found. Finally, we did not have complete data to compare any patient-reported or functional outcomes between groups, which will be an important area of focus for future research in our patient cohort.
Many successful outpatient and accelerated TJA programs have been implemented across the country, however implementation in a County Hospital system is novel. As with any successful TJA program, the standardized implementation of contemporary evidence-based TJA care is critical.21,22 Having the coordination and buy-in of a multidisciplinary team, meticulous tracking of results, and support from the administration and a dedicated program champion is important.21,22 It is also essential that the refinement of the program be an iterative process with frequent input from all stakeholders. Although a County Hospital setting and patient cohort offer a unique set of challenges, our data suggest that they can be adequately addressed to deliver safe and cost-effective TJA care to traditionally underserved patients (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JG9/A56, and Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JG9/A57).
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Supplemental Digital Content
Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.