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No Difference in Outcomes Between Short and Longer-Stay Total Joint Arthroplasty with a Discharge Home

A Propensity Score-Matched Analysis Involving 46,660 Patients

Leroux, Timothy S. MD, MEd, FRCSC1; Maldonado-Rodriguez, Naomi BKin1; Paterson, J. Michael MSc2,3; Aktar, Suriya MSc2; Gandhi, Rajiv MD, MSc, FRCSC1; Ravi, Bheeshma MD, PhD, FRCSC2,4

The Journal of Bone and Joint Surgery: November 7, 2019 - Volume Latest Articles - Issue - p
doi: 10.2106/JBJS.19.00796
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Background: Outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a short length of hospital stay have been reported; however, most studies have not accounted for an inherent patient selection bias and discharge disposition. The purpose of this study was to utilize a propensity score to match and compare the outcomes of patients undergoing THA or TKA with short and longer lengths of stay with a discharge directly home.

Methods: An administrative database from Ontario, Canada, which has a single-payer health-care system, was retrospectively reviewed to identify patients who underwent THA or TKA from 2008 to 2016. Patients were subsequently stratified into 2 groups based on their length of stay: short length of stay (≤2 days; thereafter referred to as short stay) and longer length of stay (>2 days; thereafter referred to as longer stay). Using a propensity score, patients who underwent short-stay THA or TKA were matched to patients who underwent longer-stay THA or TKA. Matching was based on 15 demographic, medical, and surgical factors. Our primary outcomes included postoperative complications, health-care utilization (readmission and emergency department presentation), and health-care costs.

Results: Overall, 89,656 TKAs (14,645 short stays and 75,011 longer stays) and 52,610 THAs (9,426 short stays and 43,184 longer stays) were included in this study. Patients who underwent short-stay THA or TKA were significantly more likely (p < 0.05) to be younger, male, healthier, and from a higher socioeconomic status and to have undergone the procedure with a higher-volume surgeon. Over 95% of short-stay cases were successfully matched to longer-stay cases, and we found no significant difference in complications, health-care utilization, and costs between patients on the basis of the length of stay.

Conclusions: Patients undergoing short-stay THA or TKA with a discharge home were more likely to be younger, healthy, male patients from a higher socioeconomic status. Higher-volume surgeons are also more likely to perform short-stay THA or TKA. These characteristics confirm the previously held belief that a selection bias exists when comparing cohorts based on time to discharge. When comparing matched cohorts of patients who underwent short-stay and longer-stay THA or TKA, we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1The Arthritis Program, University Health Network, Toronto, Ontario, Canada

2The Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

4Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Email address for T.S. Leroux: timothy.leroux@uhn.ca

Investigation performed at the Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada

Disclosure: This study was supported by a grant from the Canadian Institutes of Health Research. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/XXXXXXX).

Disclaimer: This study was supported by a grant from the Canadian Institutes of Health Research and by ICES, a non-profit research institute funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by the MOHLTC and the Canadian Institute for Health Information (CIHI). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the data providers and funding sources. No endorsement by CIHI, ICES, or the Ontario MOHLTC is intended or should be inferred.

Copyright 2019 by The Journal of Bone and Joint Surgery, Incorporated
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