It is estimated that by 2026, 50% of total joint replacement (TJR) surgeries will be performed in outpatient settings (Gabor et al., 2020). There has been an increase in TJR performed in the outpatient setting for cost containment and a shift in the reimbursement schedule (Gabor et al., 2020). Outpatient TJR has been shown to save an average of $5,000 per case compared with inpatient TJR (Gabor et al., 2020). However, outpatient readmission to the hospital within 30–90 days postoperatively can be costly for the healthcare industry.
Readmissions to the hospital after outpatient TJR and other outpatient surgical procedures are costly and impact overall healthcare expenses (Glans et al., 2020). Within 30 days of discharge, readmissions are preventable 27% of the time and account for 60% of the overall healthcare costs (Glans et al., 2020). Sandrowski et al. (2021) reported that hospital readmission rates after discharge following outpatient orthopaedic surgery were 20% in the United States. In Georgia, the readmission rate is 16% (Centers for Medicare & Medicaid Services, 2018).
Effective preoperative patient education is vital to minimize postoperative complications and improve home function after TJR (Berg et al., 2018). Readmission to the hospital within 30 days postoperatively for complications such as infection, blood clots, or pain disability can be achieved using an educational reminder tool such as a recovery messaging application (RMA; Stauber et al., 2020). The RMA is a free downloadable mobile application that can be used postoperatively by patients who have a smartphone to receive messages from the provider to remind them of important information regarding their surgery, postoperative exercises, appointment reminders, and other vital information (Stauber et al., 2020). The application delivers daily, timely notifications that apply to recovery after TJR by using the patient's discharge date (Timmers et al., 2019).
Zheng et al. (2019) add that the RMA helps the patient recognize and alert the healthcare provider of possible adverse problems during the postoperative period thus preventing readmissions. The application can be useful especially if patients choose to utilize the interactive communication mode of some RMAs. The interactive communication mode may enable the patient to send pictures in real time to the healthcare provider on call (Zheng et al., 2019). For example, for a patient who is worried about the increasing redness of their incision, this feature would allow the patient to send a picture to the provider for consultation.
The purpose of this integrative review was to examine 30-day readmission rates for adults post-TJR within a 12- to 14-week time frame using the RMA following discharge.
The clinical research question was, “For adults receiving a total joint replacement in an outpatient surgery setting, will implementation of the Recovery Messaging mobile application via smartphone following discharge, compared to current practice, impact less than 30-day readmission rates within 10–14 weeks?” The literature will be reviewed as it relates to TJR in outpatient and inpatient settings, reducing less than 30-day readmissions and using recovery messaging smartphones and mobile health applications. Literature relating directly to using recovery messaging smartphone applications to help reduce less than 30-day readmissions is preferred.
Significance of the Practice Problem
Hospital readmissions are costly, reaching $41.3 billion for patients readmitted within 30 days of discharge (Agency for Healthcare Research and Quality, 2018). Medicare cost was $26 billion for two million patients readmitted a year to the hospital after outpatient TJR and other outpatient surgical procedures (Centers for Medicare & Medicaid Services, 2018). When there is ineffective postoperative education for patients undergoing TJA, an increase in 30-day readmissions is seen. Effective preoperative/postoperative education is crucial for patients who are discharged home from the same-day surgery center to reduce complications and attain positive outcomes (Berg et al., 2018).
Translation Science Framework
The Knowledge-to-Action (KTA) framework was the change model used in this review.
It consists of two components: (1) knowledge creation and (2) action (Graham et al., 2006). Spooner et al. (2018) proposed that the three phases of the KTA model include selecting the intervention, monitoring knowledge use, and evaluating the outcomes. Each part consists of several steps that coincide with, or, in order. The KTA framework emphasizes collaboration among educators, knowledge learners, and users (Graham et al., 2006).
The KTA framework can be used as a model to help staff, providers, and stakeholders in the organizational change process. Graham et al. (2006) explained that the KTA framework includes continuous assessment, tailoring, adapting, implementation, and evaluation of outcomes. This cycle can help the organization fine-tune the new process. The KTA framework sustains knowledge usage and new processes. The sustainability of a practice change is important for strategies to maintain a new process that includes frequent education of staff, reevaluation of outcomes, and collaboration with stakeholders (Graham et al., 2006).
A literature search was conducted to locate primary research studies and systematic reviews focusing on key concepts related to TJR and readmissions to the hospital within less than 30 days postoperatively. These topics included perioperative patient education, patient compliance, and orthopaedic surgery. The search criteria included research conducted within the last 5 years from 2017 to 2022. The literature search was limited to academic databases, including PubMed Central, MEDLINE, EBSCO, Cochrane Library, and Cumulative Index to Nursing Allied Health Literature (CINHAL). The DNP student formulated specific search phrases for applications in the databases. These search phrases were combined using the Boolean operators “AND” and “OR” to refine the search. Different combinations of search phrases were applied to each database to obtain as many results as possible. The main key words were total joint replacement, total hip replacement, total knee replacement, total joint arthroplasty, hospital readmissions, readmission rates, preoperative education, postoperative complications, postoperative mobility, smartphone applications, mobile applications, and mobile health.
Initial searches produced more than 512,000 articles, of which 18 were selected and reviewed, as they matched the topic of the project and provided data to support the practice problem.
Eighteen studies were narrowed down to 15 studies that were the most relevant in addressing the intervention of using smartphone technology to reduce less than 30-day readmissions identified in the PICOT. The 15 studies were reviewed and evaluated using the John Hopkins evidence appraisal table (see Appendix A). All selected articles were ranked high based on search terms and Boolean key word searches. Multiple database searches were completed using, if not exactly, similar search terms, and the final list was merged.
A comprehensive systematic search was conducted for this integrative review using inclusion and exclusion criteria. The inclusion criteria for this review were based on criteria specific to TJR readmission research. Only articles on adult patients who had undergone TJR, or similar surgeries, patients who had been readmitted to the hospital after surgery, or patients who used smart phone applications or mobile health devices were included. Only those articles written in English were included in this study. Only those articles published between 2017 and 2022 were included in the present study. Articles that were considered over others were peer reviewed and had excellent or high-quality data, such as systematic reviews, randomized controlled trials (RCTs), meta-analyses, retrospective studies, prospective comparative studies, and before-and-after observational studies.
Data were retrieved through a literature review that included systematic reviews, retrospective and comparative reviews, and clinical trials. The selected literature examined the relationships between 30-day readmissions, patients who underwent TJR or similar surgery, and the effects of using a smartphone application or mobile health device during the postoperative period. The integrative review used qualitative data analysis to demonstrate the correlation between messaging applications and reducing less than 30-day readmissions. Data within each study were analyzed for the impact of the recovery messaging or smartphone application on measures such as positive postoperative outcomes and reduction of complications and readmissions.
The John Hopkins evidence summary table was used to evaluate the evidence levels of the selected articles. Three randomized clinical trial studies and one nonrandomized clinical trial review provided Level 1 evidence. Two prospective comparative studies were conducted at Level 2. All other studies were considered Level 2 or Level 3 because they were observational and retrospective. All selected studies were of high or good quality, as they were all consistent and produced generalizable results.
Results and Discussion Characterization of the Body of Literature
The article selection and exclusion process was based on a search for key words and inclusion and exclusion criteria. A literature search revealed 512,401 articles related to total joint replacement and 114,715 articles related to hospital readmissions. Total joint replacements and hospital readmissions were related to 5,402 of these articles. Two hundred forty-three articles were left for review after the exclusion criteria were applied. Fifteen articles were selected for inclusion after more key words were used to narrow the search for abstracts that related more to using recovery messaging or smartphone applications or to help reduce readmissions after TJR and after a close review of the quality of evidence. Of these, three were RCTs (Campbell et al., 2019; Hussain et al., 2017; Timmers et al., 2019), and one was a non-RCT (Stauber et al., 2020). A systematic review has been conducted (Bahadori et al., 2020). The remaining nine articles were observational studies categorized as prospective comparative studies, before-and-after studies, retrospective studies, and case studies (Berg et al., 2018; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Zheng et al., 2019).
The selected articles were obtained from international medical, scholarly, and peer-reviewed journals such as Journal of Nursing Care Quality, The Knee, Journal of Medical Engineering & Technology, BMC Geriatrics, BMC Musculoskeletal Disorders, JMIR Research Protocols, The Journal of Bone and Joint Surgery, Orthopedics, Acta Orthopaedica, Arthroplasty, Journal of the American Academy of Orthopaedic Surgeons, International Journal of Integrated Care, and Hospital for Special Surgery Journal. Three of the articles evaluated the impact of recovery messaging or smartphone applications on improving clinical outcomes during the postoperative period. Nine studies assessed the methods to reduce readmission rates after TJR. Three other studies evaluated the effects of smartphone applications or mobile devices on patient recovery rates and satisfaction.
Reduce Hospital 30-Day Readmissions
Ten of the 15 search articles were reviewed (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019) that described the prevalence of readmissions after TJR after the patients had received care through a fast-track process, outpatient same-day surgery, or a recovery instant messaging educational application. Each method of interventional monitoring upon patient discharge to prevent hospital readmissions for the TJR has unique benefits. Although RMA can help educate patients on possible complications such as infection of the joint, which may occur during the postoperative period, thus reducing readmission rates (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Hussain et al., 2017; Lyman et al., 2020; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019), a fast-track care pathway has been reported to reduce readmission rates among patients undergoing TJR by providing standardized discharge education and planning (Berg et al., 2018; Gabor et al., 2020; Zheng et al., 2019).
Researchers have established that using a fast-track, streamlined educational protocol or a recovery instant messaging, educational application can reduce the rate of readmission in patients undergoing TJR (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). A common theme among all articles was that same-day outpatient TJR patients who received adequate and streamlined perioperative education had fewer readmissions in the 30-day postoperative period. (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Readmission rates were measured in all studies (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Although most articles had the same goal of reducing readmission rates in the 30-day postoperative period after TJR, they differed in their methods and implementation.
According to the results of these studies, patients who undergo TJR in a same-day outpatient surgical setting and receive fast-track streamlined postoperative education or use an RMA have lower readmission rates (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Gabor et al. (2020) reported low postoperative complication rates and only 2% of the sampled patients were readmitted to the hospital. Berg et al. (2018) reported that 7.2% of the sampled population was readmitted, whereas Zheng et al. (2019) reported a 7.4% readmission rate. The economic benefits of decreased readmissions are also a common theme in the literature (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019).
Improve Patient Outcomes and Satisfaction
Other measurable effects included pain score and patient satisfaction. Pain scores, patient satisfaction, length of stay (for inpatient settings), and faster recovery and mobility in the postoperative period have been reported to improve after the use of recovery messaging or smartphone mobile health devices (Bahadori et al., 2020; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020). Improved patient outcomes, such as increased joint range of motion, increased mobilization, and improved quality of life, have been observed after the use of RMA and mobile health technology (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Improved preoperative and postoperative education also leads to improved patient satisfaction after TJR (Bahadori et al., 2020; Berg et al., 2018; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021).
Increase Patient Engagement and Early Mobility
The literature also reveals that the use of recovery messaging or smartphone applications improves clinical outcomes after TJR, such as patient engagement in recovery, faster recovery, and increased quality of life (Bahadori et al., 2020; Campbell et al., 2019; Hussain et al., 2017; Lyman et al., 2020; Stauber et al., 2020; Timmers et al., 2019). The postoperative recovery period improves after mobile technology (Bahadori et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Stauber et al., 2020; Timmers et al., 2019). Decreased postoperative complications, such as increased pain, limited mobility (frozen joint), blood clots, pneumonia, decreased quality of life, infection, and prosthesis dislocation, can be reduced by using recovery messaging and smartphone mobile health educational applications (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). The literature synthesis revealed that using streamlined protocols and RMA in patients undergoing TJR surgery can impact readmission rates and produce positive health outcomes.
Conclusions and Further Recommendations and Implications for Nursing Practice
The use of an educational reminder mobile health or smartphone recovery application can improve the number of less than 30-day readmissions (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). The reduction in hospital readmissions will decrease healthcare expenditures, both nationally and globally. Recovery messaging application and smartphone mobile health applications can be used after all surgeries. If patients are instructed on RMA during the preoperative or postoperative recovery period, the education received could improve patient outcomes and decrease complications. Recovery messaging application has the potential to help deliver quality nursing care to patients in a variety of organizations nationally and globally. The use of smartphone mobile health applications can help nurses and other healthcare team members streamline the education process.
Conclusions and Contributions to the Professions of Nursing
The literature review provides strong evidence for the use of RMA and smart mobile health applications and that proper preoperative education can reduce surgical complications, decrease less than 30-day readmissions, reduce healthcare costs nationally and globally, and increase patient engagement and satisfaction (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Glans et al., 2020; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). The utilization of RMA helps decrease the less than 30-day readmissions rate after outpatient TJR and can lead to a faster recovery and an increase in patient mobility (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Gabor et al., 2020; Gruskay et al., 2019; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Patient education regarding postoperative recovery can be streamlined through smartphone mobile health applications, thereby decreasing postoperative complications and improving patient outcomes (Bahadori et al., 2020; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019). Reducing postoperative complications and readmissions less than 30-day readmissions after TJR surgery in an outpatient setting using recovery messaging smartphone applications will help improve healthcare outcomes at the organizational, national, and global levels (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Harris et al., 2021; Hussain et al., 2017; Lyman et al., 2020; Mascioli et al., 2021; Oosterholt et al., 2017; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019).
Less than 30-day readmission after TJR or surgery increases healthcare expenditure at the local, national, and global levels. The results of this review support the use of recovery messaging smartphone mobile health applications and streamlined preoperative education to improve postoperative complications such as infection, deep vein thrombosis, decreased mobility, and pneumonia. The use of RMA has been proven to reduce less than 30-day hospital readmissions. Smartphone messaging and mobile health applications can be used in the postoperative period in outpatient and inpatient settings. Nurse leaders, facility stakeholders, and healthcare policy makers should consider implementing recovery-based messaging applications to improve patient outcomes and reduce healthcare expenditure.
Extensive preoperative and postoperative education is vital to prevent postoperative complications and decrease readmission rates. Streamlining instructions using RMA is a convenient way for patients to receive reminders and important information in the postoperative period. A literature review showed that using smartphone applications during recovery also increases patient satisfaction. Patient satisfaction and engagement during the postoperative period also facilitated recovery time.
Additional research is needed to examine the impact of streamlined education and RMA use on readmission rates of patients undergoing TJR (Bahadori et al., 2020; Berg et al., 2018; Campbell et al., 2019; Dehorney & Ashcraft, 2018; Gabor et al., 2020; Hussain et al., 2017; Lyman et al., 2020; Stauber et al., 2020; Timmers et al., 2019; Zheng et al., 2019).
Future research should evaluate the use of specific smartphone mobile health applications tailored for other surgical procedures. Further studies should be performed to measure patient satisfaction with this application. Surveys can be used to evaluate improved measures in patients during the postoperative period. Physicians, nurses, and other healthcare professionals can also be surveyed to assess their opinions on the application. Suggestions from these stakeholders should be considered when implementing future technologies.
Agency for Healthcare Research and Quality. (2018). National readmissions database. Retrieved November 4, 2021, from https://www.hcup-us.ahrq.gov
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Appendix A. Johns Hopkins Nursing Evidence-Based Practice Appendix G Individual Evidence Summary Tool
||Author and Date
||Sample, Sample Size, and Setting
||Study Findings That Help Answer the EBP Question
||Evidence Level and Quality
||Campbell et al. (2019)
||Quantitative: Randomized controlled trial
||The study consisted of 159 patients (83 in the control group and 76 in the intervention group) who were enrolled in the trial to test the effectiveness of a text-messaging service versus standardized patient education during the perioperative process.
||Results include that a text-messaging service can improve clinical outcomes and increase patient engagement in the early postoperative period following total joint arthroplasty (TJA). There are also trends of less emergency department visits with the intervention group.
||Clinical outcomes, patient engagement, ER visits.
||Limitations include that the study took place in one academic center and did not include a large portion of younger male patients. There may also be bias with enrollment and in self-reported data.
||Level I; great quality
||Hussain et al. (2017)
||Quantitative: Randomized controlled trial
||The study will evaluate 320 patients undergoing total knee replacement conducted at multiple sites (5) in many states in Australia for 13 months.
||Results show the positive impact of the app in terms of service satisfaction, acceptance, and economic benefits following total joint replacement surgery.
||Patient satisfaction, patient acceptance, and economic benefits.
||Limitations include lack of technology literacy for the targeted age group, participant unwillingness to continue using the app, and lack of training for the clinicians and healthcare workers at the sites.
||Level I; great quality
||Stauber et al. (2020)
||Quantitative: Nonrandomized, multicenter (4 sites), double arm, controlled trial with 1:1 assignment
||A total of 160 patients undergoing primary total knee or hip replacement from January until October 2019 in 4 German hospitals.
||The RECOVER-E application facilitates recovery and improves outcomes after total joint replacement surgery.
||Outcomes in the postoperative period, readmission rates, and recovery period time.
||The first limitation of the study is the nonrandomized assignment of participants. The second limitation is a potential mode effect due to different survey modes at baseline and 3 months postsurgery. The third limitation includes a potential source of bias with the exclusion of participants assigned to the intervention group who failed to download or access the app.
||Level I; great quality
||Timmers et al. (2019)
||Quantitative: A multicenter randomized controlled trial
||The study took place in five Dutch hospitals. A total of 213 participants underwent total knee replacement surgery between May and December 2018.
||The education of patients via the app shows significant positive improvements in pain, physical therapy and functioning, quality of life, self-care, and satisfaction with care compared with the patients who received standardized education.
||Positive patient outcomes: pain, physical therapy goals, functioning, QOL, and patient satisfaction.
||A limitation of the study is the number of patients in the intervention group who downloaded and used the app, including 93 out of 114. This could be due to the lack of technological knowledge. Another limitation includes the risk of bias with the use of self-developed questions. Also, direct patient feedback was not considered when the app was developed.
||Level I; great quality
||Bahadori et al. (2020)
||Quantitative: Systematic review
||Five studies were included in the review conducted from January 2000 to January 2019
||Studies reveal that patient outcome measures were more positive in the postoperative period after using technology such as a smartphone or activity tracker. Patients who received feedback from an activity tracker or smartphone app had higher activity levels after total joint replacement than those who did not receive feedback.
||Patient outcome measures the activity of the patient (activity levels).
||Limitations include limited data that explicitly investigate the use of commercial wearable technology or smartphone apps after total joint replacement. Also, the generalizability of results is problematic due to the risk of bias.
||Level I; excellent quality
||Harris et al. (2021)
||Quantitative: A prospective comparative study.
||A total of 1,714 patients underwent inpatient total shoulder arthroplasty (TSA), and 1,714 patients underwent outpatient TSA from 2010 to 2017 using the National Surgical Quality Improvement Program (NSQIP) registry.
||Readmissions were equal between both groups of patients. The study proves that as long as careful patient selection is exercised before total joint replacement, readmission rates will remain low in outpatient settings.
||Limitations include the use of the NSQIP database. When using this database, the rigidity of the data and anonymity of the patients limit the ability to analyze patient-specific information. Also, when categorizing readmissions as related to surgical complications, personal judgment must be used by whoever is entering data; therefore, could skew results.
||Level II; good quality
||Berg et al. (2018)
||A quantitative observational before-and-after study
||A total of 14,148 patients underwent total hip or knee replacement surgery at 8 Swedish hospitals from 2011 to 2015.
||Results showed that the total readmission rate of <90 days for THR was 7.2% with the fast-track program compared with the 6.7% of the previous program.
||Coding in the institutions may not be accurate—difficultly to control all compounding factors in the clinical pathway and care process.
||Level II; good quality
||Gabor et al. (2020)
||Quantitative: A retrospective study
||A total of 963 patients underwent primary THA at a single, urban, academic, tertiary institution between September 2016 and December 2018. Two cohorts: patients who underwent outpatient THA and patients who underwent inpatient THA.
||The outpatient surgery cohort had significantly fewer 90-day readmissions than the inpatient cohort.
||Inherent biases due to single-site, single surgeon, and retrospective study. 10.4% of patients in the outpatient cohort required an overnight stay.
||Level II; good quality, transparency
||Mascioli et al. (2021)
||Quantitative: Retrospective study
||Consecutive total knee arthroplasty (TKA) procedures were performed for more than 5 years between January 2014 and January 2019 at two freestanding ASCs, including 386 patients.
||The overall rates of surgical complications, 90-day hospital readmissions, and unplanned clinic visits were low after total knee replacement in ASCs. With standardized perioperative pathways, careful patient selection, and the proper protocols, total knee arthroplasty can be performed in the outpatient setting with low complication and readmission rates compared with national rates.
||Surgical complications, readmission rates, and clinic visits
||Limitations include the diagnoses leading to the need for TKA, and the cause of specific adverse events was not included in the study. Results may not be generalizable to other ASCs because the survey consists of TKA procedures performed by the same eight orthopaedic surgeons who use the same protocols. Also, this study did include a comparator arm, and some outcomes were not captured.
||Level II; good quality
||Oosterholt et al. (2017)
||Qualitative: Embedded case study, 16 semistructured interviews
||16 interviews in a teaching hospital in the Netherlands using visual care modeling tool kit to collect data.
||Results reveal that the most critical parts of the care pathway to prepare the patient for outpatient surgery include patient preparation and education, collaborative team care, early patient mobilization, flexible availability of the physiotherapist, functional discharge criteria, and joint decision making. All of these results included in another improved care pathway for future patient use can lead to a decrease in readmissions.
||Single case studies have limited external validity. The need for the analysis to be performed in other outpatient centers with the pathway would help produce more results. Visual communication has limited effects.
||Level III; good quality
||Zheng et al. (2019)
||Quantitative: Retrospective control study
||A total of 548 participants underwent arthroplasty between December 2015 and June 2018 in the Department of Joint Surgery in Beijing, China.
||The instant messaging platform has advantages over the traditional model and effectively reduces the readmission rate.
||Some patients did not use the instant messaging application and had missing contact info; many patients did not use the instant messaging tools, so this left researcher without needed postoperative information.
||Level II; good quality, transparency
||Lyman et al. (2020)
||Quantitative: Prospective cohort study
||A total of 128 THA and 139 TKA patients from February 2015 and May 2016 undergoing surgery at a hospital in New York.
||Technology helps collect patient-reported outcome measures and proves to help patients recover faster. Patients who had more steps had more positive outcomes in recovery.
||Patient activity, steps, and outcome measures
||One limitation was that the patient information was not recorded long enough preoperatively as baseline data. One-third of patients did not complete the study.
||Level II; good quality
||Dehorney and Ashcraft (2018)
||Quantitative: Quasi-experimental study. Quality improvement study
||The project included 1,425 patients in a 300-bed rural North Texas medical center in an 18-month long period.
||By the end of the project, the readmission rate of patients who underwent total joint replacement had decreased by 2.8% after experiencing joint camp. This also led to the realization of hospital cost savings due to the reduced length of stay of patients who participated in a joint camp.
||Readmission rates, LOS
||Limitations include using a small, convenience sample. Only patients older than 50 years were enrolled in the study. Also, an extended time frame is needed to evaluate the intervention.
||Level II; good quality
||Gruskay et al. (2019)
||A total of 2,600 patients undergoing outpatient knee replacement and 5,084 inpatient patients between 2007 and 2016.
||Results show that patients who had undergone surgery in outpatient setting have a decreased risk of postoperative complications and decreased risk of less than 90-day readmissions.
||Limitations of the study include that some patients did not complete the surveys, so the sample size is small.
||Level II; good quality
||Glans et al. (2020)
||Quantitative: Comparative retrospective study
||A total of 720 patients were hospitalized in Kristianstad (a 255-bed hospital in South Sweden).
||Study reveals that there is a higher risk of readmission within 30 days if the length of stay was longer than 5 days if discharged on Friday, if the patient had surgery, and was on 10 or more medications.
||One limitation of the study is that there is a high degree of internal missing internal variables, thus leading to nontrustworthy results. Also, the study was set in one hospital. This may make the results not generalizable.
||Level II; good quality
Note. ASCs = ambulatory surgery centers; EBP = evidence-based practice; ED = emergency department; LOS = length of stay; QOL = quality of life; THR= total hip replacement.
aPICOT: For adults receiving a total joint replacement in an outpatient surgery setting, will implementation of the recovery messaging mobile application via smartphone following discharge, compared with current practice, impact less than 30-day readmission rates within 10–14 weeks?