Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

Bernstein, David N.; Liu, Tiffany C.; Winegar, Angela L.; Jackson, Lauren W.; Darnutzer, Jessica L.; Wulf, K.; Schlitt, John T.; Sardan, Mauricio A.; Bozic, Kevin J.

doi:10.1016/j.arth.2018.08.018

Cited by 109 publications

(96 citation statements)

References 40 publications

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“…Reduction in LOS, increased discharge home, and reduction in perioperative complications resulting in readmission or reoperation are likely the result of improvements in preoperative patient optimization, expansion of multimodal analgesia, and patient education before these elective procedures. Interventions in the preoperative period have been shown to be highly successful in reducing LOS and decreasing overall costs of care [ [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] ]. Other advancements in arthroplasty practice, such as improvements in surgical technique, greater understanding of the hip-spine relationship, or utilization of larger femoral heads and dual-mobility components, may also have contributed to the findings observed in this study.…”

Section: Discussionmentioning

confidence: 99%

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

DeMik

Carender

Glass

et al. 2021

The Journal of Arthroplasty

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Background There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA. Methods Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed. Results In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 ( P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% ( P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases. Conclusion Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

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Section: Discussionmentioning

confidence: 99%

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

DeMik

Carender

Glass

et al. 2021

The Journal of Arthroplasty

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“…Bernstein et al reported on the value of a preoperative optimization protocol for patients leading into arthroplasty surgery. 17 This protocol, which included routine blood screening, determined that preoperative investigations resulted in decreased length of stay, fewer post-operative investigations and lower direct cost. In our patient cohort with a high frequency of abnormal results, we support a method to identify patients at risk and intervene as required to optimize them for surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Bernstein et al . reported on the value of a preoperative optimization protocol for patients leading into arthroplasty surgery . This protocol, which included routine blood screening, determined that preoperative investigations resulted in decreased length of stay, fewer post‐operative investigations and lower direct cost.…”

Section: Discussionmentioning

confidence: 99%

Utility of preoperative blood screening before hip and knee arthroplasty

Shumborski

Gooden

Salmon

et al. 2020

ANZ Journal of Surgery

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Background It is engrained in medical training that routine blood screening prior to arthroplasty is necessary for optimal patient care. There is little evidence to support their utility and the aggregate cost to the health system. The purpose of this study was to evaluate preoperative blood screening by identifying the frequency of an abnormal result and to examine the influence of age, gender and body mass index on the frequency of abnormal blood pathology. Methods This is a retrospective review of 1000 patients from a single centre who underwent elective primary hip or knee arthroplasty from 2015 to 2017. Abnormal blood results were identified and clinically relevant intervals were created for routine markers. Results A total of 939 patients had available pathology results with 84% identified as having an abnormal result and 47% having a clinically important range. Abnormal liver function tests and ferritin were most common. With increasing age, there was a significant increase in rates of abnormal clinically important range, renal dysfunction, abnormal haemoglobin and erythrocyte sedimentation rate. Males and patients with body mass index >40 had an increased rate of abnormal results, particularly liver function tests. Conclusion The ordering of preoperative investigations prior to lower limb arthroplasty is recommended by the National Institute for Health and Care Excellence guidelines, alleviating concern of post‐operative complications and covering medicolegal issues. Our study determined a high frequency of abnormal results, justifying routine blood screening is recommended prior to surgery, particularly for the elderly, males and obese patients.

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“…There is a projected increase in demand for total knee arthroplasty (TKA) to 3.5 million by 2030, 1 and thus, considerable research has focused on optimizing value-based health care. 2,3 Both modifiable and nonmodifiable risk factors have been investigated as to how they affect the cost of primary TKA. [4][5][6][7][8] A recent retrospective study by Khanuja et al evaluated a group of hospitals within a single health care system and found that the community hospitals had significantly faster operative times compared with a tertiary care academic hospital, while surgeon volume did not affect the operative time.…”

mentioning

confidence: 99%

An Academic Orthopaedic Specialty Hospital Provides the Shortest Operative Times within a Single Health System for Primary and Revision Total Knee Arthroplasty

et al. 2020

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The study aimed to optimize value-based health care practices in total joint arthroplasty (TJA), and we need to understand how the surgical setting can influence efficiency of care. While this has previously been investigated, the purpose of this study was to clarify if these findings are generalizable to an institution with an orthopaedic specialty hospital. A retrospective review was conducted of 6,913 patients who underwent primary or revision total knee arthroplasty (TKA) at one of four hospitals within a single, urban, and academic health system: a high volume academic (HVA) hospital, a low volume academic (LVA) hospital, a high volume community (HVC) hospital, or a low volume community (LVC) hospital. Patient demographics were collected in an arthroplasty database, as were operating room (OR) times and several specific time points during the surgery. The HVA (orthopaedic specialty) hospital had the shortest total primary TKA OR times and the LVC that had the longest times (156.69 vs. 174.68, p < 0.0001). The HVA hospital had the shortest total revision TKA OR times, and the LVC had the longest times (158.20 vs. 184.95, p < 0.0001). In our health system, the HVA orthoapedic specialty hospital had the shortest overall OR time, even when compared with the HVC hospital. This is in contradistinction to prior findings that HVC institutions had the shortest OR times in a health system that did not have an orthopaedic specialty hospital. This provides evidence that an orthopaedic specialty hospital can be a model for efficient care, even at an academic teaching institution.

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Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

Cited by 109 publications

References 40 publications

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases

Utility of preoperative blood screening before hip and knee arthroplasty

An Academic Orthopaedic Specialty Hospital Provides the Shortest Operative Times within a Single Health System for Primary and Revision Total Knee Arthroplasty

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