In addition to the Pearl Diver-based retrospective study by Arshi et al. on one-year complications after outpatient knee replacement, the December 6, 2017 issue of JBJS contains a NSQIP-based retrospective study by Basques et al. that compares 30-day adverse events and readmissions among 1,236 patients who underwent same-day-discharge hip or knee (total or unicompartmental) arthroplasty with an equal number of propensity score-matched patients who were discharged at least 1 calendar day after the procedure.
When analyzing all three procedures together, the authors found no overall between-group differences in the rates of any adverse event (severe or minor) or readmission. However, when authors analyzed individual adverse events, the same-day group had decreased thromboembolic events and increased 30-day reoperations compared to inpatients. Analysis of individual procedures revealed an increased 30-day reoperation rate for same-day total knee arthroplasty (TKA), compared with inpatient TKA. Overall, infection was the most common reason for reoperation and readmission following same-day procedures.
As with the Arshi et al. study, the limitations of the database prevented these authors from accounting for physician or hospital volume. However, they did identify several preoperative patient characteristics that increased the risk of 30-day readmission among same-day patients, and from those findings Basques et al. concluded that “obese patients, older patients [≥85 years of age], and those with diabetes mellitus may not be appropriate candidates for same-day procedures.”
In the April 19, 2017 issue of The Journal, Cancienne et al. compare complication and readmission rates for patients undergoing ambulatory shoulder arthroplasty with those among patients admitted as hospital inpatients postoperatively. Because the analysis was based on data from a large national insurer, we can be quite sure of appropriate coding and accurate data capture.
Similar to our recent report regarding outpatient hand and elbow surgery, in no instance were complications present at a significantly higher rate in the patients who underwent ambulatory shoulder arthroplasty, and the rate of hospital readmission after discharge was not significantly different at 30 or 90 days between the two cohorts.
This definitely is a tip of the hat to orthopaedic surgeons, nurses, and anesthesiologists, who are making sound decisions regarding which patients are appropriate for outpatient arthroplasty. Cancienne et al. found that obesity and morbid obesity were significant demographic risk factors for readmission among the ambulatory cohort, and they also identified the following comorbidities as readmission risk factors in that group:
- Peripheral vascular disease
- Congestive heart failure
- Chronic lung disease
- Chronic anemia
These results offer further documentation regarding the shift away from hospital-based care after orthopaedic surgery. Those of us who perform surgery in dedicated orthopaedic centers as well as general hospital operating rooms understand the concepts of efficiency, focus, maintenance of team skills, and limiting waste. Those objectives in large part drive the move to outpatient surgery. But patients, who almost always prefer to be at home and sleep in their own beds (or recliners in the case of shoulder replacement), may be an even more powerful driver of ambulatory care in the future.
Major advances in postoperative pain management are great enablers in this regard, and I believe the trend will continue. I envision a day when the only patients admitted to hospitals after orthopaedic surgery are those with unstable medical issues who potentially may need ICU care postoperatively.
Marc Swiontkowski, MD
In the April 5, 2017 issue of The Journal, Noureldin et al. analyzed more than 14,000 procedures from the NSQIP database to determine the rate of unplanned 30-day readmission after outpatient surgical procedures of the hand and elbow. The 1.2% rate seems well within the range of acceptability, particularly because the more than 450 institutions contributing to this database probably serve populations who don’t have the best overall health and comorbidity profiles.
Missing causes for about one-third of the readmissions illustrate one issue with data accuracy in these large administrative datasets. While the authors acknowledged a “lack of granularity” as the greatest limitation in analyzing large databases, they added that the readmissions with no listed cause “were likely unrelated to the principal procedure.”
It was not surprising that infection was the most common cause for readmission. However, it would have been nice to know the rate of confirmed infection via positive cultures, as I suspect many of these patients were readmitted for erythema, swelling, warmth, and discomfort associated with postoperative hematoma rather than infection.
Regardless of the need for higher-quality data on complications following outpatient orthopaedic surgical procedures, this analysis gives us more confidence that the move toward outpatient surgical care in our specialty is warranted. I think most patients would rather sleep in their own home as long as preoperative comorbidities and ASA levels are considered and adequate postoperative pain control can be achieved in an outpatient setting. The trend toward outpatient orthopaedic treatment is likely to continue as we gather higher-quality data and better understand the risk-benefit profile.
Marc Swiontkowski, MD
Here’s one thing about which medical studies have been nearly unanimous: Smoking is a health hazard by any measure. In the February 15, 2017 edition of The Journal of Bone & Joint Surgery, Tischler et al. put some hard numbers on the risk of smoking for those undergoing total joint arthroplasty (TJA).
After controlling for confounding factors, the authors of the Level III prognostic study found that:
- Current smokers have a significantly increased risk of reoperation for infection within 90 days of TJA compared with nonsmokers.
- The amount one has smoked, regardless of current smoking status, significantly contributed to increased risk of unplanned nonoperative readmission.
In a commentary on the Tischler et al. study, William, G. Hamilton, MD says, “…as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health.”
A case-control study by Boraiah et al. in the December 2, 2015 JBJS describes a risk-stratification tool that helps predict which patients undergoing total joint arthroplasty (TJA) are likely to be readmitted to the hospital after discharge. The authors used the tool—dubbed the Readmission Risk Assessment Tool, or RRAT—preoperatively among 207 patients who were subsequently readmitted after primary TJA and two cohorts of 234 patients each (one random and one age-matched) who were not.
The total RRAT score for each individual is the cumulative sum of all scores for modifiable risk factors such as infection, smoking, obesity, diabetes, and VTE. Non-modifiable risk factors such as age, sex, race, and socioeconomic status are not included in the scoring system.
The median RRAT score for those readmitted was 3; the median RRAT score for those not readmitted was 1. An RRAT score of ≥3 was significantly associated with higher odds of readmission. Surgical site infection was the most common cause of readmission (found in 45% of the 207 readmitted patients).
The authors note that in the current and future climate of value-based health care, “any unplanned readmission will have financial consequences on the provider and health-care institution”—not to mention the burden readmissions place on patients. While admitting that the RRAT needs to be further evaluated and validated in larger cohorts and that it may not be possible to modify individual risk factors into “an acceptable range” prior to TJA, the authors suggest that risk stratification with the RRAT “can present a ‘teachable moment’ and an opportunity for shared decision-making discussions.”
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.