Same Day Discharge After Total Joint Replacement Associated With Increased Risk for Complications
Same-day discharge following total knee arthroplasty (TKA) or total hip arthroplasty (THA) was associated with a higher risk for cardiac and pulmonary complications, according to researchers at Hospital for Special Surgery (HSS) presenting at the 2019 ASRA Annual Meeting.
In 2018, TKA was removed from the Center for Medicare and Medicaid Service inpatient-only procedure list, which may result in more of these surgeries being conducted as ambulatory procedures.
“Fast-track joint arthroplasty is feasible. However, I’m always concerned about prematurely discharging a patient, should something bad happen and the patient either will not or cannot handle the situation appropriately,” said Jiabin Liu, MD, PhD, lead investigator of the study and anesthesiologist at HSS.
To find out if same-day discharge joint arthroplasty is associated with an increased risk for adverse outcomes or unplanned readmission, Dr. Liu and colleagues at HSS conducted a population-based observational study of patients who underwent primary TKA or primary THA between 2011 and 2017 with data from the American College of Surgeons-National Surgical Quality Improvement Program® (ACS NSQIP®), which tracks surgeries performed in hospitals, not ambulatory surgery centers.
The researchers divided the patients into three groups according to length of stay (LOS 0, 1, and 2-3 days) and conducted regression analysis and propensity score matching. The primary outcomes they examined were readmission incidence and cardiac and/or pulmonary complications within 30 days of surgery, and the secondary outcomes examined were infections, major complication, and any complication.
The researchers found that between 2011 and 2017, there was an increase in the number of patients discharged on the day of surgery or the day after surgery (TKA: 1.04% in 2011 vs 26.55% in 2017; THA: 3.44% in 2011 vs 34.91% in 2017). There were no differences in 30-day mortality and no statistical differences in unplanned readmissions in patients undergoing TKA or THA who were released on the day of or the day after surgery. However, after adjusting for variables such as known risk factors prior to surgery, release on the day of surgery was associated with higher risk for cardiac and pulmonary complications in both TKA and THA when comparing to patients discharged the day after surgery.
“We did not expect same-day discharge patients to carry such high odds of complications compared with the fast-tracked group,” said Dr. Liu. “While the overall burden of complications is relatively low, until future studies can confirm or challenge our findings, a measured approach is advisable when recommending discharge of patients on the same day of surgery.”
While Dr. Liu emphasized that these results need confirmation from future studies, this study can currently alert and inform patients, clinicians, and policy-makers that patient selection is important for same-day surgery.
“When considering whether they want to be discharged the day of surgery, patients should keep in mind whether they have the knowledge, support, and necessary resources at home or close by in case they need medical attention. This does not necessarily have to be in person; telemedicine may potentially help,” Dr. Liu said.
“Clinicians need to realize that not all patients are suitable for ambulatory joint arthroplasty,” said Dr. Liu. “Existing prediction models based on risk factors are not reliable, while at least 50% of these fast-tracked patients with complications do not carry these risk factors.”
Liu J, Elkassabany NM, Poeran J, Gonzalez Della Valle A, Kim DH, Maalouf DB, Memtsoudis SG. “Same day discharge total joint arthroplasty is associated with increased risk of perioperative complications: a population-based study.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 11th consecutive year), No. 4 in rheumatology by U.S. News & World Report (2020-2021), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2020-2021). HSS is ranked world #1 in orthopedics by Newsweek (2020-2021). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.