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

BACKGROUND: Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs. METHODS: This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015). RESULTS: The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m2 or 35-40 kg/m2 with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93). CONCLUSION: In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

A Simple Tool for Recommending Postoperative Status After Lower Extremity Total Joint Replacement.

There is an increasing impetus to perform primary total hip arthroplasty and total knee arthroplasty on an outpatient basis and in the outpatient setting. However, with recent federal regulatory changes, orthopedic surgeons must now evaluate patients on a case-by-case basis to determine whether an inpatient admission will be medically necessary and appropriate. We thus created our prototype Lower Extremity Inpatient-Outpatient (LET-IN-OUT) total joint replacement tool as a simple, consistent way for other clinicians to identify specific major preoperative patient comorbidities and thus to recommend independently and objectively to the orthopedic surgeon postoperative inpatient or outpatient status for a given patient.