Rapid Discharge and Outcomes in Revision Total Knee Arthroplasty
Optimizing reimbursement under bundled payment models requires surgeons to critically examine all aspects of the total joint arthroplasty experience to determine where costs can be reduced without compromising the outcome.
The hospital length of stay (LOS) is one of the variables under scrutiny. Surgeons have found that advances in perioperative management, including better techniques and technologies, allow them to discharge their total joint arthroplasty patients quicker than ever before. The question is, are outcomes being sacrificed in this push for shorter LOS?
In general, the answer is no, they are not: A recently published study found no increased risk of 30-day complications with a shortened LOS in primary total knee arthroplasty (TKA) patients.  And, research presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) reported similar results when comparing discharge from an ambulatory care center with discharge from an inpatient hospital. 
Discharge is patient-dependent, though, regardless of efforts to reduce costs by reducing LOS: A healthier, motivated patient with an uncomplicated procedure will generally be judged safe for discharge sooner than a patient with comorbidities who develops a complication in the hospital.
Which brings us to revision joint replacement, typically performed in patients who need a more complex surgical procedure, have a higher risk of complications, and incur greater costs in the episode of care than patients who undergo primary joint replacement. Reducing LOS doesn’t seem to be on the table for this patient population.
But maybe it should be, according to research from Hospital for Special Surgery presented at the 2019 Annual Meeting of the AAOS. Alexander McLawhorn, MD, and his colleagues found that selected patients undergoing aseptic revision TKA can be discharged 0 to 2 days after the procedure – instead of the conventional 3 to 4 days – without an increase in the 30-day complication rate.
For the study, the researchers identified all patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone revision TKA between 2007 and 2016, recording demographics, risk factors, perioperative events, and complications in the 30-day postoperative period for 2 patient cohorts:
- Those with an early discharge, defined as 0 to 2 days after surgery
- Those with a conventional discharge, defined as 3 or 4 days after surgery
Patients in the early discharge group who underwent single-component revision, the researchers found, had a lower risk of developing either minor (P=0.001) or septic complications (P=0.016) in the 30 days after surgery than patients in the conventional discharge group. There was no difference in the complication rate for early and conventional discharge patients who underwent double-component revision TKA.
This finding wasn’t a surprise to Dr. McLawhorn and his colleagues, who had designed the study to evaluate current practice. “Within the past decade, rapid discharge protocols have become more prevalent for primary joint replacement surgery,” he said. “Prior studies that analyzed rapid recovery and same-day discharges for primary TKA showed no increase in short-term complications and actually demonstrated benefits in terms of patient satisfaction and costs.
“Therefore, we suspected that for select patients receiving revision TKA for aseptic diagnoses, we would not observe an increase in short-term complications.”
Noting that revision TKA patients typically have an LOS of 4 to 7 days, Dr. McLawhorn said the findings of this study suggest that “an extended hospital length of stay is not necessary for all revision patients. While we do not advocate that all patients be enrolled in rapid discharge protocols, we believe that there is a subset of patients who would be appropriate and safe for an accelerated recovery program after revision TKA.”
Dr. McLawhorn said the criteria he and his colleagues use to more-rapidly discharge patients after revision TKA are based on their criteria for discharging primary TKA patients. “In general, patients must be relatively healthy, with a low comorbidity burden, and have an aseptic diagnosis for the revision procedure,” Dr. McLawhorn said.
“Patients are typically younger than 70 years of age, with BMI between 18.5 and 35. Diabetes, if present, has to well-controlled, with a hemoglobin A1C less than 7. Patients should have adequate home support and be willing to have a short-stay or ambulatory surgery in the case of liner exchanges.”
He said that patients are probably not ideal candidates for rapid discharge if they have a history of myocardial infarction, valvular disease, arrhythmias, heart surgery, sleep apnea, or chronic opioid dependency.
Ultimately, the decision on discharge, whether rapid or conventional, should be tailored to each individual patient, Dr. McLawhorn said, taking into account the reason for revision, the patient’s baseline comorbidities, and intraoperative events.
As surgeons, patients, and hospitals become more comfortable and more experienced with short-stay and ambulatory primary arthroplasty procedures, “we suspect that we will see more revision procedures safely performed in the outpatient and ambulatory settings,” he said.
Gu A, Gerhard E, Wei C, Sobrio S, Sculco P, McLawhorn A. Effect of Early Discharge on Postoperative Comorbidity and Complications for Patients Undergoing Revision Total Knee Arthroplasty (Paper 375). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
- Sarpong NO, Boddapati V, Herndon CL, Shah RP, Cooper HJ, Geller JA. Trends in length of stay and 30-day complications after total knee arthroplasty: an analysis from 2006 to 2016. J Arthroplasty. 2019 Apr 16. pii: S0883-5403(19)30359-6. doi: 10.1016/j.arth.2019.04.027. [Epub ahead of print]
- Ast M, Davis D, Carroll K, Ong A. No Increased Risk of 90-Day Complication or Readmission, as Well as Decreased Cost, with Total Joint Replacement in a Private, Community-Based Ambulatory Surgery Center (Poster P0593). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.