Same-day Discharge May Be Feasible for Some High-Risk TJA Patients
When determining which patients are appropriate candidates for same-day discharge after total joint arthroplasty, surgeons are typically advised to avoid high-risk patients and to focus on patients who are healthy, with no serious comorbidities.
But some patients who are classified as “high risk” can be safely discharged the same day as total knee arthroplasty (TKA) or total hip arthroplasty (THA) with no increase in complications or other adverse outcomes, according to a study published online ahead of print by The Journal of Bone & Joint Surgery.
The study authors, from Southern California Permanente Medical Group in San Diego, noted that, “…same-day discharge did not increase the risk of emergency department visits, unplanned readmissions, and complications as compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge in the hospital setting while maintaining safety.”
Using the Kaiser Permanente Total Joint Replacement Registry, they identified 2 groups of “high-risk” patients who underwent THA (n=5250) or TKA (n=9752) for osteoarthritis between 2017 and 2018. All patients had an American Society of Anesthesiologists (ASA) classification of 3 or higher, indicating a higher risk of adverse outcomes related to surgery and anesthesia.
About one-third of patients in both groups were discharged on the same day as surgery, without spending a night in the hospital. Complication rates, emergency department (ED) visits, unplanned hospital readmissions, and mortality were compared for patients who underwent same-day versus inpatient surgery.
For high-risk patients undergoing THA, same-day discharge was shown to be non-inferior to inpatient surgery for most outcomes. At 90 days, same-day discharge showed no increase in complications, ED visits, or hospital readmissions. The study could not demonstrate non-inferiority for mortality, as death was uncommon within 90-days of discharge in both groups.
For patients undergoing TKA, same-day discharge was shown to be non-inferior to inpatient surgery for mortality as well as complications, ED visits, and hospital readmissions. For both THA and TKA, the authors were unable to rule out a higher risk of certain types of complications, specifically deep infections and clot-related complications. These complications occurred in fewer than 1% of patients in both groups.
Certain other medical conditions were associated with an increased risk of specific adverse outcomes following same-day discharge. For example, patients with congestive heart failure had significantly higher complication rates after both THA and TKA. Other medical conditions were also associated with increased rates of ED visits and hospital readmission. Black patients had a higher risk of ED visits following TKA with same-day discharge.
All patients were treated at Kaiser Permanente hospitals in California, where formal programs have been introduced for same-day rapid recovery following total joint arthroplasty, including preoperative education, case managers, and home health. Before discharge, patients had to meet specific requirements for pain control, mobility, and caregiver support.
Previous studies have reported that same-day discharge following THA or TKA is safe for healthy patients, leading to significant cost savings. Most of these studies have been limited to younger and healthier patients. Concerns about safety, along with potential financial penalties for patients requiring further care, have so far limited expansion of same-day discharge in higher-risk patients.
The new study supports the feasibility and safety of same-day discharge for 1 group of higher-risk patients: those with an ASA score of 3 or higher.
“Our findings suggest that it may be possible to expand the indications for same-day discharge [TKA or THA] to include a more diverse selection of patients, provided that robust, enhanced care protocols are in place to ensure patient safety and mitigate the risk of adverse events,” the study authors concluded.
They also emphasized the need for larger studies to evaluate the impact on less-frequent outcomes.
Reddy NC, Prentice HA, Paxton EW, Hinman AD, Lin AG, Navarro RA. Association between same-day discharge total joint arthroplasty and risk of 90-day adverse events in patients with ASA classification of ≥3. J Bone Joint Surg Am. 2021 Sep 8. doi: 10.2106/JBJS.20.02110. Online ahead of print.