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    Which Patients Are Candidates for Same-Day Discharge after TJA?

    By 2026 – not that far in the future – 51% of total hip and total knee arthroplasties will be done as outpatient procedures. [1] So the issue isn’t whether surgeons should consider doing outpatient total joint surgery, but rather whether they are prepared to ensure it’s done safely.

    A big part of safe outpatient joint replacement surgery is selecting the right patients. That’s pretty straightforward with young, healthy patients; most can be safely discharged the same day as surgery. But they represent just a small percentage of the roughly 1 million patients who undergo total joint arthroplasty annually in the US.

    What about the Medicare-age total hip and total knee arthroplasty patients? With the Centers for Medicare & Medicaid Services removing total knee arthroplasty from the inpatient-only list, [2] surgeons can expect pressure from their institutions to transition more older patients to the outpatient setting to control costs. Given that older patients typically have more comorbidities, surgeons will need a way to determine which patients can safely have surgery on an outpatient basis and which still need to undergo the procedure as an inpatient.

    R. Michael Meneghini, MD, from Indiana University School of Medicine in Indianapolis, is part of a team that has developed and published a scoring system – the Outpatient Arthroplasty Risk Assessment (OARA) Score – to address the issue of risk stratification for outpatient joint replacement surgery. [3] At ICJR’s annual Winter Hip & Knee Course, Dr. Meneghini reviewed this scoring system during his presentation on same-day discharge.

    Many institutions use the ASA Physical Status Classification System and/or the Charlson Comorbidity Index to determine if patients can be safely discharged the same day as surgery. But Dr. Meneghini and his colleagues found that these systems are not sensitive or specific enough for that purpose – not surprising, since that’s not their intended use.

    The OARA Score, they found, has a greater predictive value than the ASA score for determining which patients are good candidates for same-day or next-day discharge. [3] One of the reasons is that the OARA takes into account how well comorbidities are being controlled, not simply the fact that the patient has comorbidities. Using the OARA, Dr. Meneghini and his colleagues found that some patients classified as ASA 3 could actually be managed safely in an outpatient setting, while some ASA 2 patients could not.

    In his lecture at the ICJR Winter Hip & Knee Course, Dr. Meneghini describes the who, why, when, and where of same-day discharge following total joint arthroplasty. Click the image above to watch the presentation.

    Disclosures

    Dr. Meneghini has disclosed that he receives royalties and research support from and is a paid consultant for DJO Surgical; that he has stock or stock options in Emovi, MuveHealth, and PixarBio; that he receives royalties from and is a paid consultant for OsteoRemedies; that he receives gain-sharing refunds from IU Health; and that he has investment/ownership shares in IU Health Saxony ASC.

    References

    1. Outpatient Joint Replacement: An Unnecessary Concern or Market Reality? November 8, 2016. Available here. Accessed June 8, 2018.
    2. Centers for Medicare & Medicaid Services. Fact Sheet. CMS Issues Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System and Quality Reporting Programs Changes for 2018 (CMS-1678-FC). November 11, 2017. Available here. Access June 8, 2018.
    3. Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “Outpatient Arthroplasty Risk Assessment Score.” J Arthroplasty. 2017 Aug;32(8):2325-2331. doi: 10.1016/j.arth.2017.03.004. Epub 2017 Mar 14.