Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study.

In France and in the US, predictions for 2030 include an increased number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures together with an overall trend towards shorter hospital stays. Predictors of hospital length of stay (LOS) include the day of surgery, discharge destination, and patient comorbidities. Available data are conflicting, however, and to our knowledge predictors of LOS after THA or TKA have not been evaluated in France. Improved knowledge of these predictors would be expected to increase patient care efficiency. The objectives of this study were: (1) to determine whether the above-listed factors predict LOS after THA or TKA, (2) to identify predictors of discharge to a rehabilitation unit and of readmission within 30 days after surgery. Both patient-related factors unamenable to modification and modifiable organisational factors are associated with LOS after THA or TKA. This large single-centre retrospective cohort study included all adults who underwent primary THA or TKA at our university hospital between 1 January 2015 and 31 December 2016. Non-inclusion criteria were revision arthroplasty, THA with femoral or acetabular reconstruction, TKA using a constrained hinged implant, and fracture as the reason for arthroplasty. Preoperative parameters, type of arthroplasty, and postoperative care were recorded. We included 938 patients with THA and 725 patients with TKA. By multivariate analysis, the likelihood of being discharged by day 5 decreased with older age (HR, 0.986; 95%CI: 0.98-0.99) and was lower by 13% in females (HR, 0,871; 95%CI: 0.77-0.986), by 39% in patients with diabetes (HR, 0.606; 95%CI: 0.5-0.73), by 68% in patients discharged to rehabilitation units (HR, 0.322; 95%CI: 0.267-0.389), and by 27% in patients who had arthroplasty on a Friday (HR, 0.733; 95%CI: 0.631-0.852). Factors predicting discharge to rehabilitation unit were older age, female gender, chronic obstructive pulmonary disease, anxiety-depressive disorder, and a history of stroke. Risk factors for 30-day readmission were male gender, obesity, and discharge to rehabilitation unit. In this study, predictors of LOS were identified using a survival model that considered age as a continuous variable, separate comorbidities, and the discharge destination. Our findings are consistent with earlier reports and confirm the strong associations linking LOS to diabetes, day of surgery, and discharge destination in France. We also identified predictors of discharge to rehabilitation and of readmission within 30 days. IV, retrospective observational cohort study.

Roger C ，Debuyzer E ，Dehl M ，Bulaïd Y ，Lamrani A ，Havet E ，Mertl P ... -  《Orthopaedics & Traumatology-Surgery & Research》

Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years.

Pitter FT ，Jørgensen CC ，Lindberg-Larsen M ，Kehlet H ，Lundbeck Foundation Center for Fast-track Hip and Knee Replacement Collaborative Group ... -  《-》

Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.

To determine if same-day discharge total knee arthroplasty (TKA) or total hip arthroplasty (THA) is not associated with increased risk of unplanned readmission and adverse outcomes within 30 days of surgery. This is a population-based observational study. Patients from 708 participating institutions who underwent primary TKA or primary THA between 2011 and 2017 were divided into three groups by length of stay (LOS 0, 1 and 2-3 days). All patients with LOS>3 days were excluded from the current study. Regression analysis and propensity score matching were performed. American College of Surgeons-National Surgical Quality Improvement Programme database. Primary outcomes included unplanned readmission and cardiac/pulmonary complications within 30 days of surgery. We identified 226 481 TKA (LOS 0=3118, LOS 1=31 404, and LOS 2-3=1 91 959) and 140 557 THA patients (LOS 0=2652, LOS 1=29 617, and LOS 2-3=1 08 288). There were no differences in 30-day mortality. After adjusting for relevant covariates, LOS 0 (compared with LOS 1) was associated with higher odds of cardiac/pulmonary complications in both TKA (OR 1.95, 95% CI 1.20 to 3.16; 0.67% vs 0.37%) and THA (OR 1.96, 95% CI 1.05 to 3.64; 0.57% vs 0.26%). There were no statistical differences in unplanned readmissions between LOS 0 and LOS 1 groups in TKA (2.41% vs 2.31%) and THA (1.62% vs 2.04%). LOS 0 discharge after TKA and THA was associated with higher odds of cardiac/pulmonary complications compared with LOS 1 discharge. 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.

Liu J ，Elkassabany N ，Poeran J ，Gonzalez Della Valle A ，Kim DH ，Maalouf D ，Memtsoudis S ... -  《BMJ Open》

Hospital Discharge within 2 Days Following Total Hip or Knee Arthroplasty Does Not Increase Major-Complication and Readmission Rates.

The rising costs of total knee arthroplasty (TKA) and total hip arthroplasty (THA) have resulted in a substantial economic burden on the U.S. health-care system. Recent efforts to contain these costs have targeted hospital length of stay. However, shorter hospital admissions have raised concerns over possible increases in complications and readmission rates. The purpose of this study was to assess whether early discharge, from 0 to 2 days postoperatively, was associated with increased 30-day major complications and readmissions compared with standard discharge, 3 to 4 days following THA or TKA. The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent an elective, primary unilateral THA or TKA between 2011 and 2012. For each procedure, 2 groups were created consisting of patients discharged from 0 to 2 days (early discharge) and those discharged from 3 to 4 days (standard discharge). Patient demographics and perioperative variables were compared between both discharge groups. Multivariable logistic-regression models were used to assess the independent effect of length of stay on 30-day major-complication and readmission rates. A total of 31,044 patients who underwent TKA and 19,909 patients who underwent THA were included. Overall, patients who were discharged early were younger and had fewer medical comorbidities and a lower American Society of Anesthesiologists (ASA) score. The multivariable logistic-regression model revealed that early discharge was not associated with increased odds of major complications following TKA (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.75 to 1.20; p = 0.64). Furthermore, early discharge following THA was found to be an independent predictor against major complications (OR = 0.75; 95% CI = 0.58 to 0.95; p = 0.02). Lastly, early discharge was not an independent risk factor for hospital readmission following THA or TKA. Early discharge was not an independent risk factor for 30-day major complications or readmissions following THA or TKA. Rather, increased major complications and readmissions were attributed to patient comorbidities and perioperative variables. Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sutton JC 3rd ，Antoniou J ，Epure LM ，Huk OL ，Zukor DJ ，Bergeron SG ... -  《-》

Patient and Perioperative Variables Affecting 30-Day Readmission for Surgical Complications After Hip and Knee Arthroplasties: A Matched Cohort Study.

Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital. Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission. Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 [1.4-8.5]; P < .01). Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.

Ricciardi BF ，Oi KK ，Daines SB ，Lee YY ，Joseph AD ，Westrich GH ... -  《-》