Clinical Outcomes and Cost Implications of Rapid Discharge Versus Traditional Pathways after Joint Replacement

Drs McAllister, Fuchs, and Stickney are continuing to study the impact of the SwiftPath® Method for outpatient joint replacement. The early results of this work has been accepted for presentation at the Annual Meeting of the American Association of Hip and Knee Surgeons in November and at the American Academy of Orthopedic Surgeons in March of 2016.

    Clinical Outcomes and Cost Implications of Rapid Discharge Versus Traditional Pathways after Joint Replacement
    Craig McAllister, Ira Kirschenbaum, Jeff Stepanian, Geoff Burk

Traditional total joint replacement typically involves a 2 to 3 day length of stay, considerable postoperative pain, and difficult and long rehabilitation. Rapid discharge after joint replacement is gaining interest as a way to improve outcomes, enhance the patient experience, and reduce costs. Focused patient education, advanced methods in nonnarcotic pain management, minimally invasive surgical methods and newer home care protocols are allowing patients to go home on the day of their hip or knee replacement.

This study compares the outcomes of a traditional care pathway versus a rapid discharge pathway for patients undergoing knee replacement for osteoarthritis.

A single surgeon performed 169 primary total joint arthroplasties in patients with osteoarthritis. In the traditional group, 89 joints were done using a traditional care pathway. In the traditional pathway, patients attended a hospital­ based joint camp that presented a standardized clinical pathway with a 3 day hospitalization. A standard surgical approach was used. No periarticular injections, preemptive analgesics, or postoperative multimodal pain regimen were utilized.

In the rapid discharge group, 80 primary joint replacements were done using a comprehensive approach designed specifically to allow a shortened length of stay, decrease pain, and improve the early rehabilitation. This protocol included multimodal pain management, an MIS ­computer navigated method, periarticular injections, and a novel approach to preoperative patient education program. Each patient and a designated family member were enrolled prospectively and participated in a “swiftpath” joint camp.

At the joint camp, patients calculated their own selection scores, and those scores were used to assign them to a standard hospital stay, 23 hour stay or someday discharge. Patients were encouraged to go home after surgery and avoid transfers to extended care facilities. Home care was monitored by family members without visiting nursing services, labs, or home PT. All patients were followed prospectively with daily VAS pain scores, clinical parameters and long axis and standard radiographs. Additionally, patients participated in an 6 month online, cyber­ secure patient reported outcome system where they reported their daily pain experience, weekly rehabilitation, return to activities and overall patient satisfaction.

The the patients in both groups were similar demographically. There was no statistically significant difference between groups with regard to age, diagnosis, sex, weight, preoperative ROM, or medical co­morbidities. There was no statistically significant difference between groups with regard to age, diagnosis, sex, weight, or preoperative ROM.

Patients in the rapid discharge group had shorter incision length, shorter length of stay, and less pain than in the traditional group. Moreover, those patients in the rapid discharge group had better flexion 6 weeks. By 12 weeks, there was no difference in the flexion between the two groups. However, manipulation was necessary in 14% of the traditional group compared with 2% in the rapid discharge group.

All 80 patients in the rapid discharge group completed the joint camp and the 6 month protocol. Based on the selection score, 42 patients were assigned to the same day discharge and 21 patients were assigned to 23 hour stays. Seventeen (17) were admitted to the hospital. The average LOS for the entire group was 0.43 (range 0 ­ 3 days). No patients were transferred to extended care facilities.

In the outpatient protocol, all of the patients assigned to the same day discharge pathway met their discharge criteria and were successfully discharged to home. Likewise, all of the 23 hour went home the morning after surgery. No labs, physical therapy, or other formal home care was instituted in these patients. There was no difference in the readmission rate between the traditional and the outpatient groups. There were five readmissions: 2 in the rapid discharge group and 3 in the traditional group. None of the patients in the rapid discharge cohort utilized and extended care facility. This was in contrast to 27 patients (37%) in the traditional group who used the transitional care unit or other rehabilitation facility. The acute care LOS was 3.8 days for the traditional group and 0.46 for the rapid discharge group.

In terms of pain, the traditional group required significantly more narcotics and reported a higher VAS by three days. There was a significantly more pain reported in the traditional hospital group. During the first four days after surgery, oral narcotics were used for breakthrough pain 14% of the time. The overall patient satisfaction for pain control was 8.0 on a ten point scale with 90% reporting that they were satisfied with their pain control. On a 10 point scale, patients reported a 9.8 for being likely to refer a family member, and 93% of patients felt that their joint replacement met their expectations in terms of function by 12 weeks.

Traditional joint replacement offers an excellent solution for the severely arthritic joint. A significant proportion of these patients can avoid admission to the hospital. Our results show that patients can be safely and predictably assigned to same day and 23hr discharge pathways. Patients who are discharged early after joint replacement are as likely to be happy with their pain control and functional result as patients who are admitted for traditional hospitalization.

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