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Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

ABSTRACT: There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are "observed" for one or more nights. Current regulations in the United States allow these "observed" patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, "outpatient" means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data.The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of "inpatient" and "outpatient" (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions.Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed "outpatient" by the hospital. The actual hospital LOS of "outpatients" was characterized. "Outpatients" were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors.Of 72,651 patients undergoing THA, 529 were identified as "outpatients" but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as "outpatients" but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found "inpatient" THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with "outpatient" THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort.Future THA, TKA, or other investigations on this topic should consistently quantify the term "outpatient" because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications.Level III, therapeutic study.

SUBMITTER: Bovonratwet P

PROVIDER: S-EPMC5670045 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

Bovonratwet Patawut P Webb Matthew L ML Ondeck Nathaniel T NT Lukasiewicz Adam M AM Cui Jonathan J JJ McLynn Ryan P RP Grauer Jonathan N JN

Clinical orthopaedics and related research 20171201 12

<h4>Background</h4>There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients w ...[more]

PMID: 28083753

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Project description:BackgroundThe length of hospital stay after lower limb arthroplasty has rapidly decreased in the last decade, largely in part due to the rise of improved perioperative protocols, but also as a response to the increased economic demand associated with the rapid growth in hip and knee arthroplasty procedures. In line with this, the development of a new pathway after lower limb arthroplasty that allows for the surgery to be performed in an outpatient setting and permits for same-day discharge after the procedure is increasingly being offered. Although costs and complications between the inpatient and outpatient models have been compared, there appears to be little known about the effects on a patient's physical function after undergoing hip or knee outpatient arthroplasty. Therefore, this systematic review aims to explore the available evidence for the effect on functional outcomes following inpatient versus outpatient hip or knee arthroplasty.MethodsThis systematic review adhered to the PRISMA guidelines and was prospectively registered ( https://osf.io/8bfae/ ). An electronic search of three online databases (PubMed, CINAHL and EMBASE) was conducted to identify eligible studies. All studies investigating inpatient and outpatient comparator groups, for a population of patients undergoing hip or knee arthroplasty, that assessed one or more functional outcomes, were included. A methodological quality appraisal was undertaken for the final studies contained in this review. A narrative synthesis of results is described along with quantitative outcomes presented in tables and figures.ResultsA total of seven studies containing 1,876 participants were included in this review. Four studies assessed a THA population, two assessed TKA and one assessed both. Functional outcomes varied, with 20 different functional outcomes utilised, of which 18 were patient-reported tools. Results of functional outcomes offered mixed support for both inpatient and outpatient pathways.ConclusionsThe results of this review suggest that outpatient or inpatient pathway selection for hip or knee arthroplasty should not be based on the superiority of functional outcomes alone. However, given there is growing evidence in support of an outpatient pathway in select patients with respect to cost savings and without any increase in complications, it could be proposed that an equivalency of post-operative function between the two settings makes same-day discharge favourable. Publicly registered with Open Science Framework ( https://osf.io/8bfae/ ).

Project description:Length of stay after total hip arthroplasty (THA) has decreased over the last two decades. However, published studies that have examined same-day and early discharge protocols after THA have been done in highly selected patient groups operated on by senior surgeons in a nonrandomized fashion without control subjects.The purpose of this study was to evaluate and compare patients undergoing THA who are discharged on the same day as the surgery ("outpatient," less than 12-hour stay) with those who are discharged after an overnight hospital stay ("inpatient") with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission, emergency department or physician office); and (3) relative work effort for the surgeon's office staff.A prospective, randomized study was conducted at two high-volume adult reconstruction centers between July 2014 and September 2015. Patients who were younger than 75 years of age at surgery, who could ambulate without a walker, who were not on chronic opioids, and whose body mass index was less than 40 kg/m2 were invited to participate. All patients had a primary THA performed by the direct anterior approach with spinal anesthesia at a hospital facility. Study data were evaluated using an intention-to-treat analysis. A total of 220 patients participated, of whom 112 were randomized to the outpatient group and 108 were randomized to the inpatient group. Of the 112 patients randomized to outpatient surgery, 85 (76%) were discharged as planned. Of the remaining 27 patients, 26 were discharged after one night in the hospital and one was discharged after two nights. Of the 108 patients randomized to inpatient surgery with an overnight hospital stay, 81 (75%) were discharged as planned. Of the remaining 27 patients, 18 met the discharge criteria on the day of their surgery and elected to leave the same day, whereas nine patients stayed two or more nights.On the day of surgery, there was no difference in visual analog scale (VAS) pain among patients who were randomized to discharge on the same day and those who were randomized to remain in the hospital overnight (outpatient 2.8 ± 2.5, inpatient 3.3 ± 2.3, mean difference -0.5, 95% confidence interval [CI], -1.1 to 0.1, p = 0.12). On the first day after surgery, outpatients had higher VAS pain (at home) than inpatients (3.7 ± 2.3 versus 2.8 ± 2.1, mean difference 0.9, 95% CI, 0.3-1.5, p = 0.005). With the numbers available, there was no difference in the number of reoperations, hospital readmissions without reoperation, emergency department visits without hospital readmission, or acute office visits. At 4-week followup, there was no difference in the number of phone calls and emails with the surgeon's office (outpatient: 2.4 ± 1.9, inpatient: 2.4 ± 2.2, mean difference 0, 95% CI, -0.5 to 0.6, p = 0.94).Outpatient THA can be implemented in a defined patient population without requiring additional work for the surgeon's office. Because 24% (27 of 112) of patients planning to have outpatient surgery were not able to be discharged the same day, facilities to accommodate an overnight stay should be available.Level I, therapeutic study.

Project description:ObjectiveTo compare the effectiveness and acceptability of outpatient polypectomy with inpatient polypectomy.DesignPragmatic multicentre randomised controlled non-inferiority study.SettingOutpatient hysteroscopy clinics in 31 UK National Health Service hospitals.Participants507 women who attended as outpatients for diagnostic hysteroscopy because of abnormal uterine bleeding and were found to have uterine polyps.InterventionsParticipants were randomly assigned to either outpatient uterine polypectomy under local anaesthetic or inpatient uterine polypectomy under general anaesthesia. Data were collected on women's self reported bleeding symptoms at baseline and at 6, 12, and 24 months. Data were also collected on pain and acceptability of the procedure at the time of polypectomy.Main outcome measuresThe primary outcome was successful treatment, determined by the women's assessment of bleeding at six months, with a prespecified non-inferiority margin of 25%. Secondary outcomes included generic (EQ-5D) and disease specific (menorrhagia multi-attribute scale) quality of life, and feasibility and acceptability of the procedure.Results73% (166/228) of women in the outpatient group and 80% (168/211) in the inpatient group reported successful treatment at six months (intention to treat relative risk 0.91, 95% confidence interval 0.82 to 1.02; per protocol relative risk 0.92, 0.82 to 1.02). Failure to remove polyps was higher (19% v 7%; relative risk 2.5, 1.5 to 4.1) and acceptability of the procedure was lower (83% v 92%; 0.90, 0.84 to 0.97) in the outpatient group Quality of life did not differ significantly between the groups. Four uterine perforations, one of which necessitated bowel resection, all occurred in the inpatient group.ConclusionsOutpatient polypectomy was non-inferior to inpatient polypectomy. Failure to remove a uterine polyp was, however, more likely with outpatient polypectomy and acceptability of the procedure was slightly lower.Trial registrationInternational Clinical Trials Registry 65868569.

Project description:The National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) collect sample data and publish annual estimates of inpatient care in the United States, and both are commonly used in orthopaedic research. However, there are important differences between the databases, and because of these differences, asking these two databases the same question may result in different answers. The degree to which this is true for arthroplasty-related research has, to our knowledge, not been characterized.We tested the following null hypotheses: (1) there are no differences between the NHDS and NIS in patient characteristics, comorbidities, and adverse events in patients with hip osteoarthritis treated with THA, and (2) there are no differences between databases in factors associated with inpatient mortality, adverse events, and length of hospital stay after THA.The NHDS and NIS databases use different methods of data collection and weighting to provide data representative of all nonfederal hospital discharges in the United States. In 2006 the NHDS database contained 203,149 patients with hip arthritis treated with hip arthroplasty, and the NIS database included 193,879 patients. Multivariable analyses for factors associated with inpatient mortality, adverse events, and days of care were constructed for each database.We found that 26 of 42 of the factors in demographics, comorbidities, and adverse events after THA in the NIS and NHDS databases differed more than 10%. Age and days of care were associated with inpatient mortality with the NHDS and the NIS although the effect rates differ more than 10%. The NIS identified seven other factors not identified by the NHDS: wound complications, congestive heart failure, new mental disorder, chronic pulmonary disease, dementia, geographic region Northeast, acute postoperative anemia, and sex, that were associated with inpatient mortality even after controlling for potentially confounding variables. For inpatient adverse events, atrial fibrillation, osteoporosis, and female sex were associated with the NHDS and the NIS although the effect rates differ more than 10%. There were different directions for sources of payment, dementia, congestive heart failure, and geographic region. For longer length of stay, common factors differing more than 10% in effect rate included chronic pulmonary disease, atrial fibrillation, complication not elsewhere classified, congestive heart failure, transfusion, discharge nonroutine compared with routine, acute postoperative anemia, hypertension, wound adverse events, and diabetes mellitus, whereas discrepant factors included geographic region, payment method, dementia, sex, and iatrogenic hypotension.Studies that use large databases intended to be representative of the entire United States population can produce different results, likely related to differences in the databases, such as the number of comorbidities and procedures that can be entered in the database. In other words, analyses of large databases can have limited reliability and should be interpreted with caution.Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Project description:BackgroundFailure of THA or TKA to meet a patient's expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions.Questions/purposesTo determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where 'benefit' is defined as a clinically important improvement in a validated patient-reported outcomes score.MethodsIn this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0-100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons' expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively.ResultsSurgeons' expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53-0.82; p = 0.02) and 0.74 (95% CI, 0.63-0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons' expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m2, who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons' expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42-0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40-0.61], p = 0.92).ConclusionsMost patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons' expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons' expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients' expectations more effectively.Level of evidenceLevel II, therapeutic study.

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Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

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Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

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