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Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.

ABSTRACT: Background:Medicare-insured patients may be candidates for outpatient total knee and hip arthroplasty (TKA/THA) because postsurgical complications are often age unrelated. We evaluated an opioid-minimizing enhanced recovery after surgery (ERAS) pathway in an inpatient setting designed to presurgically optimize and prepare patients to reduce risk of avoidable postsurgical complications and maximize feasibility of same-day discharge. Methods:This single-center retrospective chart review included 601 unique consecutive Medicare-insured patients who underwent TKA (n = 337) or THA (n = 308) between June 1, 2015 and November 16, 2017. The ERAS pathway included presurgical nonarthroplasty treatment of osteoarthritis; physical, medical, and social optimization; and medication trials to individualize perioperative analgesia. All patients were discharged directly home without home services. Adverse events, satisfaction, and opioid use were analyzed descriptively. Results:Mean (range) age was 72 (32-92) years; 56.7% of patients were women; 84.0% were discharged the same day, 13.8% in 1 day, and 2.2% in >1 day. Rates of minor and severe adverse events within 30 days were 0.5% and 1.1%, respectively. There were no intubations, sepsis, or deaths. Twelve patients (1.9%) had unplanned readmissions within 30 days. Patient-reported satisfaction with facility, analgesia, and communication were high. Most patients (84.2%) did not require >1 seven-day opioid prescription from the surgeon within 8 weeks postsurgery. Conclusions:Using a patient-optimizing, opioid-minimizing ERAS pathway without home services, Medicare-insured patients undergoing TKA/THA experienced low complication rates and high satisfaction. Exploratory analysis suggests limited postsurgical opioid use. This presurgical patient-engagement approach may aid transition to freestanding ambulatory surgery centers.

SUBMITTER: Van Horne A

PROVIDER: S-EPMC6920716 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.

Van Horne Alaine A Van Horne James J

Arthroplasty today 20190925 4

<h4>Background</h4>Medicare-insured patients may be candidates for outpatient total knee and hip arthroplasty (TKA/THA) because postsurgical complications are often age unrelated. We evaluated an opioid-minimizing enhanced recovery after surgery (ERAS) pathway in an inpatient setting designed to presurgically optimize and prepare patients to reduce risk of avoidable postsurgical complications and maximize feasibility of same-day discharge.<h4>Methods</h4>This single-center retrospective chart re ...[more]

PMID: 31886397

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Project description:ImportanceIn 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown.ObjectivesTo describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs.Design, setting, and participantsThis observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022.Main outcomes and measuresCharacteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared.ResultsA total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001).ConclusionsThis study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

Project description:ImportanceThe Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.ObjectiveTo assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).Design, setting, and participantsThis multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.ExposuresTotal hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.Main outcomes and measuresThe primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.ResultsDuring the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P?=?.22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P?=?.02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P?<?.001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P?<?.001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P?<?.001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P?<?.001).Conclusions and relevanceAn increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Dataset Information

Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.

Publications

Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.

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