Outpatient knee arthroplasty has high readmission rates

By Fran Lowry

Performing total joint arthroplasty (TJA) for knees as a same-day procedure comes with relatively high readmission rates, according to research presented March 13th at the American Academy of Orthopaedic Surgery (AAOS) Annual Meeting in New Orleans.

Patients having TJA for hips, however, seem to have similar readmission rates whether they have same-day procedures or they're kept in the hospital for one or two nights.

"Recent advances in total joint arthroplasty have focused on pain management, speedier rehab, and earlier discharge from hospital," lead author Dr. David Vegari, formerly from Ortho Carolina, in Charlotte, North Carolina, and now from Lankenau Institute for Medical Research in Wynnewood, Pennsylvania, told Reuters Health in a telephone interview.

"The push for outpatient surgery does have potential cost savings but I think hospitals and surgeons need to be cognizant of the fact that there is a potential for more visits to the emergency room and more hospital readmissions for knee TJA," Vegari said.

Under the Patient Care and Affordability Act, Medicare is now focusing on 30-day readmission rates after TJA and will penalize hospitals financially for such readmissions.

In the current study, Vegari and his team compared readmission rates in patients undergoing outpatient TJA for both knees and hips.

The study included 137 outpatients and 98 inpatients who completed a telephone survey that asked them about hospital readmissions, unplanned care, and their satisfaction with their procedures.

The patients were treated between September 2010 and May 2011.

To be eligible for outpatient surgery, patients had to have a body mass index (BMI) of 40 kg/m2 or less, no active cardiopulmonary issues, no sleep apnea, and no history of deep venous thrombosis or pulmonary embolus. They also had to live less than one hour from the hospital and have good family support.

Patients who had inpatient surgery, which meant that they stayed in the hospital for 2 days, had the same eligibility criteria.

Vegari said the most significant difference between the same day and two-day groups was that the patients who went home on the day of their procedure were nearly twice as likely to come back to the emergency department, mostly for pain-related issues.

Specifically, six of 98 inpatients were readmitted to the hospital within the first 30 days of their surgery, compared with 14 of 137 outpatients (6.1% vs 10%; p=0.27).

When emergency room visits were combined with hospital readmissions, seven inpatients (7%) and 17 outpatients (12%) required unplanned medical care following hospital discharge.

"We are tending to think that it is better if patients stay in the hospital overnight, particularly for total knee replacement," Vegari said.

"On the hip, I would say that the difference in readmission rates is lower, so perhaps there is a role for same day surgery for hip TJA, but on the knee side of things, I don't think we're quite there yet," he said.

Dr. Richard Iorio, chief of adult reconstruction and Warname and Susan Chaffee Professor of Orthopedic Surgery at NYU Langone Medical Center Hospital for Joint Diseases in New York City said same day surgery for TJA has some advantages if it can be done safely.

"But the counterpoint is in this study, they cherry picked their patients, they took the youngest, healthiest people, and had a very small sample size. And even though they were able to choose the youngest, healthiest patients, they still had readmission and complication rates higher than what we see on a routine basis," Iorio told Reuters Health in a telephone interview.

"So the conclusion would be it's a nice attempt but needs more study, we need to wade into this in a cautionary way, it's still somewhat experimental, it's not the gold standard, and clearly it's not going to be for everybody. It may be able to be done in the most healthy, most physically able patients with reasonable success but before we try and expand this to all patients, it's going to need a great deal more study and fine tuning."

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