Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians

Abstract

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support “early” discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student’s t test and for categorical data using χ² testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

Keywords

total joint arthroplasty octogenarian fast-track early discharge

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References

Barbieri

Vanhaecht

Van Herck

, et al. Effects of clinical pathways in the joint replacement: A meta-analysis. BMC Med. 2009;7:32. https://doi.org/10.1186/1741-7015-7-32.

Berger

Kusuma

Sanders

Thill

Sporer

. The feasibility and perioperative complications of outpatient knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1443–1449. https://doi.org/10.1007/s11999-009-0736-7.

Bovonratwet

Tyagi

Sculco

Grauer

JN.

Is discharge within a day of total knee arthroplasty safe in the octogenarian population?

J Arthroplasty. 2019;34(2):235–241. https://doi.org/10.1016/j.arth.2018.10.005.

Bozic

Rubash

Sculco

Berry

DJ.

An analysis of medicare payment policy for total joint arthroplasty. J Arthroplasty. 2008;23(6 suppl 2), 133–138. https://doi.org/10.1016/j.arth.2008.04.013.

Bozic

Wagie

Naessens

Berry

Rubash

HE.

Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty. J Arthroplasty. 2006;21(6 suppl 2), 151–156. https://doi.org/10.1016/j.arth.2006.04.015.

DeJong

Horn

Smout

Tian

Putman

Gassaway

Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities. Arch Phys Med Rehabil. 2009;90(8):1284–1296. https://doi.org/10.1016/j.apmr.2009.02.009.

De Pablo

Losina

Phillips

, et al. Determinants of discharge destination following elective total hip replacement. Arthritis Care Res. 2004;15(51):1009–1017. https://doi.org/10.1002/art.20818.

Dripps

Lamont

Eckenhoff

JE.

The role of anesthesia in surgical mortality. JAMA. 1961;178(3):261–266. https://doi.org/10.1001/jama.1961.03040420001001.

Edwards

Kee

Mears

Barnes

CL.

Is rapid recovery hip and knee replacement possible and safe in the octogenarian patient?

J Arthroplasty. 2018;33(2):316–319. https://doi.org/10.1016/j.arth.2017.09.060.

10.

Edwards

Levine

Cullinan

Newbern

Barnes

CL.

Avoiding readmissions-support systems required after discharge to continue rapid recovery?

J Arthroplasty. 2015;30(4):527–530. https://doi.org/10.1016/j.arth.2014.12.029.

11.

Gondusky

Choi

Khalaf

Patel

Barnett

Gorab

Day of surgery discharge after unicompartmental knee arthroplasty: an effective perioperative pathway. J Arthroplasty. 2014;29(3):516–519. https://doi.org/10.1016/j.arth.2013.08.021.

12.

Hilton

Back

Espag

Briggs

TWR

Cannon

SR.

The octogenarian total knee arthroplasty. Orthopedics. 2004;27(1):37–39. https://doi.org/10.3928/0147-7447-20040101-15.

13.

Husted

Hansen

Holm

, et al. What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg. 2010;130(2):263–268. https://doi.org/10.1007/s00402-009-0940-7.

14.

Keswani

Tasi

Fields

Lovy

Moucha

Bozic

KJ.

Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplasty. 2016;31(6):1155–1162. https://doi.org/10.1016/j.arth.2015.11.044.

15.

Khan

Malviya

Muller

, et al. Reduced short-term complications and mortality following enhanced recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop. 2014;85(1):26–31. https://doi.org/10.3109/17453674.2013.874925.

16.

Kim

Losina

Solomon

Wright

Katz

JN.

Effectiveness of clinical pathways for total knee and total hip arthroplasty: literature review. J Arthroplasty. 2003;18(1):69–74. https://doi.org/10.1054/arth.2003.50030.

17.

Kreder

Berry

McMurtry

Halman

SI.

Arthroplasty in the octogenarian: quantifying the risks. J Arthroplasty. 2005;20(3):289–293. https://doi.org/10.1016/j.arth.2004.09.024.

18.

Kurtz

Ong

Lau

Mowat

Halpern

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–785. https://doi.org/10.2106/JBJS.F.00222.

19.

Lovald

Ong

Lau

Joshi

Kurtz

Malkani

Patient selection in outpatient and short-stay total knee arthroplasty. J Surg Orthop Adv. 2014;23(1):2–8. https://doi.org/10.3113/JSOA.2014.0002.

20.

Meneghini

Ziemba-Davis

Ishmael

Kuzma

Caccavallo

. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score.” J Arthroplasty. 2017;32(8):2325–2331. https://doi.org/10.1016/j.arth.2017.03.004.

21.

Pitter

Jørgensen

Lindberg-Larsen

Kehlet

Postoperative morbidity and discharge destinations after fast-track hip and knee arthroplasty in patients older than 85 years. Anesth Analg. 2016;122(6):1807–1815. https://doi.org/10.1213/ANE.0000000000001190.

22.

Savaridas

Serrano-Pedraza

Khan

Martin

Malviya

Reed

MR.

Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program. Acta Orthop. 2013;84(1):40–43. https://doi.org/10.3109/17453674.2013.771298.

23.

Sibia

King

MacDonald

JH.

Who is not a candidate for a 1-day hospital-based total knee arthroplasty?

J Arthroplasty. 2017;32(1):16–19. https://doi.org/10.1016/j.arth.2016.06.055.

24.

Sloan

Premkumar

Sheth

NP.

Projected volume of primary total joint arthroplasty in the US, 2014 to 2030. J Bone Joint Surg Am. 2018;100(17):1455–1460. https://doi.org/10.2106/JBJS.17.01617.

25.

Styron

Koroukian

Klika

Barsoum

WK.

Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty. J Arthroplasty. 2011;26(8):1418–1426.e2. https://doi.org/10.1016/j.arth.2010.11.008.

26.

Thienpont

Lavand’Homme

Kehlet

The constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J. 2015;97-B(10 Suppl A):40–44. https://doi.org/10.1302/0301-620X.97B10.36610.

27.

Ziemba-Davis

Caccavallo

Meneghini

RM.

Outpatient joint arthroplasty—patient selection: update on the outpatient arthroplasty risk assessment score. J Arthroplasty. 2019;34(7 suppl.):S40–S43. https://doi.org/10.1016/j.arth.2019.01.007.

28.

Zmistowski

Restrepo

Hess

Adibi

Cangoz

Parvizi

Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. J Bone Joint Surg Am. 2013;95(20):1869–1876. https://doi.org/10.2106/jbjs.l.00679.