Hospital Discharge Within a Day After Total Knee Arthroplasty Does Not Affect 1-Year Complications Compared With Rapid Discharge

Safa C. Fassihi, MD; Michael-Alexander Malahias, MD, PhD; Alex Gu, MD; Shawn S. Richardson, MD; Leonard T. Buller, MD; Seth Stake, MD; Ivan De Martino, MD; Neil Pathak, MD; Aaron Z. Chen, BA; Michael P. Ast, MD; Peter K. Sculco, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(9):397-405. 

In This Article

Abstract and Introduction

Abstract

Introduction: In patients undergoing total knee arthroplasty (TKA), it is unclear whether a difference in complication rates exists between patients discharged the day of surgery compared with subsequent postoperative days.

Methods: Data were collected from the PearlDiver Patient Records Database from 2007 to 2017. Subjects were identified using International Classification of Diseases codes. Eligible patients were stratified into the following three groups: (1) same day discharge (<24 hours postoperatively), (2) rapid discharge (1 to 2 days), and (3) traditional discharge (3 to 4 days) based on the length of stay.

Results: In total, 84,864 patients were identified as having undergone primary TKA. The incidence of same day discharge, rapid discharge, and traditional discharge was 2.36% (2,004/84,864), 28.56% (24,235/84,864), and 69.08% (58,625/84,864), respectively. After adjustment, no notable differences were observed in the overall complication and revision rates between the same day discharge group and either the rapid discharge or the traditional discharge group. On multivariate analysis, patients in the rapid discharge cohort were less likely to require manipulation under anesthesia or develop periprosthetic joint infection when compared with the traditional discharge group at 1 year postoperatively.

Conclusions: For those who qualify after careful selection, same day and rapid discharge TKA may be a feasible alternative to the traditional inpatient TKA.

Level of Evidence: A level 3 retrospective, prognostic study

Introduction

The challenge with healthcare reform has been to reduce spending without sacrificing quality in the delivery of care.[1–3] With the goal of decreasing length of stay (LOS), modern surgical techniques, advances in regional anesthesia, improved postoperative pain management with multimodal and preemptive analgesia, and rapid rehabilitation protocols have allowed patients undergoing total joint arthroplasty (TJA) to be discharged from the hospital as early as the day of surgery with high patient satisfaction and infrequent complications in appropriately selected patients.[4,5]

To successfully achieve outpatient arthroplasty, clinicians have developed accelerated clinical pathways featuring a multidisciplinary approach involving a range of healthcare professionals.[6–9] Rapid recovery protocols have safely reduced the average length of hospitalization, but it is unclear whether a difference in complication and readmission rates exists between patients discharged the day of surgery or on postoperative day 1.[10] In the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient TJA is attractive and provided the incidence of costly complications is comparable with contemporary "fast-track" inpatient pathways.[11]

Although some authors have demonstrated that no notable difference was noted in the outcomes of outpatient and inpatient total knee arthroplasty (TKA), safety and general feasibility of such procedures remain unclear.[12] One of the most important concerns with outpatient surgery has been the potential for increased complications, including readmissions to the hospital and visits to providers and emergency departments.[5]

In this study, we aimed to determine the impact of same day discharge on complications in patients undergoing TKA. Specifically, we sought to answer the following questions: (1) How commonly is same-day-discharge TKA performed? (2) Does LOS have an impact on 1-year postoperative complications after TKA? Our hypothesis was that there would be no difference in complications based on length of hospital stay.

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