THIS WEEK'S ARTICLES
Set Up for Success in Joint Replacement Surgery
Efforts to achieve positive outcomes begin as soon as procedures are scheduled.
Increasing numbers of total joint replacements will be performed in outpatient facilities as long as providers prioritize reducing negative outcomes that lead to unplanned readmissions. That requires optimizing perioperative care, addressing complication risk factors and clear communication with patients, according to a new paper.
Several criteria should exclude patients from undergoing elective joint replacements in the outpatient setting, according to the paper published in the Canadian Medical Association Journal: pre-op bleeding disorders, liver cirrhosis, renal disease of stage 2 or greater and an inability to participate in pre-op education. The authors also note patient-specific factors that should give providers pause before proceeding with joint replacement surgery: age 80 years or older; ASA classification greater than two; severe obstructive sleep apnea; history of cardiac disease; diabetes; body mass index greater than 35; and a lack of a social support system at home.
The authors add that post-discharge surveillance through follow-up phone calls or technology that provides remote real-time monitoring of a patient’s condition, as well as regular wound checks for infection, are essential to achieving positive outcomes after joint replacement surgery. Addressing modifiable risk factors can also reduce complications and readmissions. For example, they say having smokers kick the habit and optimizing patients' nutrition status leading up to their surgeries can prevent adverse events and reduce the risk of unplanned hospitalizations.
Surgeons and primary care physicians play important roles in setting the right mindset in patients for same-day surgical success. The paper's authors point out that even some patients who believe they can recover safely and comfortably at home enter surgery expecting to be hospitalized for at least a couple days. Communicating clearly with patients, beginning at the time of referral for surgery, about expected levels of pain and the recovery process can set realistic perceptions about the feasibility of same-day discharge and the active role they play in achieving positive outcomes.
"Protocols continue to evolve," say the authors. "However, patient safety must remain the priority with any change. Careful education of patients can help shift misconceptions about outpatient total joint procedures and optimize success."
Age Is Just a Number
Study identifies ways to optimize joint replacement outcomes for older patients.
Enhanced recovery after surgery (ERAS) protocols prepare Medicare patients for successful outcomes following total joint replacement procedures, according to research published in Arthroplasty Today, the journal of the American Association of Hip and Knee Surgeons.
The volume of outpatient total knees and hips is steadily increasing, with half of these procedures expected to take place in ambulatory settings by 2026. Concerns remain about the safety of performing the procedures on older patients, but the study’s authors say the most common reasons for patients being ineligible to undergo joint replacement surgery in an ASC have nothing to with age. Instead, they point to body mass index, severity of comorbid conditions and untreated sleep apnea as red flags that prevent providers from proceeding with surgery.
Uncontrolled pain and PONV are common post-op complications that delay discharge, note the researchers, who also point out opioid-related adverse events are associated with prolonged hospital stays, readmissions and increased cost of care. Controlling pain with limited opioid use is therefore a major focus of total joints programs. Enter ERAS pathways, which involve optimizing patients’ physical, mental and medical conditions while employing multimodal and opioid-sparing protocols designed to improve surgical outcomes
The study's authors analyzed the results of 601 Medicare patients with an average age of 72 years who underwent total hip or knee replacements under ERAS protocols. A single surgeon performed the procedures in a rural hospital, with 84% of the patients discharged on the day of surgery, 13.1% discharged after an overnight stay, and 2.2% discharged after more than a day. None of the patients experienced significant post-op complications, and only 12 patients had unplanned readmissions within 30 days. Additionally, 84% of the patients used opioids for less than seven days to manage their post-op pain.
The study's findings suggest that same-day discharge does not increase risk for complications, according to the study's authors, who say Medicare patients who underwent total knee and total hip procedures through the ERAS pathway experienced low rates of complications and high satisfaction. "This approach of presurgical patient engagement may provide avenues for safe transition to freestanding ASCs," they write.
Reducing Outpatient Joint Readmissions
How to optimize your outpatient joint program by preventing, diagnosing and treating key causes of readmission.
More than one million Americans receive a knee or hip replacement every year. Unfortunately, the rate of readmission 30 days after those procedures is an alarming 4.2%.1
The good news is, by knowing the top causes of readmission after large joint procedures and how best to prevent them, healthcare providers can ensure that patients recover fully and without complications — delivering the best care possible and improving their quality of life.
Additionally, there are several well-understood modifiable risk factors which, if carefully considered and addressed during the patient selection process, can have a significant impact on quality, safety, and outcomes.
This article examines three major causes of readmission following joint procedures and outlines several modifiable risk factors to consider when developing patient selection criteria. At the end you will find links to citations and a comprehensive set of resources including products, information and solutions to help optimize your outpatient joint program.
Causes of Readmission
Seven causes of readmission following a joint procedure include: surgical site infections (SSIs), deep vein thrombosis (DVT), pneumonia, urinary tract infections, pain, patient fall and sepsis. (Go here for an assessment of all seven causes.)
As one of the most common indications for revisions in total joint arthroplasty procedures, SSIs occur in one to two percent of patients, and will cost the healthcare sector more than $1.6 billion by 2030.1 Staphylococcus aureus, or MRSA, is the leading cause of SSIs. Research suggests the risk of SSIs increases up to nine percent due to nasal colonization of MRSA, and that 30% of patients are nasally colonized when they reach the operating room.1 Here is more information on how to prevent, diagnose and treat MRSA nasal colonization and other causes of SSIs.
A DVT is a blood clot that forms most commonly in the deep veins of the lower leg. Decreased activity following a joint replacement surgery can slow the flow of blood thereby increasing the risk of clot formation. Other risks include inherited conditions, certain medications, vein disease, obesity, smoking, age, or serious illness. Knee and hip replacement patients are at highest risk for developing a DVT two to 10 days after surgery and remain at risk for approximately three months.
Clot prevention includes a combination of approaches, including anticoagulants, exercise and physical therapy, compression stockings applied before surgery, and the application of a pneumatic/sequential compression device. Read more about preventing, diagnosing and treating DVTs here.
Pneumonia is a serious complication that occurs in one in 300 patients following a total joint procedure and can increase the risk of sepsis.1 A study by the American College of Surgeons National Surgical Quality Improvement Program found that four in five patients who develop pneumonia are subsequently readmitted, and one in 25 die.1 Risk factors include chronic obstructive pulmonary disease, diabetes mellitus, lower body mass index, hypertension, smoking and general anesthesia. Post-anesthesia prevention measures include early ambulation, at-home use of incentive spirometer every two hours for two weeks post operation, and, of course, proper infection prevention measures.
Modifiable Risk Factors
Proper patient selection is critical to improving outcomes in an outpatient program. Several modifiable risk factors contribute to poor clinical outcomes following a total joint replacement. Key patient selection considerations include well-known clinical factors such as obesity, smoking, diabetes, and venous thromboembolic disease; however, care should also be taken to ensure patient living conditions are suitable to recovery, and that the patient’s friends and family members are committed to helping with patient recovery.1 In fact, preoperative education and post-operative support can help reduce readmission rates by almost two percent.1
Note: Visit the McKesson orthopedics website to learn more about these risk factors, their associated complications and how to minimize them.
1. Go to https://mms.mckesson.com/resources/reducing-readmissions/joint-replacement-readmissions-resource-guide for a full list of citations.
Address Common Causes of Post-Op Complications
It's possible to predict rehospitalizations among total joint replacement patients.
Total joint patients should increase their physical activity and providers should address comorbid conditions before surgery to limit the risk of post-op complications, say a team of researchers who analyzed pre- and post-op reasons for hospital readmissions among 2,481 patients who underwent total hip or knee procedures at a U.S. hospital.
The study, published in the Journal of Orthopaedic Surgery, says 3.4% of the total hip patients and 2.2% of the total knee patients were readmitted within 30 days of their initial discharge. Joint infection was the most common cause among both groups of patients. Trauma such as joint dislocations and femoral and tibial fractures was the second most common cause of readmission among the hip patients; wound complications were the secondary cause for the knee patients.
Multiple risk factors were associated with higher rates of readmission, according to the study, including body mass index (BMI), the metabolic equivalent of task (MET) — the amount of energy the body uses during physical activity — and the Charlson comorbidity index (CCI), a weighted score used to assess 19 comorbid conditions in patients.
The researchers note high BMI was associated with increased 30-day readmission rates among both patient groups. Morbid obesity (BMIs 40 kg/m2 to <45 kg/m2) and super obesity (BMI >45 kg/m2) were significant risk factors of readmissions in total hip patients, while very obese (BMIs 35 kg/m2 to <40 kg/m2) and super obese (BMI >45 kg/m2) were predictors of readmissions in knee patients. Patients in both groups who were ASA classification 2 were at increased risk of 30-day readmission, according to the researchers, who say surgeons and the care team should exercise caution when considering offering elective joint replacement to patients with this level of systemic illness.
Low levels of physical activity before surgery, measured by MET, put patients at increased risk of readmission, note the researchers. Importantly, they also identified high CCI scores, which indicate systemic illness, as an independent risk factor for post-op complications. They say this simple-to-calculate index is a strong predictor of readmission after elective joint replacement procedures.
Patient comorbidities and preoperative functional capacity significantly affect 30-day rehospitalization rates following total joint arthroplasty, note the researchers, who say surgeons and care teams should address these parameters before procedures and use CCI and MET scores to assess and address risks of readmissions.
Why Reducing Readmission Rates Matters
Surgical leaders should strategize ways to improve the care of high-risk patients.
Efforts to deliver cost-effective care for total knee replacement patients should focus on reducing readmissions for high-risk individuals, according to a study published in the journal Health Care Manager
The study, which used data from the National Readmissions Database, showed that 15% fewer patients who underwent total knee replacements in 2014 were readmitted to hospitals within 30 days of their procedure than those who underwent the procedure in 2009. Costs of the procedure, however, were 20% higher for the 2014 patients than for those who had the surgeries in 2009.
Readmission rates were lower for older patients, women, Medicare recipients, those with higher incomes and individuals residing in metropolitan areas. The study cited financial stress, high rates of mental health issues, substance abuse disorders, medication noncompliance and housing instability as risk factors for readmission among Medicaid recipients.
The cost per initial hospital stay was highest among patients who were 45 to 64 years old, insured by Medicaid or living in non-metropolitan areas. A factor in the higher costs of care for patients who underwent procedures in 2014 was a 4% longer average hospital stay among 45- to 64-year-olds.
The study's authors say reducing readmissions after total joint procedures will become more important for surgical facilities over time as alternative payment models and increased quality measures will see them assume greater risk for managing the health of their patients, while likely receiving lower reimbursements. The study recommends that facilities compare their readmission rates to national statistics, and devise strategies to reduce those occurrences.
For example, based on the study's findings, surgical managers could tailor clinical services for successful transitions to home for younger patients. They could also determine if a lack of informal help at home following surgery explains why men have higher readmissions. "Managers can determine if there are barriers to appropriate follow-up care and focus on addressing these areas to improve outcomes and minimize their facilities' financial risk," write the researchers.