Total joint arthroplasties are one of the most common procedures performed in the United States. As changes have occurred in the surgical techniques of these procedures, postoperative recovery time has decreased and the necessity of patients recovering in a post-acute care center such as a nursing home or acute rehabilitation center has all but dissipated. Unfortunately, patient education regarding this matter has lagged and patients still anticipate being discharged to facilities despite no evidence supporting this discharge plan for most patients.
Background and Significance
Severe arthritis affects more than 15% of the population and projections predict that the prevalence will increase to 20% over the next decade (Bashinskaya et al., 2012). Total joint arthroplasty (TJA) has been accepted as a reliable and safe procedure that can improve the quality of life of those affected by severe osteoarthritis (Sikora-Klak et al., 2017). The demand for TJA was expected to grow 44% by 2020 as the prevalence of lower extremity osteoarthritis continued to rise (Sher et al., 2017) because of an aging baby boomer population. In the next 20 years, it is expected that the demand for total hip arthroplasty (THA) will grow by 174% and demand for total knee arthroplasty (TKA) will grow by as much as 670% (Napier et al., 2013). Between the years of 1993 and 2009, the rate of THA ranged between 260,200 and 436,700 per year and the rate of TKA ranged from 279,101 to 680,839 per year.
The introduction of the Comprehensive Care for Joint Replacement (CJR) program by Medicare has led to increased attention on decreasing costs and length of stay for elective TJA patients (Bashinskaya et al., 2012). The CJR program has led to hospitals focusing on decreasing the cost of episode of care by decreasing postoperative complications and seeking alternative discharge dispositions other than to skilled nursing facilities and acute rehabilitation centers. The increased goal of discharge to home is further amplified by studies demonstrating that there is a statistically significant increase in risk in postoperative complications when patients are discharged to inpatient rehabilitation facilities (Fu et al., 2017; Keswani et al., 2016; McLawhorn et al., 2017).
An area with high variability in the postoperative period is in postdischarge rehabilitation. Post-acute inpatient care can account for up to 36% of the bundled costs of a TJA. There is a lack of evidence that patients recover better or have decreased complications by transitioning to an inpatient rehabilitation setting compared with transitioning to home. In fact, patients discharged to these facilities are 1.9 times more likely to be readmitted to the hospital in the 30 days following discharge (Fu et al., 2017). Keswani et al. (2016) found that rates of serious and minor adverse events were higher in patients discharged to a facility rather than home, and discharge to a facility was an independent predictor of 90-day readmission after TJA.
Although there may be patients who exhibit true needs for placement in these facilities, this disposition is often seen in patients who do not require such intensive services and would recover more successfully at home. The goal of investigating this practice problem is to determine whether increasing the percentage of patients discharged home would also decrease postoperative complications and increasing patient satisfaction with the discharge process. By creating a discharge disposition algorithm, patients would be aware of criteria that must be met for discharge to a facility and would prepare patients for the likelihood of their discharge home. Furthermore, this algorithm could be used to ensure that patients who were not recovering well in the immediate postoperative period were identified and given the option to transition to a facility for safe discharge.
PICO question: In patients undergoing TJA (population), what is the effect of a discharge disposition algorithm (intervention) compared with discharge preintervention (comparative intervention) 30-day postoperative complications and patient readiness for discharge (outcomes)?
Aims
The current trend in TJA care is for shorter lengths of stay than were seen historically. Previously, patients were admitted to the hospital for weeks with discharge to acute care facility. This change in practice has led to a higher rate of patients being discharged home. Patient expectations have yet to catch up with current practice and this often leads to incongruities in patient expectations what is best practice for the population. The aims of this literature search were to (a) identify the safest discharge disposition for patients following TJA; (b) determine the rate of complications and readmissions among those discharged to skilled nursing facility, inpatient rehabilitation unit, and home; and (c) explore how specified care pathways affect patient expectations and outcomes.
Methods
The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest, and Cochrane were searched using the following key terms: discharge disposition, total joint arthroplasty, joint replacement, hip arthroplasty, knee arthroplasty, care pathway, discharge outcomes and readmissions, discharge protocols, and discharge algorithms. The Medicare CJR program was implemented in 2016; therefore, only full-text peer-reviewed articles written in English and published between 2013 and 2018, in English, were considered for this review. One additional article was included that was published in 2011 due to its relevance to the topic.
The search yielded 3,654 articles. Many articles needed to be removed because of focusing on surgeries other than TJA. Additional articles were removed because of being related to perioperative practices and various enhanced recovery protocols that did not focus on discharge disposition postoperatively. An additional manual search was conducted by reviewing the reference list in the articles chosen. Two additional articles were included that were identified by a secondary review of references in the chosen articles. A total of 22 articles were included in the literature review (see Figure 1).
Of the 22 articles, 17 were retrospective cohort studies, there was one observational study, two prospective cohort studies, one comparative cohort study, and a systematic review. Hansen et al. (2015) included the Risk Assessment Predictor Tool to determine how to best predict discharge disposition. Edusei et al. (2017) evaluated the effect of social support on discharge disposition by using the MOS-SSS (Medical Outcomes Study Social Support Expectation Score) scale. Four of the studies (Featherall et al., 2018; Froemke et al., 2015; Kee et al., 2017; Pelt et al., 2018) evaluated patient outcomes after the implementation of a care pathway for TJA patients and one study evaluated an educational pilot for both providers and patients to determine whether there was an impact on length of stay and outcomes.
Five key themes emerged. Patients with significant comorbidities may require longer length of stay in the hospital or potentially discharge to a facility, discharge to facility associated with high rate of complications, setting patient expectations increases likelihood of discharge home, discharge to inpatient facilities does not improve outcomes, and discharge to any post-acute care facility is more expensive than discharge to home. Below is a summary of the literature reviewed including the study design, aim of the study, and significant findings as it pertains to the clinical question (see Table 1).
Results
Patients With Significant Comorbidities May Require Longer Hospital Stay or Discharge to Facility
Sher et al. (2017) found in a retrospective review of data obtained from the National Surgical Quality Improvement Program (NSQUIP) database that patients older than 80 years or with a history of tobacco use, bleeding disorders, serious adverse events prior to discharge, or an American Society of Anesthesiologists (ASA) score of 3 or 4 had a statistically significant increased risk of postoperative complications. These findings were similar to those of Crawford et al. (2011), who also found increased risk for complications in patients with ASA scores of 3 or 4 and in patients with advanced age. Tarity and Swall (2017) also found smoking to be associated with higher risk of postoperative complications; however, Sikora-Klak et al. (2017) did not find higher rates of complications or readmission with this demographic.
Advanced age of more than 75 years as an independent predictor of discharge to a nonhome destination has also been echoed by multiple other studies (Courtney et al., 2017; Sikora-Klak et al., 2017; Tarity & Swall, 2017). Hansen et al. (2015) found that patients with a Risk Assessment Prediction Tool (RAPT) score of 0-6 could be predicted to transition to a facility other than home at the time of discharge from the hospital due to increased functional dependence and advanced age. Patients with intermediate scores of 7-10 were harder to predict discharge disposition; however, this study suggests that patients with preadmission RAPTs of less than 6 should be offered facility placement unless significant support mechanisms are in place for the patients to safely transition home.
The RAPT was originally developed by an orthopaedic surgeon named Dr. Leonie Oldmeadow. This was done with the intention of creating a tool to help stratify patients undergoing elective joint arthroplasty into their appropriate discharge disposition. The tool utilizes the risk factors of age, social support, gender, preoperative activity level, preoperative use of community support, and preoperative use of an ambulation aid to determine their disposition (Oldmeadow, 2001). The study by Hansen et al. (2015) illustrates this tool's appropriateness in determining discharge disposition.
Discharge to Facility Associated With High Rate of Complications
Fu et al. (2017) evaluated patients retrospectively after unilateral THA and found that complication rates for patients discharged to facility were significantly higher than for those who were discharged to home (5.5% vs. 2.9%; p < .001). Rate of readmission and mortality was also higher in patients discharged to facility (5.4% vs. 2.8%, p < .001; 0.1% vs. 0.0%, p < .001, respectively). McLawhorn et al. (2017) evaluated a similar sample size of patients following TKA and found similar results. The risk of any postoperative complication after discharge was 4.33% in patients discharged to facility compared with 2.72% of patients discharged home (p < .001). Major complications following discharge to facility were 3.05% vs. 1.83% in patients discharged home. This illustrates similar outcomes for all TJA patients.
Gholson et al. (2016) conducted a similar study using the same database but included all patients undergoing primary TJA and found that 30-day mortality was 10 times higher in patients discharged to facility (3.9% vs. 0.3%; p < .001) and 30-day complications were the same as seen in Fu et al. (2017), Ramos et al. (2014), and McLawhorn et al. (2017), with rates three times higher in patients discharged to facility instead of home (p < .001). Pelt et al. (2018) also found readmission rates 2.4 higher after discharge to a facility compared with home (p = .007). Reoperation rates at 30 days, 90-day readmission rates, and 90-day reoperation rates were also higher in patients discharged to facilities (p = .06, p = .018, and p = .013, respectively). Rates of wound dehiscence, deep vein thrombosis, pulmonary embolism, and deep and superficial wound infections were higher in patients discharged to both skilled nursing facilities and inpatient rehabilitation centers (p < .05 for all; Keswani et al., 2016). Severe adverse events in patients discharged to facility were 1.9% compared with 0.8% discharged home, and minor events occurred at a rate of 1.1% for patients discharged to facility compared with 0.4% for patients discharged home. This same study revealed that discharge to a facility was an independent predictor of readmission within 90 days (Keswani et al., 2016).
Setting Patient Expectations Increases Likelihood of Discharge Home
Setting appropriate patient expectations has been found to be an independent predictor of postdischarge disposition following these procedures (Tarity & Swall, 2017). Many of the published studies evaluated the effect of the implementation of a care pathway for patients undergoing TJA. Froemke et al. (2015) assessed a care pathway that presented patients with preoperative education that stressed that the expectation was that they would transition home following the acute recovery phase. Education was also provided to the multidisciplinary team that cared for these patients with the emphasis on home recovery following surgery. Following the pilot, there was an 18% decrease in length of stay (p < .001) and home discharges increased from 54.1% to 63.1% (p = .01).
Similar pathways were piloted by Pelt et al. (2018) and Featherall et al. (2018), and at the end of these pilots, there was a 20% reduction in discharge to a facility (p < .001) and an increase in discharge to home from 66.3% to 78.7%, respectively. Both pilots also resulted in a statistically significant reduction in length of stay. Kee et al. (2017) introduced a care pathway for patients with the goal of discharge on postoperative Day 1. The institution already boasted low length of stay for this population, but they were able to maintain rates of discharge home greater than 94% for both TKA and THA and decreased length of stay for TKA from 1.91 to 1.33 days and for THA from 1.92 to 1.13 days (p < .01). These studies illustrate that setting patient expectations throughout the continuum of care can positively impact length of stay and discharge to home rates.
Discharge to Inpatient Facilities Does Not Improve Outcomes
Padgett et al. (2018) sought to determine whether discharge to inpatient facilities following TKA improved patient outcomes. After propensity matching, there was no difference in postoperative patient-reported outcomes in patients discharged home versus facility. The only difference noted between these groups was that preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores favored discharge to facility (54.0 vs. 52.6; p = .042). Individuals discharged to facilities had slightly highest WOMAC scores than those who were discharged to home. Keswani et al. (2016) found that patients discharged to skilled nursing facilities or inpatient rehabilitation centers had increased rates of unplanned return to the operating room compared with patients discharged home (p < .001). Unfortunately, the authors did not specify what procedures were done during the return to the operating room, so this may include procedures related to wound dehiscence, surgical-site infection, and arthrofibrosis requiring manipulation under anesthesia. Le Meur et al. (2016), however, found that rates of surgical-site infection had no statistical difference in patients discharged to home as opposed to a facility.
Discharge to Facility More Expensive Than Discharge to Home
Multiple studies have illustrated that the costs of discharge to a skilled nursing facility or inpatient rehabilitation center far surpass the costs associated with home discharge. Ramos et al. (2014) estimated that post-acute care costs for patients discharged to home averaged $4,000 whereas discharge to a nonhome facility averaged $11,000. Crawford et al. (2011) had similar findings with costs for patients transitioning home of $15,946 and patients discharged to any facility averaging $20,415. Sabeh et al. (2017) reported costs per episode of care for patients discharged home at $55,246 with total costs for discharge to skilled nursing facility at $58,702 and inpatient rehabilitation at $63,636 (p < .001).
Tarity and Swall (2017) estimate that patients could be kept in the hospital for an additional 5.2 days without surpassing the costs of discharging a patient to a post-acute care facility. After the implementation of a care pathway, Featherall et al. (2018) estimated a cost savings of $1,329 per patient, which equated to a theoretical savings of $5.3 million for the facility if the pathway was applied to all TJA patients. Tessier et al. (2016) estimated cost differences of TKA with the use of a care pathway of $19,005 versus $22,195 without (p < .001) and costs of THA with the use of a pathway of $18,866 versus $21,332 without (p < .001). These studies demonstrate significant cost savings in both increased rates of discharge home and the use of a care pathway to guide patient disposition.
Discussion
Total joint arthroplasties are one of the most common surgical procedures performed in the United States with one million procedures performed in 2010 alone (Tarity & Swall, 2017). Innovative surgical techniques and enhanced recovery protocols have decreased postoperative pain and recovery times. This has diminished the need for prolonged post-acute care rehabilitation, and patient discharge disposition now favors home discharge over discharge to skilled nursing facilities and inpatient rehabilitation centers. Postoperative complications have been cited by many studies as being substantially higher in patients discharged to facilities following TJA. This trend combined with the increased costs of non-home discharge furthers the argument that most patients should transition to their home following these surgeries.
Certain comorbidities and risk factors do continue to favor discharge to post-acute care facilities as noted by previous studies. Age of 75 years or with a history of bleeding disorders, serious adverse events prior to discharge, functional dependence preoperatively, or an ASA score of 3 or 4 was found to have statistically significant increased rates of postoperative complications and 30-day and 90-day readmission rates. History of tobacco use was not unanimously found to be an independent risk factor; however, these patients should be carefully stratified according to their other comorbidities to determine the best disposition for them.
Conclusion
Severe arthritis affects more than 15% of the population and projections predict that the prevalence will increase to 20% in the next decade (Bashinskaya et al., 2012). Total joint arthroplasty has been accepted as a reliable and safe procedure that can improve the quality of life of those affected by severe osteoarthritis (Sikora-Klak et al., 2017). The demand for TJA is expected to increase for THA by 174% and demand for TKA will grow by as much as 670% (Napier et al., 2013).
The introduction of the CJR program by Medicare has led to increased attention on decreasing costs and length of stay for elective TJA patients (Bashinskaya et al., 2012). This has led to hospitals focusing on decreasing the cost of episode of care by decreasing postoperative complications and seeking alternative discharge dispositions other than to skilled nursing facilities and acute rehabilitation centers. An estimated 40% of episode of care charges arise from the post-acute care period, signifying an area where cost savings mechanisms may have the greatest impact. This review identified themes in postoperative care of TJA patients that can be utilized to create a discharge disposition algorithm using best practices to stratify patients into the appropriate discharge disposition while setting appropriate expectations for patients undergoing these procedures to ensure high levels of patient satisfaction following these procedures.
References