Predictors of Delayed Discharge after Total Joint Arthroplasty of the Hip and Knee Open Access

Premkumar, Ajay (2016)

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Background: Total joint arthroplasty (TJA) is a common orthopaedic procedure that comprises a significant portion of US healthcare expenditures, particularly in the elderly. With the recent push towards value-based health care, predicting delays in discharge is crucial. Postoperative hypotension is a common side effect of major surgery. While other risk factors for prolonged hospital stay have been identified in TJA patients, postoperative hypotension has been understudied in the orthopaedic literature. This study examines postoperative hypotension along with other potentially modifiable risk factors and their relation to prolonged hospitalization after TJA.

Methods: This retrospective cohort study identified 2561 primary total hip and total knee arthroplasty cases performed at a single institution between June 2012 and August 2014. We compared characteristics of cases with a hospital length of stay of less than two days to those with a length of stay two days or longer. Postoperative hypotension, pre and post-operative labs, medication usage, demographics, and surgical factors were the main independent variables of interest. A multivariate logistic regression model was used to identify independent risk factors for delayed hospital discharge after TJA.

Results: Among 2651 TJA patients in this study, 732 (28.5%) had a length of stay of less than 2 days. The number of postoperative hypotensive events in the acute postoperative period (POD 0 and 1), defined as a systolic blood pressure less than 90 mmHg or a diastolic blood pressure less than 60 mmHg, was significantly associated with an increased length of stay (OR 1.35 [1.20, 1.53]). Patients with a higher Charlson Comorbidity Index (OR 1.77 [1.54, 2.01]), females (OR 2.13 [1.75, 2.59]), African Americans (OR 2.09 [1.68, 2.61]), the elderly (OR 1.40 [1.30, 1.51]), and unmarried patients (OR 1.98 [1.63, 2.41]), were also more likely to have an increased length of stay. Patients who stayed more than 2 days used a higher Oral Morphine Equivalent dose in the first two days, then those who stayed less than 2 days, 127 mg versus 106 mg, respectively (OR 1.11 [1.10, 1.13]).

Conclusions: As the financial landscape of US health care is evolving, identifying means of decreasing hospital length of stay without compromising care after TJA could have a significant impact. With increased use of outpatient TJA, it is important to identify factors that may improve patient safety while reducing any potential burden from readmissions.

Table of Contents

Chapter 1 Introduction 1-3

Chapter 2 Comprehensive Review of the Literature 3-13

Chapter 3 Manuscript 13

3a Title Page for Manuscript 13

3b Contribution of student 13

3c Abstract 14

3d Introduction 15-17

3e Methods 17-20

3f Results 20-23

3g Discussion 23-26

3h References 26-29

3i Tables and Figures 29-33

3j Appendices 33-34

Chapter 4 Conclusion and Recommendations 34-44

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