In our series, we looked at 3,200 arthroplasty procedures over the last three years. Only 7% had to stay overnight. Half were for convenience. Nine out of 3,000—stayed because of pain. We had 98% patient satisfaction.
We’ve got 1,252 total hips to look at. Overnight stay 6%, just under half for medical tourism or convenience. Just over half for urinary retention, obstructive sleep apnea or postoperative nausea and vomiting.
Non-operative complications were less than 1% and those patients either went to an ER or were admitted to a hospital, died, or had a significant postoperative complication. That’s less than 1%. That has nothing to do with the operation and the timeframe of these complications has nothing to do with them going home the same day.
But…it does have to do with medical optimization preoperatively. These are healthy patients that can go home. They don’t need to be subjected to unnecessary hospitalization.
Operative complications were less than 2%. All together we had less than 3% of either readmission, operative complication or medical complication and that’s significantly lower than that reported in the literature for almost any hospitalization. Patient satisfaction is high at almost 98%, meaning patients don’t feel like they’re being pushed out or they’re going home without the education, without the proper training.
I’ve just shown you a 2.2% 90-day readmission or complication rate, which is about a quarter of that in the literature. And 98% good to excellent satisfaction. The paradigm shift has already occurred, and the future is now.
Dr. Lieberman: Total hip replacement…let’s define it. We’re talking about total hip replacement performed in an ambulatory surgery center or hospital where the patient is discharged the same day as the procedure. I routinely discharge patients on postoperative day 1. Not really against it. Larry Dorr does this at our institution. He’s done it successfully. But I think there are some caveats.
It needs to be demonstrated that it’s better for the patient. There are no appropriately powered multi-centered randomized trials demonstrating the advantage with same day surgery. Why would the patient want to go home?
Why should the patient go home? Is it safer for the patient? Is it better to drive home the same day and sit in a car for an hour or two? Is it better to be home if you’re nauseous? Will the patient be more comfortable at home? Is it easier on the spouse to have to take care of the patient? The patients go home because they’re told they should go home.
The safety needs to be confirmed. What are the selection criteria? What are the risk factors for admission to the hospital? What are the risk factors for readmission once the patient goes home?
A study from John Callaghan’s group looked at early discharge and complications using the AJRR database. It gets data from 674 hospitals in a prospective fashion. They looked at demographics, comorbidities, 30-day complications and readmissions. They propensity-matched comparisons between postoperative day zero and postoperative day one discharge and then they did a statistical analysis. There were no differences in complications or readmissions after total knee or unicondylar knee, but in total hip replacement patients there is increased rate of complications in same day surgery.
The risk factors for that were age greater than 70; smoking, COPD; coronary artery disease; and hematocrit less than 36.
Total hip replacement discharge on postoperative day zero significantly riskier than day one. They also had higher rates of diabetes; steroid use; and lower hematocrit and serum albumin.
The total knee group had higher percentage of ASA 3 and 4.
