Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors

Abstract

Aims The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691.

Predictors of Failure to Achieve Planned Same-Day Discharge after Primary Total Joint Arthroplasty: a Multivariable Analysis of Perioperative Risk Factors

“…32,33 This study's findings support existing evidence [26][27][28][29][30] that relatively few U.S. patients fail planned SDD TJA in the ASC setting and that up to a third or more fail planned SDD TJA performed in the hospital. 4,5,7,8 The study results suggest that patient characteristics such as anemia, use of depression/anxiety medications, and nonwhite race, as well as higher postoperative pain medication utilization, predispose failure for planned SDD TJA performed in the hospital setting. To increase the success of SDD TJA performed in hospital environments, faithful replication of ASC protocols, limiting cases to early in the day and/or extending perioperative care, ensuring adequate time to resolve barriers to discharge, enhanced understanding of pain tolerance, 7,8 increased understanding of patient motivation for SDD, and understanding the impact of convenient availability of an overnight stay regardless of the medical necessity 34 are recommended.…”

“…Our ASC failure rate is consistent with published failure rates of 0% to 6% for the same population, 26-30 as is our hospital failure rate compared with similarly designed U.S. studies. 4,5,7,8 As shown in Table 1, six preoperative, eight intraoperative, and three postoperative patient care characteristics markedly differentiated hospital and ASC patients. Table 1 observations support and expand work comparing U.S. patients undergoing SDD THA in a hospital and an ASC.…”

“…n the United States, same-day discharge (SDD) after primary hip and knee total joint arthroplasty (TJA) has evolved from investigating whether SDD is feasible 1,2 to why patients fail this increasingly common practice. [3][4][5][6][7][8][9]…”

“…Nonetheless, failure to achieve planned SDD for primary TJA occurs in as many as 7% to 49% of patients in the United States. [3][4][5][6][7][8][9] This study evaluated the relative association of 43 perioperative risk factors to help explain failures of planned SDD primary TJA and inform what is required for success, differentiating between high and low failure risk patients assigned to hospital or ASC locations.…”

“…In the United States, same-day discharge (SDD) after primary hip and knee total joint arthroplasty (TJA) has evolved from investigating whether SDD is feasible 1,2 to why patients fail this increasingly common practice. 3-9 The safety and efficacy of SDD TJA has been established in the intervening 15 years 10-13 with demonstrated reliance on the selection of appropriate patients, avoidance of intraoperative complications, and a clinical team skilled in protocols designed to minimize complications and maximize recovery. 14-17 Consequently, payers have begun to direct qualifying cases to ambulatory surgery center (ASC).…”