TJA performed earlier in the week linked with reduced length of stay

Issue: May 2015

Patients who underwent primary total joint arthroplasty at the beginning of the operative week experienced shorter postoperative length of stay and faster overall recovery, according to results of a recently published study.

“The take-home message from our study was that elective primary total joint replacement performed earlier in the operative week (Monday or Tuesday) resulted in a significantly shorter length of overall stay in the hospital vs. those patients who had surgery on Thursday and Friday,” study co-author Eric L. Smith, MD, chief of arthroplasty service at Tufts Medical Center, told Orthopedics Today. The research was published in the Journal of Arthroplasty.

Length of stay

Smith and his colleagues identified 547 patients who underwent primary, elective total hip or knee arthroplasty at either Tufts Medical Center or University of California Irvine Medical Center between March 2011 and April 2013, and categorized patients by the specific day they had operations: Monday, Tuesday, Thursday or Friday. Length of hospital stay, location of discharge, BMI, ASA score, procedure, age, gender and operative side were obtained from patient medical records.

Compared with patients who underwent surgery on Thursday (mean length of stay 3.69 days) or Friday (3.7 days), results showed patients who underwent surgery on either a Monday (3.56 days) or Tuesday experienced a significantly shorter length of stay, with Tuesday having the shortest length of stay (3.51 days).

However, regardless of which day the surgery was performed, patients discharged to rehabilitation centers had longer lengths of stay overall, according to the researchers.

The researchers also found patients who had ASA scores of three or greater had a 0.37-day longer length of stay vs. patients with ASA scores of two or less.

According to the researchers, the variations in length of stay between the groups could be a result of inconsistencies in weekend functionality, less-experienced part-time staff or inaccessibility of rehabilitation personnel.

“The surprising aspect of our study was that even though the magnitude of the difference in the length of stay between days of the week was significant, the overall difference was not that great,” Smith told Orthopedics Today. “In other words, the significant difference of 5% in the length of stay was less than anticipated. Even though this may not seem like a clinically significant amount of difference, if this strategy is applied across many thousands of total joint replacements, the cost savings to the hospitals and insurers would be significant.”

Limitations

According to Smith, the main limitation of the study was the retrospective evaluation of the patients. The researchers controlled for procedure by evaluating primary, elective total joint procedures, as well as for ASA score and BMI, which are two factors that have been shown to independently increase length of stay. However, Smith believe a more robust evaluation would include a prospectively collected cohort without variation in BMI and ASA.

“We felt that by establishing a cohort from two academic centers and evaluating [BMI] and ASA independently we could identify the impact of day of surgery as cleanly as possible,” Smith said. “The next step in our research on this topic is evaluating overall costs associated with the day of the week surgery is performed.” – by Casey Tingle

References:

Muppavarapu RC, et al. J Arthroplasty. 2014;doi:10.1016/j.arth.2014.06.004.

For more information:

Eric L. Smith, MD, can be reached at Tufts Medical Center, 800 Washington St., Boston, MA 02111; email: esmith@tuftsmedicalcenter.org.

Disclosure: Smith is on the speakers bureau for DePuy; is a paid consultant for Omni Life Science and DePuy; is an unpaid consultant for Omni Life Science, DePuy and Conformis; and received research support from Stryker, DePuy, Pfizer, Conformis and Omni Life Sciences.