Elsevier

The Journal of Arthroplasty

Volume 33, Issue 10, October 2018, Pages 3138-3142
The Journal of Arthroplasty

Health Policy & Economics
Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting

https://doi.org/10.1016/j.arth.2018.07.004Get rights and content

Abstract

Background

Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.

Methods

In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.

Results

After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).

Conclusion

In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Section snippets

Materials and Methods

On July 1, 2016, a new rapid recovery TJA protocol was implemented at our institution’s associated VA Hospital. This protocol was based on current literature and was approved by the Iowa City VA Pharmacy and Therapeutic Committee as well as the Clinical Executive Board. It was developed with multidisciplinary input from orthopedic staff and residents, midlevel providers, anesthesia staff, physical therapists, pharmacists, nurses, and social workers. Briefly, the protocol consisted of required

Patient Demographics

In total, 252 primary TJAs (THA = 72, TKA = 180) were analyzed in 220 patients: 174 in the pre-protocol cohort and 78 in the protocol cohort. Five patients had 1 surgery in both the pre-protocol and protocol periods. There were 19 patients with 2 surgeries in the pre-protocol period and no surgery in the protocol period, and there were 8 patients with 2 surgeries in the protocol period but no surgery in the pre-protocol period. For those receiving multiple interventions, each surgery and its

Discussion

It has been well documented that institutional clinical pathways for TJA patients can reduce costs and improve patient care in some patient populations [1], [2], [3], [4], [5], [6]. Caring for Veterans in the VA hospital setting, however, presents unique challenges in the form of increased patient complexity and systemic obstacles. We sought to determine the effect and feasibility of implementing a comprehensive rapid recovery perioperative TJA protocol in the VA setting.

As summarized by Sculco

Conclusion

In the VA hospital setting, rapid recovery TJA is both safe and effective. Implementation of a rapid recovery protocol resulted in decreased hospital LOS and an increase in patients discharging directly home without increasing readmission or complication rates. These changes also decreased the average cost of TJA by approximately 10%. Such protocols are important for improved patient care and essential for cost control as we transition into an era of value-based arthroplasty.

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    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2018.07.004.

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