Total Joint Arthroplasty Surgery: Does Day of Surgery Matter?

doi:10.1016/j.arth.2014.06.004

The Journal of Arthroplasty

Volume 29, Issue 10, October 2014, Pages 1943-1945

https://doi.org/10.1016/j.arth.2014.06.004 Get rights and content

Abstract

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Section snippets

Methods

After approval was obtained from the Tufts Medical Center IRB, we performed a retrospective review of all primary TJA procedures performed over a two year period, from March 2011 to April 2013, by two fellowship trained surgeons at Tufts Medical Center and University of California Irvine Medical Center. Our cohort included a total of 547 patients all of whom underwent primary total hip or knee arthroplasty. In order to avoid type II error (P < 0.05), a power analysis was performed, the results of

Results

LOS was significantly shorter for patients who had surgery on either a Monday or a Tuesday, when compared to those who had surgery on either a Thursday or a Friday (Table 2). Tuesday had the shortest LOS (mean = 3.51), and was significantly (P < 0.05) less than Thursday (mean = 3.69) and Friday (mean = 3.70) (Table 2). Patients discharged to rehabilitation centers had longer LOS, regardless of which day the surgery was performed (Table 3). This result was not significant. There was no significant

Conclusion

Early discharge following TJA benefits both patient and hospital, while maintaining, and in some cases improving, patient outcomes 11., 12.. Expedited recovery, as a result of decreased LOS, can lead to better health outcomes overall 13., 14., 15., 16., 17.. In addition, reduced LOS can decrease hospital expenses 18., 3.. Results from this study indicate a significant association between day of surgery and postoperative length of stay. It can be postulated, based on these results, that TJA

References (25)

G.S. Butler et al.
Prehospital education: effectiveness with total hip replacement surgery patients
Patient Educ Couns
(1996)
G. DeJong et al.
Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities
Arch Phys Med Rehabil
(2009)
P. Pilot et al.
Experience of the first four years of Rapid Recovery; is it safe?
Injury
(2006)
K.A. Reilly et al.
Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty – a randomized controlled trial
Knee
(2005)
D.F. Bindelglass
Effectiveness of best practice implementation in reducing hip arthroplasty length of stay
J Arthroplasty
(2008)
K.A. Stockton et al.
Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial
Arch Phys Med Rehabil
(2009)
C. Jenkins et al.
Physiotherapy management of minimally invasive Oxford medial compartment knee arthroplasty: an observational study of 100 patients following an accelerated treatment protocol
Physiotherapy
(2006)
T. Dixon et al.
Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need
Ann Rheum Dis
(2004)
S.S. Liu et al.
Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States
Int Orthop
(2009)
F. Koechlin et al.
Comparing price levels of hospital services across countries: results of a pilot study

S. MacDonald et al.

Preoperative education for hip and knee replacement

Cochrane Database Syst Rev

(2004)

J. Foote et al.

Length of stay following primary total hip replacement

Ann R Coll Surg Engl

(2009)

Cited by (26)

Safe on Saturday: Elective abdominal and perineal surgeries can be performed on Saturday without increased risk of poor post-operative outcome
2019, American Journal of Surgery
Citation Excerpt :
However, many of these studies have focused on patients undergoing either high-risk surgeries (i.e. intrathoracic, intraabdominal) or a specific type of procedure (i.e. orthopedic).1,5,7,9,13 Further, there are reported differences in outcomes between different countries and between academic and non-academic hospitals.9,11,13 Interestingly, contrary to previous studies, some recent studies that better adjusted for patient and institutional factors have failed to reveal any “weekend effect.”14–16
The “weekend effect,” whereby surgeries performed during weekend haven been associated with poorer postoperative outcomes. We explored whether Saturday elective procedures at our hospital were associated with poorer post-operative outcomes when compared with weekday surgeries.
A retrospective cohort study of patients undergoing elective surgery on the abdomen or perineum from 2008 to 2015 was performed. Procedures were classified by day (Group 1: Monday, Tuesday, Wednesday; Group 2: Saturday). Multivariate regression analyses were performed to determine group differences in procedure duration, length-of-stay (LOS) and complications.
In adjusted analyses, there were no statistically significant differences between Group 1 (n = 816) and Group 2 (n = 269) procedures in terms of procedure duration (Group 2 - Group 1 = 13.6 min, p = .19), LOS (Group 2 - Group 1 = 1.9 days, p = .14) and complications (OR 0.58, p = .46).
Saturday elective procedures were not associated with poorer outcomes.
Carotid Endarterectomy Performed before the Weekend is Associated with Increased Length of Stay
2018, Annals of Vascular Surgery
Citation Excerpt :
In the study by Rothman et al.,10 cholecystectomies performed on Friday had increased LOS (P < 0.05). Total joint arthroplasty performed earlier in the week had a significantly shorter LOS that ranged from 0.13 to 0.19 days (P < 0.05) as demonstrated by Muppavarapu et al.20 The findings of these studies were similar to ours, and as such, our recommendations regarding action to shorten LOS mirrors those offered. However, unlike other studies, we did not find specific complications or mortality associated with an extended LOS.
Length of stay (LOS) is commonly used to gauge hospital resource utilization and can affect hospital profit margin. Other fields of surgery have showed that operations performed close to the weekend have longer LOS and higher patient morbidity. Our goal was to investigate whether asymptomatic patients undergoing elective carotid endarterectomy (CEA) earlier in the week had a shorter LOS and improved clinical outcomes compared to those treated before the weekend.
The Vascular Quality Initiative database was queried for elective weekday CEAs performed for asymptomatic carotid stenosis from 2005 to 2017. Univariate and multivariate analyses were completed to compare outcomes based on the day of the week.
There were 26,882 asymptomatic CEAs performed on Monday (20.3%), Tuesday (23.0%), Wednesday (21.3%), Thursday (18.8%), and Friday (16.6%). The mean patient age was 70.5 years, and 59.2% were male. Thirty-day mortality (0.4%) and perioperative complications including stroke (1.4%), myocardial infarction (0.7%), and return to the operating room (1.5%) were not significantly different across weekdays. Patients were discharged on statins in 84.2% of cases and aspirin in 91.5% of cases. The mean LOS ranged from 1.6 ± 2.2 days to 1.8 ± 3.2 days. CEAs performed on Fridays had a longer LOS (1.8 ± 2.4; P < 0.001). Multivariate analysis demonstrated that CEAs performed on Friday had longer LOS compared to those performed on Monday through Thursday (means ratio: 1.05, 95% confidence interval [CI]: 1.03–1.07; P < 0.001). However, there were no differences in perioperative complications to attribute this to. Friday CEA did not have an effect on discharge medication compliance with aspirin (odds ratio: 0.94, 95% CI: 0.82–1.07; P = 0.339) or statin medications (odds ratio: 0.90, 95% CI: 0.79–1.03; P = 0.126).
Asymptomatic CEA performed before the weekend was associated with longer LOS although there were no differences in perioperative mortality, morbidity, and discharge medication compliance. Such LOS increase, albeit small, may affect the hospital profit margin for the procedure and performing an elective CEA on asymptomatic patients earlier in the week may benefit in a shorter LOS. Improved team staffing and resources on weekends are potential areas for improvement for earlier discharge; however, further investigation is needed.
Is Day of Surgery Associated With Adverse Clinical and Economic Outcomes Following Primary Total Knee Arthroplasty?
2017, Journal of Arthroplasty
Citation Excerpt :
Our study found that the mean LOS was higher for primary TKAs performed later in the week. This finding is consistent with a prior study of 547 patients who underwent THA or TKA at a major American academic medical center [6]. The mean LOS was 3.69 days for Thursday and 3.70 days for Friday, compared with 3.56 days for Monday and 3.51 days for Tuesday.
As orthopedics transition to value-based purchasing, hospitals and providers are incentivized to identify inefficiencies of care delivery. In our experience, weekends are characterized by decreased staffing of ancillary services to coordinate patient discharges, which can lead to prolonged hospital stays for many of our primary total knee arthroplasty (TKA) admissions.
We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State. We used mixed effects regression models to compare length of stay (LOS), 90-day readmission, and cost according to the day of TKA.
Mean LOS was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). There was no significant difference in 90-day readmission risk according to day of surgery. Mean cost was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). When LOS was held constant across every day of the week, the mean cost of TKA decreased by $247 for Wednesday, $627 for Thursday, and $394 for Friday.
Primary TKA performed later in the week is associated with an increased LOS and increased costs of admission, but a similar risk of 90-day readmission. Preferential scheduling of primary TKA cases early in the week, as well as the development of standardized clinical care pathways with appropriate weekend staffing of social work and rehabilitation services, could help to decrease the daily variation in LOS and increase the value of TKA episodes.
Letter to the Editor on “Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty”
2017, Journal of Arthroplasty
Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty
2017, Journal of Arthroplasty
Citation Excerpt :
Our results suggest that primary THA and TKA performed later in the week have an increased LOS, while only primary TKA performed later in the week has increased total charges, when controlling for independent risk factors. Muppavarapu et al [22] reported on 547 patients who underwent TJA and found patients who had surgery on Monday and Tuesday had significantly shorter LOS compared to surgery performed on Thursday and Fridays (P = .04). Similarly, in a large study using national Medicare claims data, Chen et al [34] reported that patients who had TKAs on a Monday had 9.5% and 6.4% shorter LOS than TKAs performed on Thursday and Friday, respectively.
Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).
An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS.
Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001).
Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.
Effect of Total Joint Arthroplasty Surgical Day of the Week on Length of Stay and Readmissions: A Clinical Pathway Approach
2016, Journal of Arthroplasty
The demand for total joint arthroplasty (TJA) is increasing at the same time that alternative payment models place increased scrutiny on the cost of these procedures. Using a clinical pathway model, this study aimed to examine the effect of day of surgery on length of stay (LOS).
A retrospective electronic chart review was conducted on 2968 cases over 20 months at a single hospital. Least square means analysis of the effect of surgical day of the week on LOS was conducted using Statistical Analysis Software 9.3, followed by Tukey's multiple comparison test. Logistic regression assessed the effect of surgical day of week on readmission.
Within the primary TJA group, there was no significant difference in mean LOS for each day of the week (1.17, 1.32, 1.29, 1.27, and 1.27 for Monday through Friday, respectively). Of all days, mean LOS for revision TJA (1.51, 1.57, 1.57, 2.49, and 2.03) only differed significantly for Thursday (P < .0001), although in adjusted analysis with age and American Society of Anesthesiologist, this difference was no longer significant (P = .3954). Readmission was likewise not significantly affected by surgical day of week (chi sq = 1.426, P = .8396) in the sample.
As the volume of joint arthroplasties increases and alternative payment models are implemented, programs that promote decreased LOS regardless of operative day of the week are critical. Practices can use clinical pathway models to reduce costs related to LOS while maintaining a high level of patient care.

View all citing articles on Scopus

: Study performed at Tufts University School of Medicine and University of California, Irvine.

: Financial Disclosure: No financial support was received in connection with this study.

: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2014.06.004.

View full text

Total Joint Arthroplasty Surgery: Does Day of Surgery Matter?

Abstract

Section snippets

Methods

Results

Conclusion

Patient Educ Couns

Arch Phys Med Rehabil

Injury

Knee

J Arthroplasty

Arch Phys Med Rehabil

Physiotherapy

Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need

Ann Rheum Dis

Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States

Int Orthop

Comparing price levels of hospital services across countries: results of a pilot study

Preoperative education for hip and knee replacement

Cochrane Database Syst Rev

Length of stay following primary total hip replacement

Ann R Coll Surg Engl