Elsevier

The Journal of Arthroplasty

Volume 31, Issue 11, November 2016, Pages 2426-2431
The Journal of Arthroplasty

Health Policy and Economics
Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty

https://doi.org/10.1016/j.arth.2016.04.013Get rights and content

Abstract

Background

The United States spends $12 billion each year on ∼332,000 total hip arthroplasty (THA) procedures with the postoperative period accounting for ∼40% of costs. The purpose of this study was to evaluate the effect of surgical scheduling (day of week and start time) on clinical outcomes, hospital length of stay (LOS), and rate of nonhome discharge in THA patients.

Methods

Analysis of perioperative variables was performed for patients who underwent THA at an urban tertiary care teaching hospital from 2009 to 2014.

Results

A total of 580 THA patients were included for analysis. LOS was higher for the Thursday/Friday cohort compared to Monday/Tuesday (3.7 vs 3.4 days; P = .03). Patients who had a surgical start time after 2 PM had longer LOS compared to patients operated on before 2 PM (3.9 vs 3.5 days; P = .03). After controlling for patient comorbidities and THA surgical approach (direct anterior vs posterior), Thursday/Friday THAs were associated with a 3.27 times risk of extended LOS (>75th percentile LOS) compared to Monday/Tuesday THAs (P < .001). Additionally, case start before 2 PM was protective and associated with a 0.46 times odds of extended LOS (P = .01). LOS reduction opportunity for changing surgical start time to before 2 PM was 0.9 days for high-risk patients (American Society of Anesthesiology class 3/4 and/or liver disease) and 0.2 days for low-risk patients (American Society of Anesthesiology class 1/2).

Conclusion

Patients who underwent THA Thursday/Friday or had start times after 2 PM had significantly extended hospital LOS. Preoperative risk modification along with adjustments to surgical scheduling and/or perioperative staffing may reduce LOS and thus hospital expenditures for THA procedures.

Section snippets

Methods

The institutional review board approved this retrospective study. Medical records for all patients undergoing elective THA by 1 fellowship-trained, experienced orthopedic surgeon at an urban, tertiary care hospital from 2009 to 2014 were reviewed. All patients had the same general selection of implants during the 5-year period including DePuy Summit stems, DePuy Pinnacle shells, and Biolox ceramic heads (typically 36 mm) on highly cross-linked polyethylene. Cases from January 2009 through

Results

A total of 580 THA patients were included for analysis, of which 307 received DAA and 273 PA. Patients were divided into groups based on day of week (Monday/Tuesday vs Thursday/Friday) and time of day (before 2 PM vs after 2 PM) the surgery was performed. Patient demographics were generally consistent across these groups (Table 1); however, those operated on after 2 PM were more likely to have a body mass index greater than 40 (P = .003) and chronic obstructive pulmonary disease (P = .03)

Discussion

Given the increase in demand for THA and Medicare's CJR mandating bundled payments for primary THA, the care team (including clinical and nonclinical members from the inpatient, postacute, and primary care settings) must identify strategies to improve the value (outcomes divided by cost) of THA across the care cycle 5, 7. Modifiable patient and provider factors are prime targets for these care redesign efforts. Our study aimed at (1) evaluating the effect of day of the week of surgery and time

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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 http://dx.doi.org/10.1016/j.arth.2016.04.013.

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