HSS study explores trends and outcomes in outpatient joint replacement compared to hospital stay

With outpatient hip and knee replacements on the rise, Geoffrey Westrich, MD, and colleagues at Hospital for Special Surgery (HSS) launched a study to analyze trends and compare complication rates of patients who go home the same day they have surgery versus those who spend one or more nights in the hospital.

Analyzing information from a large database that included patients nationwide, the researchers found no significant difference in complication rates requiring a hospital readmission for outpatient total hip replacement. For total knee replacement, they found slightly higher odds of complications in patients who left the hospital on the day they had surgery. The study appeared online ahead of print in The Journal of Arthroplasty.

“In recent years there has been increasing interest among surgeons and hospital systems in shifting joint replacement to outpatient centers safely and efficiently,” said Dr. Westrich, research director emeritus in the Adult Reconstruction and Joint Replacement Service at HSS. “However, there has been limited data on trends, comorbidities, and complications in patients discharged the same day they have surgery.”

Using the PearlDiver Mariner Database, Dr. Westrich and colleagues identified almost 1.8 million patients who underwent a primary, elective total hip or total knee replacement between 2010 and 2017. Patients were divided into groups based on which surgery they had and whether it was performed on an inpatient or outpatient basis. For each group, researchers collected data on patient demographics, comorbidities, and complications within 90 days of surgery that required readmission to the hospital.

Investigators found that the annual prevalence of outpatient hip replacement and outpatient knee replacement increased exponentially from 2010 to 2017, with a mean annual change of 15.8% in the hip replacement group and 11.1% in the outpatient knee replacement group. Overall, patients discharged on the day they had surgery were younger and healthier, with fewer medical conditions such as diabetes and chronic pulmonary disease.

For hip replacement patients, there was no significant difference in complications requiring readmission to the hospital within 90 days, whether the surgery was performed outpatient or with a hospital stay. In knee replacement patients discharged the same day, there was a slightly higher odds ratio of complications requiring a hospital readmission. Overall, complications were not common in either knee replacement group, with an incidence of less than 1 percent.

The study authors indicated that they believe same-day discharge joint replacement is safe but requires additional patient monitoring in the early postoperative period. Dr. Westrich emphasizes the importance of patient selection to ensure the best outcomes, noting that good general health is essential for anyone considering outpatient joint replacement. People who have heart or lung disease, diabetes or sleep apnea would not qualify. They should be nonsmokers. Younger patients in their 40s or 50s and 60s tend to be better candidates, but people in their early 70s in very good general health may also qualify.

“Individuals considering same-day discharge should feel comfortable forgoing a night in the hospital where they would receive nursing care,” Dr. Westrich added. “A patient who is very anxious about surgery or experiences a great deal of stress about recovery may not be a good candidate.”

Dr. Westrich notes that the shift toward outpatient joint replacement has become more pronounced with the introduction of the Bundled Payment for Care Improvement (BPCI) by the Center for Medicare and Medicaid Services (CMS), which incentivizes reducing nonessential hospital-associated costs and length of stay.

“Our study aimed to augment the literature on outpatient joint replacement surgery to help orthopedic surgeons and their patients make an informed decision,” he says. “Although we found it can be performed safety and efficiently, it’s an option, not a requirement. Every patient is different, and individuals and their doctors should make an informed decision based on what makes patients feel most comfortable.”

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 12th consecutive year), No. 4 in rheumatology by U.S. News & World Report (2021-2022), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2021-2022). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a second consecutive year (2021). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 145 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu