Reduced Length of Stay Following Patient Pathway Optimization for Primary Hip and Knee Arthroplasty at a Swiss Hospital

Figures & data

Table 1 Enhanced Recovery Principles Implemented Before and After Patient Pathway Optimization

Component	Pre-PPO	Post-PPO
		TKA	THA
Preoperative information, education and counselling	No	Yes	Yes
Preoperative optimization
Management of anemia	Yes	Yes	Yes
Pre-operative physiotherapy	No	Yes	Yes
Preoperative fasting	No	No	No
Standard anesthetic protocol	Yes	Yes	Yes
Use of local anesthetics for infiltration analgesia and nerve blocks	No	Yes	Yes
Postoperative nausea and vomiting*	Yes	Yes	Yes
Prevention of perioperative blood loss	Yes	Yes	Yes
Perioperative oral analgesia (pre-emptive analgesia)	No	Yes	Yes
Maintaining normothermia	Yes	Yes	Yes
Antimicrobial prophylaxis	Yes	Yes	Yes
Antithrombotic prophylaxis treatment	Yes	Yes	Yes
Perioperative surgical factors	Yes	Yes	Yes
Perioperative fluid management	Yes	Yes	Yes
Postoperative nutritional care	No	No	No
Early mobilization	No	Yes	Yes
Criteria-based discharge	Yes	Yes	Yes
Continuous improvement and audit	No	Yes	Yes

Notes: *For all patients where required. Bold indicates principles that were changed with the PPO program implementation. Table based on data from Wainwright et al, 2020.⁴⁹

Abbreviations: PPO, patient optimization pathway; THA, Total Hip Arthroplasty; TKA, Total Knee Arthroplasty.

Table 2 Patient Demographics and Baseline Clinical Characteristics in the Total Knee Arthroplasty Cohort

	Total Knee Arthroplasty
Baseline Characteristics	Pre-PPO	Post-PPO	Total
N	122	45	167
Sex, n (%)
Male	44 (36.1%)	16 (35.6%)	60 (35.9%)
Age, years
Mean, years (SD)	66.8 (9.3)	64.0 (10.9)	66.1 (9.8)
ASA, n (%)
1	15 (12.3%)	5 (11.1%)	20 (12.0%)
2	107 (87.7%)	40 (88.9%)	147 (88.0%)
BMI
Mean (SD)	30.6 (6.2)	28.5 (4.7)	30.1 (5.9)
Missing (n)	1	1	2
Year of procedure, n (%)
2014	47 (38.5%)	-	47 (28.1%)
2015	67 (54.9%)	-	67 (40.1%)
2016 *	8 (6.6%)	11 (24.4%)	19 (11.4%)
2017	-	12 (26.7%)	12 (7.2%)
2018	-	13 (28.9%)	13 (7.8%)
2019	-	9 (20.0%)	9 (5.4%)
Surgeon seniority, n (%)
Chief	16 (13.1%)	22 (48.9%)	38 (22.8%)
Senior	106 (86.9%)	21 (46.7%)	127 (76.0%)
Junior	0 (0%)	2 (4.4%)	2 (1.2%)
Diagnosis, n (%)
Primary gonarthrosis	107 (87.7%)	39 (86.7%)	146 (87.4%)
Secondary, posttraumatic and other gonarthrosis	13 (10.7%)	6 (13.3%)	19 (11.4%)
Other	2 (1.6%)	0 (0%)	2 (1.2%)

Note: *The PPO program was implemented on 1 April 2016.

Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classification System; BMI, Body Mass Index; PPO, Patient Pathway Optimization; SD, standard deviation.

Table 3 Patient Demographics and Baseline Clinical Characteristics in the Total Hip Arthroplasty Cohort

	Total Hip Arthroplasty
Baseline Characteristics	Pre-PPO	Post-PPO	Total
N	180	93	273
Sex, n (%)
Male	89 (49.4%)	54 (58.1%)	143 (52.4%)
Age, years
Mean, years (SD)	66.7 (11.0)	60.9 (11.4)	64.7 (11.4)
ASA, n (%)
1	24 (13.3%)	13 (14.0%)	37 (13.6%)
2	156 (86.7%)	80 (86.0%)	236 (86.4%)
BMI
Mean (SD)	26.8 (4.6)	27.1 (3.9)	26.9 (4.4)
Year of procedure, n (%)
2014	82 (45.6%)	-	82 (30.0%)
2015	90 (50.0%)	-	90 (33.0%)
2016 *	8 (4.4%)	18 (19.4%)	26 (9.5%)
2017	-	29 (31.2%)	29 (10.6%)
2018	-	29 (31.2%)	29 (10.6%)
2019	-	17 (18.3%)	17 (6.2%)
Surgeon seniority, n (%)
Chief	41 (22.8%)	42 (45.2%)	83 (30.4%)
Senior	139 (77.2%)	48 (51.6%)	187 (68.5%)
Junior	0 (0%)	3 (3.2%)	3 (1.1%)
Diagnosis, n (%)
Primary coxarthrosis	141 (78.3%)	68 (73.1%)	209 (76.6%)
Secondary, posttraumatic and other coxarthrosis	25 (13.9%)	18 (19.4%)	43 (15.8%)
Necrosis	14 (7.8%)	7 (7.5%)	21 (7.7%)

Note: *The PPO program was implemented on 1 April 2016.

Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classification System; BMI, Body Mass Index; PPO, Patient Pathway Optimization; SD, standard deviation.

Table 4 Summary of Study Outcomes for Total Knee and Hip Arthroplasty Cohorts Pre- and Post-Patient Pathway Optimization Implementation – Multivariate Analyses

Outcomes*	Total Knee Arthroplasty			Total Hip Arthroplasty
	Pre-PPO (N=122)	Post-PPO (N=45)	Significance of Treatment Effect	Pre-PPO (N=180)	Post-PPO (N=93)	Significance of Treatment Effect
Length of stay, days
Mean^†	8.43 (95% CI: 8.08, 8.80)	5.96 (95% CI: 5.53, 6.43)	Ratio of means: 0.71 (95% CI: 0.65, 0.77; p<0.001)	7.67 (95% CI: 7.37, 7.98)	5.25 (95% CI: 4.96, 5.55)	Ratio of means: 0.68 (95% CI: 0.64, 0.73; p<0.001)
Inpatient costs during the index hospitalization, USD
Mean^†	20,420 (95% CI: 19,631, 21,242)	18,405 (95% CI: 17,166, 19,732)	Ratio of means: 0.90 (95% CI: 0.83, 0.98; p=0.015)	17,681 (95% CI: 17,084, 18,298)	17,341 (95% CI: 16,513, 18,210)	Ratio of means: 0.98 (95% CI: 0.92, 1.04; p=0.54)
Hospital (inpatient) costs up to 90 days post-admission, USD
Mean^†	20,741 (95% CI: 19,821, 21,703)	18,816 (95% CI: 17,367, 20,384)	Ratio of means: 0.91 (95% CI: 0.82, 1.00; p=0.048)	17,681 (95% CI: 17,084, 18,298)	17,341 (95% CI: 16,513, 18,210)	Ratio of means: 0.98 (95% CI: 0.92, 1.04; p=0.54)
Discharge destination, %
Home	68.40% (95% CI: 57.87, 77.33)	83.77% (95% CI: 68.51, 92.45)	OR: 2.38 (95% CI: 0.92, 6.18; p=0.074)	73.90% (95% CI: 65.10, 81.13)	80.40% (95% CI: 69.20, 88.22)	OR: 1.45 (95% CI: 0.71, 2.94; p=0.306)

Notes: *Adjusted for age, gender, BMI, ASA score, surgeon seniority and main diagnosis (history was only available for few patients and hence not included in model); except for discharge destination, where analysis was adjusted for age, gender, BMI and ASA score only. ^†Means refer to adjusted (least square) means following multivariate analysis.

Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classification System; BMI, Body Mass Index; CI, Confidence Interval; OR, odds ratio; PPO, Patient Pathway Optimization; SD, standard deviation; USD, United-States Dollar.

Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica. 2020;91(1):3–19. doi:10.1080/17453674.2019.1683790

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