围手术期骨科手术之家：优化全关节置换术候选者并预防再入院。
Perioperative Orthopedic Surgical Home: Optimizing Total Joint Arthroplasty Candidates and Preventing Readmission.
机构信息
Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY.
出版信息
J Arthroplasty. 2019 Jul;34(7S):S91-S96. doi: 10.1016/j.arth.2019.01.020. Epub 2019 Jan 18.
BACKGROUND
It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities.
METHODS
A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk.
RESULTS
Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P < .05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred.
CONCLUSION
The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA.
LEVEL OF EVIDENCE
Level III, Retrospective Cohort Study.
背景
众所周知，全关节置换术（TJA）后计划外再入院在合并症患者中更为常见。然而，很少有研究人员在手术前延迟手术并对患者进行医学优化。目前，围手术期矫形外科治疗之家（POSH）是一种由外科医生主导的筛查和优化计划，针对 8 种常见的可改变的合并症。
方法
回顾性筛选了 2014 年 1 月至 2016 年 12 月期间接受 TJA 的 4188 名患者，使用再入院风险评估工具（RRAT）评分。1194 名患者术前 RRAT 评分≥3 分，符合纳入标准。然后，根据患者是否参加围手术期矫形外科治疗之家（POSH）计划（POSH；n=216）或尽管存在风险仍继续手术（非 POSH；n=978），将患者分为两组。
结果
POSH 计划实施后，RRAT 评分为 3-5 的患者 30 天（1.6%比 5.3%，P=0.03）和 90 天（3.2%比 7.4%，P<0.05）的再入院率较低。参加 POSH 计划的经医学优化患者中，仅有 15.3%出院至康复医疗机构，而非 POSH 患者中有 23.4%出院至康复医疗机构（P=0.01）。两组患者的住院时间和感染率无差异。此外，非 POSH Medicare TJA 接受者的 90 天医疗费用增加了 14.9%，如果发生再入院，则增加了 32.6%。
结论
在手术干预前识别和优化合并症可以提高 TJA 候选者接受的治疗价值。对高危 TJA 候选者进行标准化多学科医疗优化的方法可能会提高患者的参与度和围手术期结果，同时降低与 TJA 相关的成本。
证据等级
三级，回顾性队列研究。
Zotero 插件