Van Horne Alaine, Van Horne James
Paragon Orthopedic Center, Grants Pass, OR, USA.
Arthroplast Today. 2019 Sep 25;5(4):497-502. doi: 10.1016/j.artd.2019.08.008. eCollection 2019 Dec.
Medicare-insured patients may be candidates for outpatient total knee and hip arthroplasty (TKA/THA) because postsurgical complications are often age unrelated. We evaluated an opioid-minimizing enhanced recovery after surgery (ERAS) pathway in an inpatient setting designed to presurgically optimize and prepare patients to reduce risk of avoidable postsurgical complications and maximize feasibility of same-day discharge.
This single-center retrospective chart review included 601 unique consecutive Medicare-insured patients who underwent TKA (n = 337) or THA (n = 308) between June 1, 2015 and November 16, 2017. The ERAS pathway included presurgical nonarthroplasty treatment of osteoarthritis; physical, medical, and social optimization; and medication trials to individualize perioperative analgesia. All patients were discharged directly home without home services. Adverse events, satisfaction, and opioid use were analyzed descriptively.
Mean (range) age was 72 (32-92) years; 56.7% of patients were women; 84.0% were discharged the same day, 13.8% in 1 day, and 2.2% in >1 day. Rates of minor and severe adverse events within 30 days were 0.5% and 1.1%, respectively. There were no intubations, sepsis, or deaths. Twelve patients (1.9%) had unplanned readmissions within 30 days. Patient-reported satisfaction with facility, analgesia, and communication were high. Most patients (84.2%) did not require >1 seven-day opioid prescription from the surgeon within 8 weeks postsurgery.
Using a patient-optimizing, opioid-minimizing ERAS pathway without home services, Medicare-insured patients undergoing TKA/THA experienced low complication rates and high satisfaction. Exploratory analysis suggests limited postsurgical opioid use. This presurgical patient-engagement approach may aid transition to freestanding ambulatory surgery centers.
医疗保险参保患者可能适合门诊全膝关节置换术和全髋关节置换术（TKA/THA），因为术后并发症通常与年龄无关。我们在住院环境中评估了一种减少阿片类药物使用的术后加速康复（ERAS）方案，该方案旨在术前优化并使患者做好准备，以降低可避免的术后并发症风险，并使当日出院的可行性最大化。
这项单中心回顾性病历审查纳入了2015年6月1日至2017年11月16日期间连续接受TKA（n = 337）或THA（n = 308）的601例医疗保险参保患者。ERAS方案包括骨关节炎的术前非关节置换治疗；身体、医疗和社会状况优化；以及个体化围手术期镇痛的药物试验。所有患者均直接出院回家，无需居家服务。对不良事件、满意度和阿片类药物使用情况进行了描述性分析。
平均（范围）年龄为72（32 - 92）岁；56.7%的患者为女性；84.0%的患者当日出院，13.8%在1天内出院，2.2%在超过1天出院。30天内轻微和严重不良事件的发生率分别为0.5%和1.1%。没有插管、败血症或死亡病例。12例患者（1.9%）在30天内有计划外再入院情况。患者报告对设施、镇痛和沟通的满意度较高。大多数患者（84.2%）在术后8周内不需要外科医生开具超过1张为期7天的阿片类药物处方。
采用一种优化患者、减少阿片类药物使用且无需居家服务的ERAS方案，接受TKA/THA的医疗保险参保患者并发症发生率较低且满意度较高。探索性分析表明术后阿片类药物使用有限。这种术前患者参与方法可能有助于向独立门诊手术中心的过渡。
