Indiana University School of Medicine, Indianapolis, IN.
Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; Indiana University Health Orthopedics, Indiana University Health Physicians, Indianapolis, IN.
J Arthroplasty. 2021 Jan;36(1):24-29. doi: 10.1016/j.arth.2020.07.021. Epub 2020 Jul 16.
Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA.
1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions.
759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention.
Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.
医保和医疗补助服务中心（Centers for Medicare and Medicaid Services）一直将全关节置换术（Total joint arthoplasty，TJA）的成本控制作为重点，这催生了大量的研究和项目变革，包括向提前出院和门诊 TJA 转变。门诊 TJA 患者在出院前接受的医疗干预很少（如果有的话），但住院过夜的 TJA 患者接受的干预类型和数量尚不清楚。本研究量化了初次 TJA 后住院过夜期间发生的干预措施的性质、频率和结果。
对一名外科医生在围手术期内科专家管理的快速出院计划下于 2012 年至 2017 年间进行的 1725 例连续单侧初次 TJA 进行回顾性研究。检查病历以了解诊断性检查、治疗和操作、干预结果和再入院情况。
759 例患者在术后第 1 天出院。84%（641/759）在住院过夜期间未接受任何医疗干预。12 例（1.6%）接受了诊断性检查，90 例（11.9%）接受了治疗，29 例（3.8%）接受了操作。12 项诊断性检查中 92%（11 项）结果为阴性，90 例患者中有 66%（100 项治疗中的 100 项）接受了静脉补液治疗少尿或低血压，所有操作均为导尿术以治疗尿潴留。接受（2.5%）和未接受（3.3%）临床干预的患者 90 天全因再入院率相似。
大多数患者未接受夜间干预，这表明住院治疗没有必要。最常见的问题是少尿、尿潴留和低血压。制定预防这些情况的方案将有助于门诊 TJA、提高患者安全性并降低成本。
