同一天出院的全关节置换术与 ASA 分级≥3 的患者 90 天内不良事件风险之间的关系。
Association Between Same-Day Discharge Total Joint Arthroplasty and Risk of 90-Day Adverse Events in Patients with ASA Classification of ≥3.
机构信息
Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California.
Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California.
出版信息
J Bone Joint Surg Am. 2021 Nov 3;103(21):2032-2044. doi: 10.2106/JBJS.20.02110.
BACKGROUND
Although safety in same-day discharge total joint arthroplasty (TJA) has been reported, findings are limited to healthier patients, specific surgeons, and/or specific institutions. Indications for same-day discharge TJA have expanded to include patients with multiple comorbidities; however, safety in this specific patient population remains unknown. Therefore, we sought to compare the risk of 90-day adverse events in higher-risk patients undergoing same-day discharge versus inpatient TJA.
METHODS
The Kaiser Permanente Total Joint Replacement Registry was utilized to conduct a cohort study. All patients with an American Society of Anesthesiologists (ASA) classification of ≥3 who underwent primary elective TJA for osteoarthritis from 2017 through 2018 were identified. The risk of 90-day adverse events (i.e., emergency department visits, unplanned readmissions, complications, and mortality) was evaluated with use of propensity score-weighted Cox proportional hazard regression including noninferiority testing with a margin of 1.10.
RESULTS
The cohort included a total of 5,250 patients who underwent total hip arthroplasty and 9,752 patients who underwent total knee arthroplasty, of whom 1,742 (33.2%) and 3,283 (33.7%) had same-day discharge, respectively. Same-day discharge hip arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (hazard ratio [HR], 0.73; 1-sided HR 95% upper bound [UB], 0.84), readmissions (HR, 0.47; 95% UB, 0.61), and complications (HR, 0.63; 95% UB, 0.75); we did not have evidence of noninferiority for mortality (HR, 0.84; 95% UB, 1.97). Same-day discharge knee arthroplasty was noninferior to an inpatient stay in terms of emergency department visits (HR, 0.79; 95% UB, 0.87), readmission (HR, 0.80; 95% UB, 0.95), complications (HR, 0.72; 95% UB, 0.82), and mortality (HR, 0.53; 95% UB, 1.03).
CONCLUSIONS
We found that same-day discharge TJA did not increase the risk of emergency department visits, unplanned readmissions, and complications compared with an inpatient stay for higher-risk patients, suggesting that it is possible to expand indications for same-day discharge TJA in the hospital setting while maintaining safety.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景
虽然当日出院全关节置换术（TJA）的安全性已有报道，但这些发现仅限于更健康的患者、特定的外科医生和/或特定的机构。当日出院 TJA 的适应证已扩展到包括患有多种合并症的患者；然而，这一特定患者群体的安全性仍不清楚。因此，我们旨在比较高风险患者行当日出院与住院 TJA 的 90 天不良事件风险。
方法
利用 Kaiser Permanente 全关节置换登记处进行了一项队列研究。从 2017 年至 2018 年，我们确定了所有接受择期初次 TJA 治疗骨关节炎且美国麻醉医师协会（ASA）分级≥3 的患者。使用倾向评分加权 Cox 比例风险回归评估 90 天不良事件（即急诊就诊、非计划再入院、并发症和死亡率）的风险，并进行非劣效性检验，置信区间为 1.10。
结果
该队列包括 5250 例全髋关节置换术患者和 9752 例全膝关节置换术患者，其中 1742 例（33.2%）和 3283 例（33.7%）行当日出院。当日出院髋关节置换术在急诊就诊（风险比[HR]，0.73；单侧 HR 95%上限[UB]，0.84）、再入院（HR，0.47；95%UB，0.61）和并发症（HR，0.63；95%UB，0.75）方面不劣于住院治疗；我们没有证据表明死亡率不劣于（HR，0.84；95%UB，1.97）。当日出院膝关节置换术在急诊就诊（HR，0.79；95%UB，0.87）、再入院（HR，0.80；95%UB，0.95）、并发症（HR，0.72；95%UB，0.82）和死亡率（HR，0.53；95%UB，1.03）方面不劣于住院治疗。
结论
我们发现，对于高风险患者，与住院治疗相比，当日出院 TJA 并不会增加急诊就诊、非计划再入院和并发症的风险，这表明在维持安全性的同时，有可能扩大当日出院 TJA 的适应证。
证据水平
治疗性 III 级。请参阅作者说明以获取完整的证据水平描述。
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