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AAOS Now

Published 3/25/2022
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Patrick Daly

Adjusting Patient Length-of-stay Expectations in Total Hip Arthroplasty Care Pathways

Care pathways in hip arthroplasty programs have effectively lowered the length of stay (LOS) after primary total hip arthroplasty (THA). However, according to Michael Tanzer, MD CM, FRCSC, adult hip and knee specialist and professor of surgery at McGill University Health Centre in Montreal, the concurrent implementation of several components of a pathway has obscured the impact of individual care modifications administered before a patient enters one.

Dr. Tanzer and colleagues studied whether changing a patient’s expectations about anticipated LOS (without changing other components of the care pathway) resulted in a change in LOS after THA.

Their report, presented by Dr. Tanzer at the AAOS 2022 Annual Meeting, revealed that LOS can be “significantly reduced” by modifying patient expectations. In fact, the authors suggested that it “has a greater effect than merely the implementation of a standardized care pathway.”

The study tracked LOS in 100 consecutive patients who were undergoing primary cementless THA following the implementation of a two-day care pathway at their institution. Nurses and preoperative written instructions all indicated two-day LOS, but participants were specifically told by their surgeon to expect a one-day LOS. Only the patient and surgeon were aware of the accelerated discharge plan; otherwise, no changes were made in surgery or intra- or postoperative management.

All enrolled patients were successfully discharged home after surgery. According to the report, the mean LOS was 1.6 days, with 56 percent of patients being discharged on postoperative day one. Otherwise, 2 percent of patients had a zero-day LOS, 31 percent had a two-day LOS, and 11 percent stayed in the hospital for three or more days. The mean LOS was comparable among age groups (1.4, 1.7, and 1.4 days for patients aged 50 to 59 years, 60 to 69 years, and 70 to 79 years, respectively). The rate of discharge on postoperative day one slightly favored patients aged 50 to 59 years—67 percent were discharged on day one, compared with 53 percent of patients aged 60 to 69 years and 57 percent of those aged 70 to 79 years. No patients required hospital readmission.

In a multivariate analysis, factors significantly associated with LOS longer than one day included female gender, no social support, and presence of comorbidities (Table 1).

Ultimately, the study’s authors suggested that their work “highlights the significant influence patient education and expectations have on the effectiveness of care pathways in THA, as well as the importance of continuous reinforcement of discharge planning both preoperatively and in-hospital.”

Dr. Tanzer’s coauthor of “Patient Expectations Trump Care Pathways for Length of Stay following Total Hip Arthroplasty” is Bardia Barimani, MD, MSc.

Patrick Daly is a freelance writer for AAOS Now.