Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: the “Outpatient Arthroplasty Risk Assessment Score”

• Published in: The Journal of arthroplasty 2017-08, Vol.32 (8), p.2325-2331
• Main Authors: Meneghini, R. Michael, MD, Ziemba-Davis, Mary, Ishmael, Marshall K., BS, Kuzma, Alexander L., MD, Caccavallo, Peter, MD, MS
• Format: Article
• Language: English
• Subjects: Aged; Ambulatory Surgical Procedures; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; Male; Middle Aged; OARA; Orthopedics; outpatient; outpatient arthroplasty risk assessment; Outpatients - statistics & numerical data; Patient Discharge - statistics & numerical data; Patient Selection; Retrospective Studies; Risk Assessment - methods; total hip arthroplasty; total joint arthroplasty; total knee arthroplasty
• ISSN: 0883-5403; 1532-8406
• DOI: 10.1016/j.arth.2017.03.004

Abstract Background Current patient selection criteria and medical risk stratification methods for outpatient primary total joint arthroplasty (TJA) surgery are unproven. This study assessed the predictive ability of a medically based risk assessment score in selecting patients for outpatient and short stay surgery. Methods A retrospective review of 1120 consecutive primary TJAs in an early discharge program was performed. An Outpatient Arthroplasty Risk Assessment (“OARA”) score was developed by a high-volume arthroplasty surgeon and perioperative internal medicine specialist to stratify patients as “low-moderate risk (≤59)” and “not appropriate” (≥60) for early discharge. OARA, American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and Charlson comorbidity index (CCI) scores were analyzed with respect to length of stay. Results The positive predictive value of the OARA score was 81.6% for the same or the next day discharge, compared with that of 56.4% for ASA-PS ( P < .001) and 70.3% for CCI ( P  = .002) scores. Patients with OARA scores ≤59 were 2.0 (95% confidence interval [CI], 1.4-2.8) times more likely to be discharged early than those with scores ≥60 ( P < .001), while a low ASA-PS score was 1.7 (95% CI, 1.2-2.3) times more likely to be discharged early ( P  = .001). CCI did not predict early discharge ( P ≥ .301). With deliberate patient education and expectations for outpatient discharge, the odds of early discharge predicted by the OARA score, but not the ASA-PS score, increased to 2.7 (95% CI, 1.7-4.2). Conclusion The OARA score for primary TJA has more precise predictive ability than the ASA-PS and CCI scores for the same or next day discharge and is enhanced with a robust patient education program to establish appropriate expectations for early discharge. Early results suggest that the OARA score can successfully facilitate appropriate patient selection for outpatient TJA, although consideration of clinical program maturity before adoption of the score is advised.