Health Policy & Economics| Volume 32, ISSUE 8, P2325-2331, August 2017

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

Published:March 13, 2017DOI:



      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.


      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.


      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).


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Aynardi M.
        • Post Z.
        • Ong A.
        • Orozco F.
        • Sukin D.C.
        Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study.
        J Hosp Spec Surg. 2014; 10: 252-255
        • Berger R.A.
        A comprehensive approach to outpatient total hip arthroplasty.
        Am J orthopedics. 2007; 36: 4-5
        • Berger R.A.
        • Jacobs J.J.
        • Meneghini R.M.
        • Della Valle C.
        • Paprosky W.
        • Rosenberg A.G.
        Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty.
        Clin orthopaedics Relat Res. 2004; 429: 239-247
        • Berger R.A.
        • Sanders S.
        • Gerlinger T.
        • Della Valle C.
        • Jacobs J.J.
        • Rosenberg A.G.
        Outpatient total knee arthroplasty with a minimally invasive technique.
        J arthroplasty. 2005; 20: 33-38
        • Bertin K.C.
        Minimally invasive outpatient total hip arthroplasty: a financial analysis.
        Clin orthopaedics Relat Res. 2005; 435: 154-163
        • Dorr L.D.
        • Thomas D.J.
        • Zhu J.
        • Dastane M.
        • Chao L.
        • Long W.T.
        Outpatient total hip arthroplasty.
        J arthroplasty. 2010; 25: 501-506
        • Kolisek F.R.
        • McGrath M.S.
        • Jessup N.M.
        • Monesmith E.A.
        • Mont M.A.
        Comparison of outpatient versus inpatient total knee arthroplasty.
        Clin orthopaedics Relat Res. 2009; 467: 1438-1442
        • Lovald S.
        • Ong K.
        • Lau E.
        • Joshi G.
        • Kurtz S.
        • Malkani A.
        Patient selection in outpatient and short-stay total knee arthroplasty.
        J Surg orthopaedic Adv. 2014; 23: 2-8
        • Sculco P.K.
        • Pagnano M.W.
        Perioperative solutions for rapid recovery joint arthroplasty: get ahead and stay ahead.
        J arthroplasty. 2015; 30: 518-520
        • Stambough J.B.
        • Nunley R.M.
        • Curry M.C.
        • Steger-May K.
        • Clohisy J.C.
        Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions.
        J arthroplasty. 2015; 30: 521-526
        • Hozack W.J.
        • Matsen-Ko L.
        Rapid recovery after hip and knee arthroplasty: a process and a destination.
        J arthroplasty. 2015; 30: 517
        • Berger R.A.
        • Kusuma S.K.
        • Sanders S.A.
        • Thill E.S.
        • Sporer S.M.
        The feasibility and perioperative complications of outpatient knee arthroplasty.
        Clin orthopaedics Relat Res. 2009; 467: 1443-1449
        • Berend K.R.
        • Lombardi Jr., A.V.
        • Mallory T.H.
        Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients.
        Surg Technol Int. 2004; 13: 239-247
        • Lavernia C.J.
        • Villa J.M.
        Rapid recovery programs in arthroplasty: the money side.
        J arthroplasty. 2015; 30: 533-534
        • Berger R.A.
        • Sanders S.
        • D'Ambrogio E.
        • Buchheit K.
        • Deirmengian C.
        • Paprosky W.
        • et al.
        Minimally invasive quadriceps-sparing TKA: results of a comprehensive pathway for outpatient TKA.
        J knee Surg. 2006; 19: 145-148
        • Berger R.A.
        • Sanders S.A.
        • Thill E.S.
        • Sporer S.M.
        • Della Valle C.
        Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients.
        Clin orthopaedics Relat Res. 2009; 467: 1424-1430
        • Schneider M.
        • Kawahara I.
        • Ballantyne G.
        • McAuley C.
        • Macgregor K.
        • Garvie R.
        • et al.
        Predictive factors influencing fast track rehabilitation following primary total hip and knee arthroplasty.
        Arch orthopaedic Trauma Surg. 2009; 129: 1585-1591
        • Saklad M.
        Grading of patients for surgical procedures.
        Anesthesiology. 1941; 2: 281-284
        • Dripps R.D.
        • Lamont A.
        • Eckenhoff J.E.
        The role of anesthesia in surgical mortality.
        Jama. 1961; 178: 261-266
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Pagnano M.W.
        • Trousdale R.T.
        • Meneghini R.M.
        • Hanssen A.D.
        Slower recovery after two-incision than mini-posterior-incision total hip arthroplasty. A randomized clinical trial.
        J bone Jt Surg Am volume. 2008; 90: 1000-1006
        • Meneghini R.M.
        • Smits S.A.
        • Swinford R.R.
        • Bahamonde R.E.
        A randomized, prospective study of 3 minimally invasive surgical approaches in total hip arthroplasty: comprehensive gait analysis.
        J arthroplasty. 2008; 23: 68-73
        • Meneghini R.M.
        • Smits S.A.
        Early discharge and recovery with three minimally invasive total hip arthroplasty approaches: a preliminary study.
        Clin orthopaedics Relat Res. 2009; 467: 1431-1437
        • Romano P.S.
        • Roos L.L.
        • Jollis J.G.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives.
        J Clin Epidemiol. 1993; 46: 1075-1079
        • Hackett N.J.
        • De Oliveira G.S.
        • Jain U.K.
        • Kim J.Y.
        ASA class is a reliable independent predictor of medical complications and mortality following surgery.
        Int J Surg. 2015; 18: 184-190
        • Schaeffer J.F.
        • Scott D.J.
        • Godin J.A.
        • Attarian D.E.
        • Wellman S.S.
        • Mather 3rd, R.C.
        The association of ASA class on total knee and total hip arthroplasty readmission rates in an academic hospital.
        J arthroplasty. 2015; 30: 723-727
        • Fitz-Henry J.
        The ASA classification and peri-operative risk.
        Ann R Coll Surgeons Engl. 2011; 93: 185-187
        • Owens W.D.
        American Society of Anesthesiologists Physical Status Classification System in not a risk classification system.
        Anesthesiology. 2001; 94: 378
        • D'Hoore W.
        • Sicotte C.
        • Tilquin C.
        Risk adjustment in outcome assessment: the Charlson comorbidity index.
        Methods Inf Med. 1993; 32: 382-387
        • D'Hoore W.
        • Bouckaert A.
        • Tilquin C.
        Practical considerations on the use of the Charlson comorbidity index with administrative data bases.
        J Clin Epidemiol. 1996; 49: 1429-1433
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Ghali W.A.
        • Hall R.E.
        • Rosen A.K.
        • Ash A.S.
        • Moskowitz M.A.
        Searching for an improved clinical comorbidity index for use with ICD-9-CM administrative data.
        J Clin Epidemiol. 1996; 49: 273-278
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • Fong A.
        • Burnand B.
        • Luthi J.C.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Quan H.
        • Li B.
        • Couris C.M.
        • Fushimi K.
        • Graham P.
        • Hider P.
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Yurkovich M.
        • Avina-Zubieta J.A.
        • Thomas J.
        • Gorenchtein M.
        • Lacaille D.
        A systematic review identifies valid comorbidity indices derived from administrative health data.
        J Clin Epidemiol. 2015; 68: 3-14
        • Sharabiani M.T.
        • Aylin P.
        • Bottle A.
        Systematic review of comorbidity indices for administrative data.
        Med Care. 2012; 50: 1109-1118
        • Lovald S.T.
        • Ong K.L.
        • Malkani A.L.
        • Lau E.C.
        • Schmier J.K.
        • Kurtz S.M.
        • et al.
        Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients.
        J arthroplasty. 2014; 29: 510-515
        • Courtney P.M.
        • Rozell J.C.
        • Melnic C.M.
        • Lee G.C.
        Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty.
        J arthroplasty. 2015; 30: 1-4
        • Parvizi J.
        • Mui A.
        • Purtill J.J.
        • Sharkey P.F.
        • Hozack W.J.
        • Rothman R.H.
        Total joint arthroplasty: when do fatal or near-fatal complications occur?.
        J bone Jt Surg Am volume. 2007; 89: 27-32