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Short-Stay Arthroplasty is Not Associated With Increased Risk of 90-Day Hospital Returns

Published:January 26, 2022DOI:https://doi.org/10.1016/j.arth.2022.01.050

      Highlights

      • Transition to short-stay total joint arthroplasty is crucial in today’s healthcare system.
      • Length of stay <24 hours associated with lower risk of 90-day readmissions/emergency department visits.
      • Length of stay <24 hours was associated with lower average total costs.

      Abstract

      Background

      With the removal of total hip arthroplasty (THA) and total knee arthroplasty (TKA) from the inpatient-only list, medical centers are faced with challenging transitions to outpatient surgery. We investigated if short-stay arthroplasty, defined as length of stay (LOS) <24 hours, would influence 90-day readmissions and emergency department (ED) visits at a tertiary referral center.

      Methods

      The institutional database was retrospectively queried for primary TKAs and THAs from July 2015 to January 2018, resulting in 2,217 patients (1,361 TKA and 856 THA). Patient demographics, including age, gender, body mass index, and American Society of Anesthesiologists score were collected. LOS, disposition, cost of care, 90-day ED visits, and readmissions were identified through the institutional database using electronic medical record data. Univariable and multivariable models were used to evaluate rates of 90-day readmissions and ED visits based on LOS <24 hours vs ≥24 hours.

      Results

      LOS <24 h was associated with significant decreases in 90-day ED visits (P = .003) and readmissions (P = .002). After controlling for potential confounding variables with a multivariable model, a significant decrease in ED visits (P = .034) remained in the THA cohort alone. Within TKA and THA cohorts, LOS <24 h was associated with lower costs (P < .001). Eighteen percent of patients with ≥24 h LOS were discharged to skilled nursing or rehabilitation facilities.

      Conclusion

      In this cohort, LOS <24 hours was associated with decreased 90-day readmissions, ED visits, and costs. With the goal of minimizing costs and maintaining patient safety while efficiently using resources, outpatient and short-stay arthroplasty are valuable, feasible options in tertiary academic centers.

      Keywords

      In the last several years, utilization of outpatient and short-stay joint arthroplasty has increased significantly, thanks to the advancements in surgical and perioperative managements [
      • Pollock M.
      • Somerville L.
      • Firth A.
      • Lanting B.
      Outpatient total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty: a systematic review of the literature.
      ,
      • Barrington J.W.
      Fast-track recovery and outpatient joint arthroplasty.
      ,
      • Berger R.A.
      • Cross M.B.
      • Sanders S.
      Outpatient hip and knee replacement: the experience from the first 15 years.
      ]. In addition, the removal of total knee arthroplasty (TKA) and total hip arthroplasty (THA) from the Centers for Medicare and Medicid Services’ inpatient-only list has accelerated this transition. Importantly, decreasing postoperative length of stay (LOS) and performing safe outpatient and short-stay arthroplasty have been targets for reducing healthcare costs associated with total joint arthroplasty (TJA) [
      • 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.
      ,
      • Huang A.
      • Ryu J.J.
      • Dervin G.
      Cost savings of outpatient versus standard inpatient total knee arthroplasty.
      ,
      • Schwartz A.J.
      • Clarke H.D.
      • Sassoon A.
      • Neville M.R.
      • Etzioni D.A.
      The clinical and financial consequences of the centers for Medicare and Medicaid Services’ two-midnight rule in total joint arthroplasty.
      ]. Thus, the average LOS has decreased from 3.1 days in 2012 to 2.4 days in 2016. In addition, the percentage of arthroplasties that incurred only a 1-midnight stay increased from 3.9% in 2012 to 21.2% in 2016, whereas the percentage of prolonged 3-midnight stays fell from 54.6% to 29.6% [
      • Schwartz A.J.
      • Clarke H.D.
      • Sassoon A.
      • Neville M.R.
      • Etzioni D.A.
      The clinical and financial consequences of the centers for Medicare and Medicaid Services’ two-midnight rule in total joint arthroplasty.
      ].
      Multiple authors have demonstrated the efficacy and feasibility of outpatient and short-stay arthroplasty without increase in short-term complications [
      • Pollock M.
      • Somerville L.
      • Firth A.
      • Lanting B.
      Outpatient total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty: a systematic review of the literature.
      ,
      • Barrington J.W.
      Fast-track recovery and outpatient joint arthroplasty.
      ,
      • 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.
      ,
      • Kiskaddon E.M.
      • Lee J.H.
      • Meeks B.D.
      • Barnhill S.W.
      • Froehle A.W.
      • Krishnamurthy A.
      Hospital discharge within 1 Day after total joint arthroplasty from a veterans affairs hospital does not increase complication and readmission rates.
      ,
      • Courtney P.M.
      • Froimson M.I.
      • Meneghini R.M.
      • Lee G.C.
      • Della Valle C.J.
      Can total knee arthroplasty be performed safely as an outpatient in the Medicare population?.
      ,
      • Banerjee S.
      • Hamilton W.G.
      • Khanuja H.S.
      • Roberts J.T.
      Outpatient lower extremity total joint arthroplasty: where are we heading?.
      ,
      • Greenky M.R.
      • Wang W.
      • Ponzio D.Y.
      • Courtney P.M.
      Total hip arthroplasty and the Medicare inpatient-only list: an analysis of complications in Medicare-aged patients undergoing outpatient surgery.
      ,
      • Hoeffel D.P.
      • Daly P.J.
      • Kelly B.J.
      • Giveans M.R.
      Outcomes of the first 1,000 total hip and total knee arthroplasties at a same-day surgery center using a rapid-recovery protocol.
      ,
      • Husted C.
      • Gromov K.
      • Hansen H.K.
      • Troelsen A.
      • Kristensen B.B.
      • Husted H.
      Outpatient total hip or knee arthroplasty in ambulatory surgery center versus arthroplasty ward: a randomized controlled trial.
      ,
      • Lovald S.
      • Ong K.
      • Lau E.
      • Joshi G.
      • Kurtz S.
      • Malkani A.
      Patient selection in outpatient and short-stay total knee arthroplasty.
      ,
      • Meneghini R.M.
      • Ziemba-Davis M.
      • Ishmael M.K.
      • Kuzma A.L.
      • Caccavallo P.
      Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score”.
      ,
      • Parcells B.W.
      • Giacobbe D.
      • Macknet D.
      • Smith A.
      • Schottenfeld M.
      • Harwood D.A.
      • et al.
      Total joint arthroplasty in a stand-alone ambulatory surgical center: short-term outcomes.
      ,
      • Weiser M.C.
      • Kim K.Y.
      • Anoushiravani A.A.
      • Iorio R.
      • Davidovitch R.I.
      Outpatient total hip arthroplasty has minimal short-term complications with the use of institutional protocols.
      ], most often in carefully selected patient populations. Concerns regarding the safety and applicability of accelerated discharge remain [
      • Arshi A.
      • Leong N.L.
      • D’Oro A.
      • Wang C.
      • Buser Z.
      • Wang J.C.
      • et al.
      Outpatient total knee arthroplasty is associated with higher risk of perioperative complications.
      ], and in “unselected” patients, the percentage of individuals who actually discharge as outpatient or short-stay arthroplasty is relatively limited [
      • Gromov K.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Kehlet H.
      • Husted H.
      Feasibility of outpatient total hip and knee arthroplasty in unselected patients.
      ,
      • Gromov K.
      • Jorgensen C.C.
      • Petersen P.B.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Troelsen A.
      • et al.
      Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls.
      ,
      • Lan R.H.
      • Samuel L.T.
      • Grits D.
      • Kamath A.F.
      Contemporary outpatient Arthroplasty is safe compared with inpatient surgery: a propensity score-matched analysis of 574,375 procedures.
      ]. With pressures on the healthcare system resources throughout surges in the COVID-19 pandemic, inpatient beds for elective orthopedic surgery have been limited. In addition, because of the concerns over patient safety and the consequences in bundled reimbursement models for complications such as readmissions, the stakes for performing safe outpatient and short-stay arthroplasty are high [
      • Phillips J.L.H.
      • Rondon A.J.
      • Vannello C.
      • Fillingham Y.A.
      • Austin M.S.
      • Courtney P.M.
      How much does a readmission cost the bundle following primary hip and knee arthroplasty?.
      ,
      • Bedard N.A.
      • Elkins J.M.
      • Brown T.S.
      Effect of COVID-19 on hip and knee arthroplasty surgical volume in the United States.
      ].
      In light of the current economic pressures, the purpose of this study was to investigate if short-stay arthroplasty, defined as LOS <24 hours, would influence 90-day readmissions and emergency department (ED) visit rates at a single tertiary referral academic center. A secondary objective was to evaluate differences in hospital cost of care and discharge disposition for patients with LOS <24 hours. We hypothesized that patients with LOS <24 hours would have similar rates of return to the hospital in the postoperative period compared with patients with LOS ≥24 hours while also having lower inpatient direct hospital costs.

      Materials and Methods

      Institutional review board approval was obtained before the initiation of this study. The institutional database at a single academic tertiary referral center was retrospectively queried for primary TKAs and THAs performed between July 2015 and January 2018. Patient demographics, including age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) score were collected [
      • Goltz D.E.
      • Ryan S.P.
      • Howell C.B.
      • Attarian D.
      • Bolognesi M.P.
      • Seyler T.M.
      A weighted index of elixhauser comorbidities for predicting 90-day readmission after total joint arthroplasty.
      ,
      • Hinton Z.W.
      • Fletcher A.N.
      • Ryan S.P.
      • Wu C.J.
      • Bolognesi M.P.
      • Seyler T.M.
      Body mass index, American Society of Anesthesiologists score, and elixhauser comorbidity index predict cost and delay of care during total knee arthroplasty.
      ,
      • Ryan S.P.
      • Goltz D.E.
      • Howell C.B.
      • Jiranek W.A.
      • Attarian D.E.
      • Bolognesi M.P.
      • et al.
      Predicting costs exceeding bundled payment targets for total joint arthroplasty.
      ,
      • Ryan S.P.
      • Politzer C.
      • Green C.
      • Wellman S.
      • Bolognesi M.
      • Seyler T.
      Albumin versus American Society of Anesthesiologists score: which is more predictive of complications following total joint arthroplasty?.
      ]. In addition, LOS (time from incision to time of discharge), discharge disposition, 90-day ED visits, 90-day readmissions, and total hospital cost of care for the index procedure were identified. All patients were divided into 2 cohorts based on LOS <24 hours or ≥24 hours. Patients were also divided by procedure (THA or TKA) separately. Cohorts were compared based on patient demographics, comorbidities (BMI and ASA score), cost of care, and 90-day readmissions and ED visits. Total hospital cost of care was tabulated based on the institutional accounting database, which tracks all costs associated with the episode of care. The average cost for all TKAs and average cost for all THAs were used as denominators. Cost of care for each individual patient was normalized to the mean cost of the corresponding procedure.

      Statistical Analysis

      Univariable models and multivariable logistic regression models controlling for age, gender, BMI, and ASA score were used to evaluate the rates of readmission and ED visits within 90 days postoperatively. A chi-square test was used to compare categorical variables, and a Mann-Whitney test was used to compare continuous variables with nonparametric distributions. Statistical analysis was performed with Wizard Pro for Mac (E. Miller, Chicago, IL). A P value of <.05 denotes statistical significance.

      Results

      There were a total of 2,217 primary total joint procedures (TKA 1,361; THA 856), which were stratified by LOS <24 hours (N = 256) or ≥24 hours (N = 1,961). Within the TKA cohort, 165 patients had LOS <24 hours, and 1,196 patients had LOS ≥24 hours. Within the THA cohort, there were 91 patients with LOS <24 hours, and 765 patients with LOS ≥24 hours (Figure 1).
      Table 1Hip and Knee Hospital Outcome Variables Across Length of Stay <24 Hours.
      Variable<24 h (N = 256)≥24 h (N = 1,961)P Value
      Age (y)64 (57, 70)65 (58, 71).053
      Female gender88 (34.4%)1,116 (56.9%)<.001
      BMI (kg/m2)29.1 (26.1, 32.3)30.5 (26.6, 34.9).001
      ASA >2132 (51.6%)1,131 (57.7%).063
      SNF/Rehab disposition0 (0.0%)356 (18.2%)<.001
      90-d ED visit11 (4.3%)199 (10.2%).003
      90-d readmission2 (0.8%)101 (5.2%).002
      Average total hospital cost
      Normalized to mean hospital cost.
      0.95 (0.90, 1.02)1.04 (0.96, 1.16)<.001
      BMI, body mass index; ASA, American Society of Anesthesiologists Score; SNF, skilled nursing facility; Rehab, rehabilitation; dispo, disposition; ED, emergency department.
      The use of bold font indicates statistical significance.
      a Normalized to mean hospital cost.
      Figure thumbnail gr1
      Fig. 1Patient stratification and analysis schema. TJA, total joint arthroplasty; LOS, length of stay; TKA, total knee arthroplasty; THA, total hip arthroplasty; ED, emergency department.

      Hip and Knee Arthroplasty Outcomes

      In the combined TJA cohort, LOS <24 hours was associated with male gender, lower average BMI, lower 90-day readmissions and ED visits, and lower average total hospital costs (Table 1). None of the THA or TKA patients with LOS <24 hours were discharged to a facility, compared with 18.2% of the patients with LOS ≥24 hours. The average normalized cost for LOS <24 was statistically significantly lower than that of patients with LOS ≥ 24 hours. A multivariable logistic regression for readmissions within 90 days demonstrated that patients with LOS <24 hours were significantly less likely to have a readmission (odds ratio [OR] 0.170, 95% confidence interval [CI] 0.041-0.697; P = .014). Similarly, in multivariable logistic regression for ED visits, patients with an LOS <24 hours were less likely to have an ED visit in the 90-day postoperative period (OR 0.422, 95% CI 0.219-0.812; P = .010). Patients with an LOS <24 hours had an average LOS of 20.85 hours, with 91.80% of patients staying >12 hours.

      Total Knee Arthroplasty Outcomes

      In the TKA cohort, LOS <24 h was associated with lower average BMI, male gender, and lower average total hospital costs (Table 2). None of the patients with LOS <24 hours were discharged to a facility, compared with 19.2% of patients with LOS ≥24 hours. Again, the average normalized cost for LOS <24 hours was statistically significantly lower than that of patients with LOS ≥24 hours. However, in a multivariable regression for 90-day readmissions and ED visits, LOS <24 hours after TKA was not significantly associated with decreased readmission (OR 0.347, 95% CI 0.083-1.46; P = .148) nor ED visit (OR 0.608, 95% CI 0.300-1.233; P = .168) in our patient population.
      Table 2Total Knee Arthroplasty Hospital Outcome Variables Across Length of Stay <24 Hours.
      Variable<24 h (N = 165)≥24 h (N = 1,196)P Value
      Age (y)66 (60, 71)67 (61, 72).163
      Female gender63 (38.2%)707 (59.1%)<.001
      Statistical significance.
      BMI (kg/m2)29.6 (26.8, 33.4)31.3 (27.3, 35.6).006
      Statistical significance.
      ASA >276 (46.1%)497 (41.6%).272
      SNF/Rehab disposition0 (0.0%)229 (19.2%)<.001
      Statistical significance.
      90-d ED visit9 (5.5%)115 (9.6%).082
      90-d readmission2 (1.2%)47 (4.0%).077
      Average total hospital cost
      Normalized to mean hospital cost.
      0.94 (0.88, 1.01)1.02 (0.95, 1.14)<.001
      Statistical significance.
      BMI, body mass index; ASA, American Society of Anesthesiologists Score; SNF, skilled nursing facility; Rehab, rehabilitation; Dispo, disposition; ED, emergency department.
      a Statistical significance.
      b Normalized to mean hospital cost.

      Total Hip Arthroplasty Outcomes

      In patients undergoing primary THA, LOS <24 hours was associated with male gender, lower average BMI, shorter OR time, decreased 90-day readmissions and ED visits, and lower average total hospital costs (Table 3). None of the patients with LOS <24 hours were discharged to a facility, compared with 16.6% of patients with LOS ≥24 hours. In addition, average normalized cost for LOS <24 was statistically significantly lower than that of patients with LOS ≥24 hours. In a multivariable regression for ED visits, patients with LOS <24 hours were significantly less likely to have an ED visit (OR 0.116, 95% CI 0.016-0.085; P = .034).
      Table 3Total Hip Arthroplasty Hospital Outcome Variables Across Length of Stay <24 Hours.
      Variable<24 h (N = 91)≥24 h (N = 765)P Value
      Age (y)61 (50, 68)63 (54, 70).079
      Female gender66 (72.5%)356 (46.5%)<.001
      Statistical significance.
      BMI (kg/m2)28.3 (24.8, 30.4)29.2 (25.5, 33.5).021
      Statistical significance.
      ASA >243 (47.3%)432 (56.5%).094
      OR time92.4 (79.8, 103.2)96.0 (82.2, 118.8).011
      Statistical significance.
      SNF/Rehab disposition0 (0.0%)127 (16.6%)<.001
      Statistical significance.
      90-d ED visit2 (2.2%)84 (11.0%).008
      Statistical significance.
      90-d readmission0 (0.0%)54 (7.1%).009
      Statistical significance.
      Average total hospital cost
      Normalized to mean hospital cost.
      0.99 (0.92, 1.04)1.08 (0.99, 1.20)<.001
      Statistical significance.
      BMI, body mass index; ASA, American Society of Anesthesiologists Score; OR, operating room; SNF, skilled nursing facility, Rehab, rehabilitation; dispo, disposition; ED, emergency department.
      a Statistical significance.
      b Normalized to mean hospital cost.

      Discussion

      In our patient population, short-stay arthroplasty was associated with male gender, lower BMI, lower costs, and decreased 90-day readmissions and ED visits. After controlling for potentially confounding variables, there was a lower risk of readmission and ED visits in the combined TJA cohort, but when evaluating by procedure, significant differences in the likelihood of a postoperative ED visit remained only for the THA cohort. Our data support the continued practice of short-stay TJA in a less selective (BMI, age, and ASA score), tertiary referral center patient population.
      In our study, LOS of 24 hours was chosen as a cutoff for groups to examine complication rates between short-stay and inpatient arthroplasty. Thus, our patient cohorts represent an organic cross-sectional look at the characteristics of patients who were able to safely discharge in <24 hours versus those who were not. Overall, 11.5% of all TJA patients, 12.1% of TKA patients, and 10.6% of THA patients had LOS <24 hours. This is similar to Gromov et al. who reported day of surgery discharge in 13%-15% of patients [
      • Gromov K.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Kehlet H.
      • Husted H.
      Feasibility of outpatient total hip and knee arthroplasty in unselected patients.
      ]. Interestingly, these researchers also found that female gender increased odds of longer LOS [
      • Gromov K.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Kehlet H.
      • Husted H.
      Feasibility of outpatient total hip and knee arthroplasty in unselected patients.
      ].
      In randomized controlled trials, inpatient and outpatient THA patients had no difference in hospital readmissions or ED visits, although inclusion and exclusion criteria were very strict with limitations on age, BMI, preoperative ambulatory status, and exclusion of patients with chronic pain medication [
      • Gromov K.
      • Jorgensen C.C.
      • Petersen P.B.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Troelsen A.
      • et al.
      Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls.
      ,
      • Goyal N.
      • Chen A.F.
      • Padgett S.E.
      • Tan T.L.
      • Kheir M.M.
      • Hopper R.H.
      • et al.
      Otto Aufranc Award: a multicenter, randomized study of outpatient versus inpatient total hip arthroplasty.
      ]. Even among these patients, 24% of patients who were expected to discharge as outpatient required a longer stay than expected [
      • Goyal N.
      • Chen A.F.
      • Padgett S.E.
      • Tan T.L.
      • Kheir M.M.
      • Hopper R.H.
      • et al.
      Otto Aufranc Award: a multicenter, randomized study of outpatient versus inpatient total hip arthroplasty.
      ] and 90-day readmissions occurred in 6% of outpatients and 4% of inpatients. Two large database studies have also demonstrated fewer adverse events in outpatient arthroplasty [
      • Lan R.H.
      • Samuel L.T.
      • Grits D.
      • Kamath A.F.
      Contemporary outpatient Arthroplasty is safe compared with inpatient surgery: a propensity score-matched analysis of 574,375 procedures.
      ] or no significant differences in overall adverse events [
      • Basques B.A.
      • Tetreault M.W.
      • Della Valle C.J.
      Same-day discharge compared with inpatient hospitalization following hip and knee arthroplasty.
      ], although only 3.74% and 0.70% of patients identified underwent an outpatient procedure, respectively.
      In addition to concerns regarding patient comfort and safety, readmissions and ED visits within the 90-day postoperative period impact Medicare reimbursement. Some studies have shown that about 2%-7% of patients after THA or TKA are readmitted at a mean cost of $8,560 per admission [
      • Lan R.H.
      • Samuel L.T.
      • Grits D.
      • Kamath A.F.
      Contemporary outpatient Arthroplasty is safe compared with inpatient surgery: a propensity score-matched analysis of 574,375 procedures.
      ,
      • Phillips J.L.H.
      • Rondon A.J.
      • Vannello C.
      • Fillingham Y.A.
      • Austin M.S.
      • Courtney P.M.
      How much does a readmission cost the bundle following primary hip and knee arthroplasty?.
      ,
      • Darrith B.
      • Frisch N.B.
      • Tetreault M.W.
      • Fice M.P.
      • Culvern C.N.
      • Della Valle C.J.
      Inpatient versus outpatient arthroplasty: a single-surgeon, matched cohort analysis of 90-day complications.
      ]. In our patient population, 4.6% of the combined cohort, 3.6% of the TKA cohort, and 6.3% of the THA cohort had a readmission in the 90-day postoperative period. Although further work is needed to better inform patients and surgeons of how to minimize risks of readmission after TJA, this work and that of others demonstrates that outpatient or short-stay arthroplasty does not seem to directly increase risks of 90-day hospital returns [
      • Gromov K.
      • Jorgensen C.C.
      • Petersen P.B.
      • Kjaersgaard-Andersen P.
      • Revald P.
      • Troelsen A.
      • et al.
      Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls.
      ,
      • Lan R.H.
      • Samuel L.T.
      • Grits D.
      • Kamath A.F.
      Contemporary outpatient Arthroplasty is safe compared with inpatient surgery: a propensity score-matched analysis of 574,375 procedures.
      ].
      With the ongoing global COVID-19 pandemic, the importance of how to manage elective orthopedic surgery patients safely and effectively remains critical. Interestingly, some studies have shown that average LOS increased despite no difference in age or ASA post-COVID [
      • Green G.
      • Abbott S.
      • Vyrides Y.
      • Afzal I.
      • Kader D.
      • Radha S.
      The impact of the COVID-19 pandemic on the length of stay following total hip and knee arthroplasty in a high volume elective orthopaedic unit.
      ], whereas others have shown significant increases in same-day discharges without increases in postoperative readmissions or ED visits [
      • Cherry A.
      • Montgomery S.
      • Brillantes J.
      • Osborne T.
      • Khoshbin A.
      • Daniels T.
      • et al.
      Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19.
      ]. In the setting of limited healthcare resources and hospital beds, short-stay and outpatient arthroplasty are valuable programs in which to invest.
      This study has several limitations, including its retrospective nature and single-center patient population. In addition, our 90-day complications were focused on the incidence of hospital readmissions and ED visits in general, rather than a specific cause or reason for these visits. Further details on causes for hospital return will require further study. Importantly, these unplanned contacts with the healthcare system in the global period have an impact on bundled reimbursements, prompting our choice to use these measures. In addition, we explored short-stay arthroplasty <24 hours but did not further look at same-day discharges. At our center, the number of patients with same-day discharge relative to LOS <24 hours would be a much smaller cohort, although we continue to make strides toward that effort. Approximately 8% of the LOS <24 hours cohort (21 of 256) and only 0.96% of the total primary joint patient cohort had an LOS <12 hours and would have been probable same-day discharges. The results of this study could be different for same-day discharge, and we will continue to evaluate this cohort.

      Conclusions

      In this retrospective study of patients undergoing primary TJA at a single tertiary referral study, we found that patients undergoing short-stay arthroplasty, defined as an LOS <24 hours, had a decreased cost of care, no discharges to facilities, and had decreased incidence of early postoperative hospital returns with lower incidence of readmissions and ED visits within 90 days postoperatively. After controlling for potential confounding variables of age, gender, BMI, and ASA score, a significant decrease in ED visits remained in the total hip arthroplasty cohort only. In the current healthcare environment, given limited staffing and bedspace shortages because of the ongoing COVID-19 pandemic, incentivization of shorter hospital stays, and financial consequences of postoperative complications, the ability to safely provide outpatient arthroplasty is key. This work suggests that outpatient and short-stay arthroplasty are feasible options, even in the context of tertiary academic centers.

      Appendix A. Supplementary Data

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