Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: The "Outpatient Arthroplasty Risk Assessment Score"

R. Meneghini, Mary Ziemba-Davis, Marshall K. Ishmael, Alexander L. Kuzma, Peter Caccavallo

Research output: Contribution to journalArticle

34 Citations (Scopus)

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.

Original languageEnglish (US)
JournalJournal of Arthroplasty
DOIs
StateAccepted/In press - Dec 30 2016

Fingerprint

Arthroplasty
Outpatients
Joints
Comorbidity
Patient Selection
Patient Education
Confidence Intervals
Internal Medicine
Length of Stay
Anesthesiologists

Keywords

  • OARA
  • Outpatient
  • Outpatient arthroplasty risk assessment
  • Total hip arthroplasty
  • Total joint arthroplasty
  • Total knee arthroplasty

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine

Cite this

Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification : The "Outpatient Arthroplasty Risk Assessment Score". / Meneghini, R.; Ziemba-Davis, Mary; Ishmael, Marshall K.; Kuzma, Alexander L.; Caccavallo, Peter.

In: Journal of Arthroplasty, 30.12.2016.

Research output: Contribution to journalArticle

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title = "Safe Selection of Outpatient Joint Arthroplasty Patients With Medical Risk Stratification: The {"}Outpatient Arthroplasty Risk Assessment Score{"}",
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.",
keywords = "OARA, Outpatient, Outpatient arthroplasty risk assessment, Total hip arthroplasty, Total joint arthroplasty, Total knee arthroplasty",
author = "R. Meneghini and Mary Ziemba-Davis and Ishmael, {Marshall K.} and Kuzma, {Alexander L.} and Peter Caccavallo",
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AU - Meneghini, R.

AU - Ziemba-Davis, Mary

AU - Ishmael, Marshall K.

AU - Kuzma, Alexander L.

AU - Caccavallo, Peter

PY - 2016/12/30

Y1 - 2016/12/30

N2 - 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.

AB - 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.

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KW - Outpatient

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KW - Total hip arthroplasty

KW - Total joint arthroplasty

KW - Total knee arthroplasty

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