Abstract
Introduction
Total joint arthroplasty (TJA) is projected to be the most common elective surgical procedure in the coming decades, however TJA now accounts for the largest expenditure per procedure for Medicare and Medicaid provided interventions. This is coupled with increasing complexity of surgical care and concerns about patient satisfaction. The Perioperative Surgical Home (PSH) model has been proposed as a method to both improve patient care and reduce costs. The PSH model provides evidence-based protocols and pathways from the time of surgical decision to after postoperative discharge. PSH pathways can further be standardized with integration into electronic medical records (EMRs). The purpose of this study is to see if the implementation of PSH with and without EMR integration effects patient outcomes and cost.
Methods
A retrospective review was performed for all patients who underwent elective primary total joint arthroplasty at our institution from January 1, 2012 to April 1, 2018. Three cohorts were compared. The first cohort included patients before the implementation of the PSH model (January 1, 2012 - December 31, 2014). The second cohort included patients in the PSH model without EMR integration (January 1, 2015 – August 1, 2016). The third cohort included patients in the PSH model with EMR integration (August 1, 2016 - April 1, 2018). The clinical outcome criteria measured were average hospital length of stay (LOS), 30-day readmission rates, and discharge disposition. Financial data was collected for each cohort and primary measurements included average total cost, diagnostic cost, anesthesia cost, laboratory cost, room and board cost, and physical therapy cost.
Results
Overall, 3,384 primary total joint arthroplasty cases were included. Implementation of a PSH without EMR significantly reduced LOS (1.79 vs 3.59, p<0.05), readmission rates (1.9% vs 4.3%, p<0.05), and decreased the rate of skilled nursing facility (SNF) disposition (15.2% vs 31.1%, p<0.05) and increased discharge to home care (84.8% vs 68.9%, p<0.05). EMR integration did not significantly reduce LOS or readmission rates but did further decreased the rate of SNF disposition (10.2% vs 15.2%, p<0.05), while increasing the rate of home care disposition (89.8% vs 84.8%, p<0.05). Per case, implementation of the PSH model without EMR integration decreased diagnostic cost (−$9.37, p<0.05), anesthesia cost (−$71.34, p<0.05), room and board cost (−$285.18, p<0.05) and total overall cost (−$1432.38, p<0.005). Integrating pathways into an EMR led to further cost-reduction in laboratory cost (−$47.04, p<0.05), physical therapy cost (−$57.79, p<0.05), and total overall cost (−$2,837.28, p<0.05). EMR integration did not lead to significant increases in other cost variables.
Conclusions
The implementation of a PSH model for total joint arthroplasty, especially with electronic medical record integration, reduces cost, average LOS, 30-day readmissions, and increases discharge to home care.
