Abstract
Background
The Perioperative Surgical Home (PSH) is a physician-led, patient centered, rapid recovery care delivery model that includes multi-specialty care teams and cost-efficient use of resources developed to deliver patient centered value based care. The purpose of this study was to compare a group of patients undergoing primary total hip arthroplasty (THA) managed in the PSH model to a matched group managed in a more traditional fashion with respect to clinical outcomes, complications, and costs.
Methods
We prospectively followed the first 180 THA patients from the PSH group, comparing them to a group matched for age, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) Score, and Charlson Comorbidity Index (CCI) that was treated prior to implementation of the PSH. A combination of regional anesthesia and multi-modal pain control was used to minimize patient narcotic consumption. There was a rapid de-escalation of care post-operatively. Weekly multi disciplinary meetings were held where advanced discharge planning was discussed and we evaluated successes and areas of improvement of the prior week in an effort to continuously improve. We used Wilcoxon, Chi square, and multivariate regression analysis to compare the groups for length of stay (LOS), total direct cost (TDC), complications, 30-day readmissions, and discharge location.
Results
The mean age, BMI, ASA Score, and CCI was 64, 30, 3.0, and 3.5 for both groups. The LOS in the PSH group was 2.1 days, which was significantly lower than the Non Surgical Home (NSH) group at 3.6 days (P<0.001). Significantly more patients were discharged home in the PSH group, 83%, versus 71% in the NSH (P=0.006). No significant difference was found between the two groups with regard to complications (P=0.346), TDC (P=0.883), or readmissions at 30 days (P=0.637). Regarding the TDC, room and board cost $1,916 for the NSH group, and $1,375 for the PSH group secondary to the shorter LOS. This was a 28% reduction in room and board cost for the PSH group. This was offset, however, by an unforeseen increase in operating room labor cost during the study period. This cost increased from $1,672 in 2012–2013 (the period from which the NSH cohort was obtained) to $2,265 in the PSH time period. This was over a 26% increase.
Multivariate analysis showed the PSH cohort was an independent variable associated with decreased LOS (P<0.001) and discharge to home (P<0.001).
Conclusion
We believe the implementation of the Perioperative Surgical Home led to decreased LOS and allowed more patients to be discharged to home, without an increase in complications or readmissions. We believe this model is successful at providing patient centered value based care. The actual clinical pathway continues to be in use and is being further refined as we are regularly evaluating outcomes and finding areas of improvement.
