The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.

Abstract

The Perioperative Surgical Home (PSH) seeks to remedy the currently highly fragmented and expensive perioperative care in the United States. The 2 specific aims of this health services research study were to assess the association between the preoperative and postoperative elements of an initial PSH model and a set of (1) clinical, quality, and patient safety outcomes and (2) operational and financial outcomes, in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). A 2-group before-and-after study design, with a nonrandomized preintervention PSH (PRE-PSH group, N = 1225) and postintervention PSH (POST-PSH group, N = 1363) data-collection strategy, was applied in this retrospective observational study. The 2 study groups were derived from 2 sequential 24-month time periods. Conventional inferential statistical tests were applied to assess group differences and associations, including regression modeling. Compared with the PRE-PSH group, there was a 7.2% (95% confidence interval [CI], 4.0%-10.4%, P < .001) increase in day of surgery on-time starts (adjusted odds ratio [aOR] 2.54; 95% CI, 1.70-3.80; P < .001); a 5.8% (95% CI, 3.1%-8.5%, P < .001) decrease in day of surgery anesthesia-related delays (aOR 0.66; 95% CI, 0.52-0.84, P < .001); and a 2.2% (95% CI, 0.5%-3.9%, P = .011) decrease in ICU admission rate (aOR 0.45; 95% CI, 0.31-0.66, P < .001) in the POST-PSH group. There was a 0.6 (95% CI, 0.5-0.7) decrease in the number of ICU days in the POST-PSH group compared with the PRE-PSH group (P = .028); however, there was no significant difference (0.1 day; 95% CI, -0.03 to 0.23) in the total hospital length of stay between the 2 study groups (P = .14). There was also no significant difference (1.2%; 95% CI, -0.6 to 3.0) in the all-cause readmission rate between the study groups (P = .18). Compared with the PRE-PSH group, the entire POST-PSH group was associated with a $432 (95% CI, 270-594) decrease in direct nonsurgery costs for the THA (P < .001) and a $601 (95% CI, 430-772) decrease in direct nonsurgery costs for the TKA (P < .001) patients. On the basis of our preliminary findings, it appears that a PSH model with its expanded role of the anesthesiologist as the "perioperativist" can be associated with improvements in the operational outcomes of increased on-time surgery starts and reduced anesthesia-related delays and day-of-surgery case cancellations, and decreased selected costs in patients undergoing THA and TKA.