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The Journal of Arthroplasty Vol. 13 No. 2 1998         Factors Affecting Length of Stay and Need for        Rehabilitation...
Length of Stay/Need for Rehabilitation AfterTHA/TKA                 •    Forrest et al.          187discharged home or to ...
188        The Journal of Arthroplasty Vol. 13 No. 2 February 1998        T a b l e 2. Demographics of Patients Who Went  ...
Length of Stay/Need for Rehabilitation After THA/TKA          •   Forrest et al.     189correlations b e t w e e n BMI and...
190    The Journal of Arthroplasty Vol. 13 No. 2 February 19983. Harris WH, Sledge CB: Total hip and total knee replace-  ...
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Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty

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Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty

  1. 1. The Journal of Arthroplasty Vol. 13 No. 2 1998 Factors Affecting Length of Stay and Need for Rehabilitation After Hip and Knee Arthroplasty George Forrest, MD,* Marc Fuchs, MD,J- Ariel Gutierrez,{ and James Girardy, MD§ Abstract: The purpose of this study was to determine the factors that predict the length of stay on a surgical service after total hip or knee arthroplasty and the factors that predict whether a patient will require admission to a rehabilitation unit before he or she is ready to return home. The authors reviewed the records of all patients admitted to the Albany Medical Center for elective total hip or total knee arthroplasty in 1995. The study looked for correlations of patients age, sex, marital status, body mass index, and comorbid illnesses with length of stay on the surgical service and need for inpatient rehabilitation. The only factor that correlated with length of stay on the surgical unit was age. The factors that correlated with the need for inpatient rehabilitation were age and diabetes mellitus. K e y words: hip arthroplasty, knee arthroplasty, length of stay, rehabilitation.Hip a n d k n e e joint arthroplasties are the best treat- 1974, Coventry et al. reported protocols for m a n a g e -m e n t s for patients with a d v a n c e d arthritis that is m e n t of hip arthroplasties at the M a y o Clinic thatpainful, limits function, a n d does n o t r e s p o n d to r e c o m m e n d e d discharge on day 21 [1]. In 1990,conservative care. In p r o p e r l y selected patients, the Harris and Sledge reported a n average length of stayp r o c e d u r e s are safe a n d effective. The mortality rate of 9 - 1 0 days [2,3]. Current protocols call for dis-is less t h a n one half of 1%. The rate of serious charge on the fifth postoperative day. Protocols ofmedical complications (myocardial infarction, p n e u - streamlined care w i t h short length of stay o n acutemonia, p u l m o n a r y embolus, renal failure) is less surgical units assume that most patients will be ready tot h a n 2%. The rate of local complications, such as r e t u m directly to their homes or the homes of family orperipheral n e r v e injury, w o u n d infection, a n d peri- friends at the time of discharge but that some patientsprosthetic fracture, is less t h a n 5 %. The success rate will require admission to a rehabilitation unit.in reducing pain and i m p r o v i n g function is greater M o r r o w - H o w e l l and Proctor n o t e d that the basist h a n 9 0 % [1-3]. on w h i c h decisions are m a d e as to w h i c h patients The n u m b e r of patients a d m i t t e d for total joint are discharged to h o m e and w h i c h to rehabilitationarthroplasty is increasing yearly. The length of time is not clear [4]. Several investigators h a v e looked atpatients stay in the hospital is steadily decreasing. In the factors that w o u l d predict the n e e d for extensive rehabilitation. Age, sex, race, insurance, comorbid illnesses, type of arthritis, operative complications, From the *Department of PhysicaI Medicine and Rehabilitation andthe §Department of Medicine, Albany Medical College; -~Capital Region and living situation h a v e all b e e n cited as factorsOrthopedic Associates; and ¢Rensselaer Polytechnic Institute, Albany, that can d e t e r m i n e w h e t h e r a patient can receiveNew York. a d e q u a t e rehabilitation at h o m e or will require Supported by the David Cornell Lawrence Memorial Endow-ment Fund. transfer to a rehabilitation unit {4-8]. Address correspondence to George Forrest, MD, Department of The p u r p o s e of this study was to review the dataPhysical Medicine and Rehabilitation, Albany Medical Center, 43 f r o m p r o c e d u r e s done at the Albany Medical CenterNew Scotland Avenue, Albany, NY 12208. Copyright © 1998 Churchill Livingstone. to d e t e r m i n e if at the time the surgery is planned, it 0883-5403l 1302-000955.00/0 is possible to predict w h e t h e r a patient is likely to be 186
  2. 2. Length of Stay/Need for Rehabilitation AfterTHA/TKA • Forrest et al. 187discharged home or to require admission to a in the past medical history included history of priorrehabilitation unit. joint arthroplasty, organic heart disease (coronary artery disease, myocardial infarction, congestive Materials and Methods heart failure, valvular heart disease, arrhythmia), asthma, chronic obstructive pulmonary disease The Albany Medical Center is a 620-bed hospital (COPD), diabetes, stroke, Parkinsons disease, andin the Capital District of New York State. It is the rheumatoid arthritis or other systemic collagenmain teaching hospital of the Albany Medical Col- vascular disease. Body mass index (BMI) was calcu-lege. Full-time faculty, physicians in private prac- lated based on the patients height and weighttice, and physicians who work for a staff model (BMI = weight in kilograms divided by height inhealth maintenance organization have privileges to meters squared).practice orthopaedic surgery at the hospital. One hundred forty-seven patients were admitted Patients are seen on the first postoperative day by for elective joint arthroplasty. Twenty-one werephysical therapy. Before being discharged home, excluded from the study because their recordspatients are expected to be able to transfer from either could not be located or were incompletesupine to sitting and from sitting to standing and to (height and weight were not obtained). There was 1walk household distances with a walker or crutches. mortality; that patient was excluded from the study.Patients are expected to be independent in dressing The data were analyzed using the Statistical Analy-and bathroom activities or to be able to perform sis System. Pearsons correlation coefficient wasthese activities with help that is available at home. used to look for significant correlations betweenPatients who have had hip arthroplasties are ex- age, sex, marital status, premorbid conditions, andpected to understand appropriate precautions to BMI with length of stay on the surgical service andprevent dislocation of the prosthesis, and patients with place of discharge.who have had knee arthroplasties are expected tohave 90 ° of range of motion or to be making Resultsprogress sufficient to indicate that they will achievethat range with in-home therapy. All insurers in the One hundred and twenty-five patients were in-Capital District of upstate New York provide for cluded in the study. Eleven surgeons performed thein-home nursing if necessary and in-home physical operations. There were 63 hip arthroplasties and 62therapy for at least 60 days if necessary. Medicare knee arthroplasties. The average length of stay onand Medicaid provide for home health aides as the surgical service was 6.4 days. One hundred onenecessary to assist in personal care such as bathing, patients were discharged to their homes or thedressing, and meal preparation. Private insurance homes of friends or relatives, and 24 were admittedpolicies vary as to whether they provide home to rehabilitation units. The demographic features ofhealth aides. Patients must rely on friends or family the entire group of patients in the study are listed infor help with household cleaning, transportation, Table 1. The demographic features of the patientsand shopping. The decision as to whether patients who were admitted to rehabilitation units are listedare discharged home or transferred for rehabilita- in Table 2.tion is made by the patients surgeon with input The only characteristic that had a statisticallyfrom the nursing staff, the patients therapists, significant correlation with length of stay on thedischarge planning, the patient, and the patients surgical floor was age (Table 3). The only character-family. Most third-party payors other than Medicareand Medicaid require prior authorization for fund-ing of admissions to rehabilitation units. T a b l e 1. D e m o g r a p h i c s of Total P a t i e n t G r o u p We reviewed the medical records of all patientsadmitted to the Albany Medical Center in 1995 for n 125elective hip and knee joint arthroplasty. Patients Average age (y) 63.6 Women 56.8%who underwent joint arthroplasty after fracture or Men 43.2%resection of neoplasms were excluded from the Married 48%study. The information obtained from each chart Body mass index 30.7 Chronic obstructive pulmonary disease/asthma 15 %included the patients age, sex, height, weight, past Organic heart disease 30%medical history, marital status, surgeon, operation Diabetes 7%performed, postoperative complications, length of Rheumatoid arthritis 7% History of prior joint arthroplasty 38%stay on surgical service, and place of discharge (to Admitted for revision of prior joint arthroplasty 14%home or to rehabilitation). The problems recorded
  3. 3. 188 The Journal of Arthroplasty Vol. 13 No. 2 February 1998 T a b l e 2. Demographics of Patients Who Went T a b l e 4. C o r r e l a t i o n W i t h Discharge to R e h a b i l i t a t i o n to R e h a b i l i t a t i o n P Value*n 24Average age (y) 70.8 Age (y) .006Women 75 % Marital status 0Men 25% Body mass index .06Married 62% Chronic obstructive pulmonary disease/asthma .6Body mass index 32.9 Organic heart disease .4Chronic obstructive pulmonary disease/asthma 21% Diabetes .004Organic heart disease 38% Rheumatoid arthritis .813Diabetes 21% Prior joint arthroplasty .06Rheumatoid arthritis 10 % Revision .32History of prior joint arthroplasty 46%Admitted for revision 21% *P values < .05 indicate statistical significance. E l e v e n s u r g e o n s p e r f o r m e d 125 o p e r a t i o n s . Theistics t h a t h a d a s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n n u m b e r of o p e r a t i o n s p e r s u r g e o n v a r i e d f r o m 38 tow i t h t h e n e e d for a d m i s s i o n to a r e h a b i l i t a t i o n u n i t 1. T h e p e r c e n t a g e of e a c h s u r g e o n s p a t i e n t s w h ow e r e age a n d d i a b e t e s m e l l i t u s . w e r e t r a n s f e r r e d to r e h a b i l i t a t i o n v a r i e d f r o m 0 to T h e a v e r a g e age of t h e t o t a l g r o u p w a s 63.4 y e a r s . 26. T h e r e w a s n o statistical s i g n i f i c a n c e (P = .412)T h e a v e r a g e a g e of t h e p a t i e n t s w h o w e r e a d m i t t e d b e t w e e n s u r g e o n a n d t r a n s f e r to r e h a b i l i t a t i o n orto r e h a b i l i t a t i o n u n i t s w a s 70.8 y e a r s . A l t h o u g h age b e t w e e n s u r g e o n a n d l e n g t h of stay.w a s c o r r e l a t e d w i t h t h e n e e d for r e h a b i l i t a t i o n , t h e T w e n t y - f i v e p e r c e n t of w o m e n i n t h e s t u d y a n dm a j o r i t y ol e l d e r l y p a t i e n t s w e r e a b l e to b e dis- i 2 . 5 % of m e n in t h e s t u d y r e q u i r e d t r a n s f e r toc h a r g e d to h o m e (Table 4). E l e v e n p a t i e n t s w e r e r e h a b i l i t a t i o n u n i t s (Table 5). B y P e a r s o n s c o r r e l a -m o r e t h a n 80 y e a r s old; 7 w e r e d i s c h a r g e d to h o m e t i o n coefficient, this d i f f e r e n c e w a s n o t statisticallya n d 4 to r e h a b i l i t a t i o n u n i t s . T h e a v e r a g e l e n g t h of significant. T h e r e w e r e t h r e e d i f f e r e n c e s in t h es t a y o n t h e s u r g i c a l u n i t of t h e p a t i e n t s w h o w e r e d e m o g r a p h i c d a t a of t h e m e n a n d w o m e n . T h ed i s c h a r g e d to h o m e w a s 8.2 days. w o m e n w e r e o l d e r ( m e a n age, 65.4 vs 61.2). T h e T h e o n l y c o m o r b i d illness t h a t a f f e c t e d p l a c e of w o m e n w e r e h e a v i e r (BMI, 31.6 vs 29.6 for m e n ) .discharge was diabetes mellitus. Nine patients had T h e w o m e n w e r e m u c h less l i k e l y to be m a r r i e d .diabetes m e l l i t u s . F i v e (55 % ) w e r e d i s c h a r g e d to T h i r t y - t w o p e r c e n t of w o m e n a n d 7 8 % of m e n inrehabilitation units. Patients with any combination the study were married.of t w o o t h e r p r e m o r b i d illnesses o r o n e o t h e r B o d y m a s s i n d e x is t h e p a t i e n t s w e i g h t in k i l o -p r e m o r b i d illness a n d o b e s i t y ( B M I > 30) d i d n o t g r a m s d i v i d e d b y t h e s q u a r e of t h e p a t i e n t s h e i g h th a v e i n c r e a s e d l e n g t h of s t a y or i n c r e a s e d n e e d for i n m e t e r s . A p e r s o n w i t h a B M I of 2 7 - 2 9 . 9 isa d m i s s i o n to r e h a b i l i t a t i o n u n i t s . Statistical a n a l y s i s c o n s i d e r e d to b e o v e r w e i g h t , a n d o n e w i t h a B M I ofwas not done on patients with Parkinsons disease 30 o r greater, to b e o b e s e [9]. As t h e a v e r a g e B M I ofor s t r o k e b e c a u s e t h e n u m b e r of p a t i e n t s w i t h t h e s e t h e g r o u p w a s 30.7, m o s t of t h e p a t i e n t s w e r ed i s o r d e r s w a s t o o s m a l l (0, P a r k i n s o n s ; 4, s t r o k e ) . overweight. There were no statistically significant T a b l e 3. C o r r e l a t i o n With Length of Stay T a b l e 5. Proportion of Patients Sent to R e h a b i l i t a t i o n o n Surgical Service No. of No. of Patients P Value* Surgeon Cases to RehabilitationAge (y) .0011 1 29 4Marital status .77 2 11 1Body mass index .74 3 38 10Chronic obstructive pulmonary disease/asthma .88 4 4 0Organic heart disease .11 5 4 1Diabetes .21 6 4 0Rheumatoid arthritis .88 7 15 4Prior joint arthroplasty .22 8 9 3Revision .57 9 7 lSurgeon .15 10 1 0 11 3 0 *P values < .05 indicate statistical significance,
  4. 4. Length of Stay/Need for Rehabilitation After THA/TKA • Forrest et al. 189correlations b e t w e e n BMI and length of stay or f o u n d that the factors that correlated with the n e e db e t w e e n BMIs of those discharged to h o m e and for rehabilitation w e r e age, presence of 2 comorbidthose discharged to a rehabilitation unit. W h e n BMI conditions, w h e t h e r the patient lived alone, andwas correlated w i t h all of the other factors looked at level of pain after surgery.in the study, the only correlation of statistical A m a j o r difference b e t w e e n M u n i n and col-significance was that patients a d m i t t e d for revision leagues study a n d this study is that at the Universityof a prior arthroplasty w e r e heavier t h a n the group of Pittsburgh, 4 0 % of patients w e r e discharged toas a w h o l e (P = .0446). rehabilitation units and in this study only 19% of The rate of complications was low. There was 1 patients were discharged to rehabilitation units.mortality; a patient h a d a myocardial infarction in This is m o s t likely due to the increasing emphasis onthe perioperative period. That patient was not in- reducing total length of stay, reducing total costs,cluded in the study, as the p u r p o s e of the study was and providing medical services at h o m e or in theto look for correlations with length of stay and place outpatient setting rather t h a n in the hospital. Theof discharge. There w e r e a total of 13 d o c u m e n t e d m a j o r similarity b e t w e e n the studies is that age ispostoperative complications. Two patients devel- the factor that has the greatest effect on length ofoped congestive heart failure; l, angina pectoris; stay and the n e e d for extensive rehabilitation. Inand 1, an a r r h y t h m i a . One patient developed a deep this study, patients with cardiac disease a n d / o rvein thrombosis. One patient h a d a fever, the source p u l m o n a r y disease w h o w e r e acceptable candidatesof w h i c h could not be identified. Two patients h a d for the p r o c e d u r e tolerated it well and did not h a v eurinary tract infections, and 1 developed urinary increased length of stay or increased n e e d forretention. One developed cellulitis at an inlrave- admission to rehabilitation units. Patients with rheu-nous site and 1 developed p n e u m o n i a . One patient matoid arthritis and patients admitted for revisionsdeveloped depression and 2 developed confusion. of prior surgeries did not h a v e increased length ofThese patients t e n d e d to stay longer t h a n the group stay or increased n e e d for admission to rehabilita-as a whole. The average length of stay of these tion units. Patients with diabetes h a d increasedpatients was 9.16 days. Six w e r e discharged to h o m e frequency of admission to rehabilitation units. Thisa n d 6 to rehabilitation units, a n d 1 was transferred m a y be due to the small sample size or to theto a psychiatric unit before being discharged to characteristics of that disease, w h i c h m a y includeh o m e . N o n e of these patients was discharged to proximal muscle weakness and peripheral neuropathy.h o m e in less t h a n i week. We recognize 2 weaknesses in the study. First, The type of insurance did not s e e m to be a m a j o r marital status m a y not be an adequate indication of factor in d e t e r m i n i n g w h e t h e r patients w e r e dis- the a m o u n t of assistance a patient can obtain f r o m charged to rehabilitation units. In the Capital Dis- friends or family after discharge. Second, this was atrict of New York State, virtually all insurers, w h e t h e r retrospective study that correlated patients d e m o - health m a i n t e n a n c e organizations, providers of in- graphics and comorbid illnesses with length of stay d e m n i t y plans, or providers of coverage secondary and need for rehabilitation. A prospective study that to Medicare, require authorization prior to admis- looks at level of function prior to surgery m i g h t sion to a rehabilitation unit. Only patients with provide additional i n f o r m a t i o n t o w a r d a m o d e l that Medicaid or Medicare/Medicaid can be trans{erred can predict the time and resources necessary to help f r o m acute care to rehabilitation w i t h o u t s o m e a patient regain function after a hip or k n e e arthro- oversight f r o m a third-party payor. Of the 7 patients plasty. w h o h a d Medicaid coverage, 5 w e r e discharged to h o m e and 2 to rehabilitation. Five patients h a d Acknowledgments Medicare with Medicaid as a backup, and all w e r e discharged to h o m e . We t h a n k Michelle Kmieciak and R u t h Cook for their help with research and p r e p a r a t i o n of the Discussion manuscript. The p u r p o s e of the study was to d e t e r m i n e if Referencesthere is a m e t h o d of predicting w h i c h patientsa d m i t t e d for total joint arthroplasty will be dis- 1. Coventry M, Beckenbaugh R, Nolan D, Ilstrup D: 2,012charged to h o m e and w h i c h patients will require total hip arthroplasties: a study of post-operative coursetransfer to a rehabilitation unit. The best prior study and early complications. J Bone Joint Surg 56A:273, 1974that has looked at this issue was done by M u n i n et 2. Harris WH, Sledge CB: Total hip and total knee replace-al. at the University of Pittsburgh in 1993 [6]. They ment. N Engl J Med 323:725, 1990
  5. 5. 190 The Journal of Arthroplasty Vol. 13 No. 2 February 19983. Harris WH, Sledge CB: Total hip and total knee replace- 7. Sharma L, Sinacore J, Daugherty C et ah Prognostic ment. N Engl J Med 323:801, 1990 factors for functional outcome of total knee replace r4. Morrow-Howell N, Proctor E: Discharge destinations ment: a prospective study. J Gerontol 152, 1966 of Medicare patients receiving discharge planning: 8. Wolfe F, Nietfields, Hedrick R et ah Length of hospital who goes where? Med Care 51B:486, 1994 stay and complications of total joint replacement are5. Kwow CK, Whitley DM, Azadak KH et al: Predictors of unrelated to functional status, pain, or psychological functional i m p r o v e m e n t after total knee arthroplasty. variables. Abstract. Arthritis Rheum 36(suppl):S59, Abstract. Arthritis R h e u m 36(suppl):S98, 1993 19936. Munin M, K w o h K, Glynn N e t al: Predicting discharge 9. National Institute of Health Consensus Development outcome after elective hip and knee arthroplasty. Am 3 Conference: health implications of obesity. Ann Intern Phys Med Rehabil 74:294, 1995 Med 103:147, 1985

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