Do Hip Surgery Patients Need Longer Hospital Stays?

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Between 1991 and 2008, the mean length of hospital stay for Medicare patients who had total hip arthroplasty surgery has declined by more than 50%. During this same time, the proportion discharged to intermediate- and skilled-care facilities doubled while the number of patients sent home decreased from 68% to 48%.

This information comes from a report in the the April 20 issue of the Journal of the American Medical Association. The authors state the purpose of their article was “to examine demographics and outcomes of patients undergoing primary and revision total hip arthroplasty.’

To do this, Peter Cram, MD, of the University of Iowa in Iowa City, and co-authors, analyzed Medicare Part A data to identify beneficiaries who underwent primary (1,453,493) or revision (348,596) total-hip arthroplasty during 1991 to 2008.

Outcomes of interest included changes in patient demographics and comorbidity, hospital length of stay (LOS), mortality, discharge disposition, and all-cause readmission rates.

Cram and colleagues found the patient risk and procedure complexity increased over time for primary and revision procedures. Patient age increased, prevalence of diabetes doubled, and the proportion of patients who were obese tripled.

Between 1991 and 2008, the mean age for patients undergoing primary total hip arthroplasty increased from 74.1 to 75.1 years and for revision total hip arthroplasty from 75.8 to 77.3 years (P

The mean number of comorbid illnesses per patient increased from 1.0 to 2.0 for primary total hip arthroplasty and 1.1 to 2.3 for revision (P

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Obesity prevalence increased from 2.2% to 7.6% in primary arthoplasty patients and from 1.4% to 4.7% in revision arthoplasty patients.

Even with this increase in comorbid illnesses, the mean LOS declined by more than 50%. For primary total hip arthroplasty, the LOS decreased from 9.1 days in 1991-1992 to 3.7 days in 2007-2008 (P = .002).

Unadjusted in-hospital and 30-day mortality decreased during this time period from 0.5% to 0.2% and from 0.7% to 0.4%, respectively (P

The proportion of primary total hip arthroplasty patients discharged directly to their homes declined from 68.0% to 48.2% while the proportion discharged to skilled care increased from 17.8% to 34.3%.

During the time period reviewed, the 30-day all-cause readmission increased from 5.9% to 8.5% (P

Similar trends were observed in hospital LOS, in-hospital mortality, discharge disposition, and hospital readmission rates were seen in the revision total hip arthroplasty patients.

Since the study was limited to a Medicare population, the authors cautioned that extrapolating the findings to a general population was problematic. Moreover, they relied on an administrative database so were unable to assess functional status and quality of life.

The study wasn’t designed to analyze cost, but it would be interesting to know if the cost savings of the decreased hospital days were off-set by the increased days in the skilled care or rehabilitation facilities. Do the increased readmissions offset any cost savings of the decrease hospital days? Would there be fewer re-admissions if patients stayed one more day? Would more patients be discharged directly to home if they were able to stay one or two more days?

Source reference:
Clinical Characteristics and Outcomes of Medicare Patients Undergoing Total Hip Arthroplasty, 1991-2008; Cram P, Lu X, Kaboli PJ, Vaughan-Sarrazin MS, Cai X, Wolf BR, Li Y; JAMA. 2011;305(15):1560-1567.doi:10.1001/jama.2011.478

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