CORR Insights®: Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

Where Are We Now?

Hospital readmissions after total joint arthroplasty add substantial costs to our healthcare systems [6, 10], and postoperative visits to the emergency department (ED) may be almost twice as common as readmissions [3]. In the current study, Chaudhary and colleagues [1] found that routine, outpatient orthopaedic care following hip or knee arthroplasty decreased ED visits by about 30% within the 30 and 90-day postoperative windows. Furthermore, the study highlighted how 75% of ED visits within the first 90 days following hip or knee arthroplasty were not related to surgical complications.

The findings from the current study suggest that the majority of postoperative ED visits are avoidable and adds further evidence that gaps in the patient-care pathway can increase the financial and clinical burden of care [3, 4, 10]. In an effort to streamline the care provided to arthroplasty patients and to decrease overall costs [2, 5, 9], healthcare providers are utilizing clinical care pathways and enhanced recovery after surgery (ERAS) programs.

Still, studies continue to show that a lack of patient education and expectation management can increase the risk of unplanned returns to the hospital [3, 4, 7]. This is particularly true for questions about postoperative pain control, medications, and mobilization—the most-common reasons for ED visits, according to both the current study [1] and previously research [3, 4]. It makes sense that patients will have questions and anxiety after surgery, and managing expectations and the overall experience are critically important [5, 7, 11]. We need to continue to find ways to communicate and educate our patients after surgery—whether by routine followup visits or alternative means such as through smartphone applications—so that patients do not go back to the hospital seeking answers to questions we can easily provide other ways.

Where Do We Need To Go?

While the current study adds to our knowledge on this topic, questions remain. Chaudhary and colleagues did not collect specific clinical details related to the ED visits, nor did they seek the discharge instructions or education provided to the patients. Future studies should obtain these data so clinicians can better understand why patients are visiting the ED after surgery and, more importantly, how we can prevent the need for such visits.

Future studies should also examine how patients’ social factors, education levels, employment, and self-efficacy contribute to postoperative outcomes, complications, and pain [7]. These factors may contribute to ED visits after surgery [3-5, 9]. Postoperative pain and medication complications were two of the most-common reasons for visiting the ED in the current study [1], supporting a previously published study’s finding [3]. Is this due to poor communication and poor postoperative education on the part of the physician? Are we taking advantage of the advancements available to us such as automated digital patient engagement platforms [10]? We need more research into how to help patients become more-active managers of their postoperative care in order to decrease unnecessary care episodes.

How Do We Get There?

Telemedicine and media-based applications are promising avenues for providing postoperative care in lieu of routine postoperative visits [7]. Studies of these applications across specialties seem to indicate that they are at least equivalent to routine postoperative visits and, in many instances, they improve the value of postoperative care [8, 10]. In one study, seven out of every eight patients who had questions during the acute postoperative period after TKA or THA could be educated and dispositioned over the phone without any additional care [4]. While this was not the focus of the current study [1], setting up an appropriately powered, prospective, cohort study in which one group received traditional postoperative visits and the other group exclusively used a media application for postoperative communication (except for radiographs) would help us determine any differences in complication rates or overall outcomes.

The current study’s findings highlight why registries and other means of large-scale patient information collection will be so important as we move forward. By knowing specific details about each patient’s education, social support, care pathway, and postoperative course, clinicians can better delineate how to educate and care for their patients, which may ultimately lead to a decrease in unnecessary patient-care episodes and complications.

We also need larger observational studies that focus on patient-centered care pathways to determine whether they improve the care and decrease the costs associated with TKA and THA [5]. However, this will be a major challenge, as implementing new patient-care pathways within most healthcare systems requires changing engrained behaviors of patients, surgeons, and hospital systems alike [2, 9].

Considering that we are in the smartphone era, it seems valuable to further investigate the power of media-based applications and telemedicine as a way to potentially reduce avoidable hospital visits [7]. While small studies have yielded encouraging data on their use, larger studies are still needed. If a large medical system, subspecialty society, or collaborative effort between institutions could navigate the regulatory issues regarding such platforms in an effort to perform a large-scale study looking at their use, the results could be transformative.