Table 2.

Studies describing comprehensive preoperative risk management programs

Study	Total number of patients	Procedure	Study type	Study purpose	Conclusions	Mentions eligibility criteria?	Includes citations for eligibility criteria?	Mentions healthcare disparities?
Bernstein et al. [7]	665	THA and TKA	Retrospective institutional study	Evaluated the impact of a preoperative risk factor management program on postoperative LOS, readmissions, discharge disposition, and cost	The authors found that the preoperative protocol decreased LOS and cost, and there was no difference in discharge location or 90-day readmissions.	Recommended BMI < 40 kg/m2 or between 35-40 kg/m2 if additional comorbidity and recommended HgbA1c < 7.0%; additional recommendations for other lab values including platelets, hemoglobin, and creatinine	No	No mention of race, gender, or income related to disparities in care; insurance type could not be acquired for participants
Bullock et al. [12]	3114	THA and TKA	Retrospective institutional study	Evaluated performance of a “bundle” to decrease PJI incidence after THA or TKA	Implementation of the bundle to modify risk factors was associated with a decreased incidence of PJI after TKA.	Recommended BMI < 40 kg/m2, HgbA1c < 7.0%, and smoking < 0.5 packs/day	No	No mention of race, gender, income, or insurance type related to disparities in care
Dlott et al. [19]	463	THA and TKA	Retrospective institutional study	Examined associations between implementation of a preoperative risk factor management protocol and LOS, ED visits, and readmissions following THA or TKA	Implementation of the protocol was associated with reduced LOS and ED visits.	Recommended BMI < 38 kg/m2 and HgbA1c < 8%	No	No mention of race, gender, income, or insurance type related to disparities in care
Featherall et al. [25]	6090	THA	Retrospective institutional study	Assessed association between implementation of a care pathway for THA with LOS, discharge disposition, 90-day complications, and cost	Implementation of the full protocol was associated with reduced LOS, an increase in home discharges, and decreased cost. Implementation of the full protocol was not associated with change in 90-day complications.	Recommended HgbA1c < 7%; no BMI cutoff specified	Yes	Male gender and White race were associated with reduced LOS and increased home discharges but did not discuss disparities in care; found that public insurance was associated with increased LOS, decreased home discharge, and increased 90-day complications but did not discuss disparities in care; no mention of income
Featherall et al. [24]	6760	TKA	Retrospective institutional study	Assessed association between implementation of a care pathway for TKA with LOS, discharge disposition, 90-day complications, and cost	Implementation of the full protocol was associated with decreased LOS, increased home discharges, and reduced cost. Implementation of the full protocol was not associated with change in 90-day complications.	Same as above study	N/A	Male gender and White race were associated with reduced LOS and increased home discharge but do not discuss disparities in care; nonWhite race was associated with increased 90-day complications; found that public insurance is associated with increased LOS, decreased home discharge, and increased 90-day complications; no mention of income
Gray et al. [29]	1536	THA and TKA	Retrospective institutional study	Evaluated association between implementation of CJR model and cost, discharge disposition, complications, readmissions, and LOS	Implementation of CJR model was associated with reduced costs, increased home discharges, decreased readmissions, complications, and LOS.	None	N/A	No mention of race, gender, income, or insurance type related to disparities in care
Kim et al. [41]	1194	THA and TKA	Retrospective institutional study	Assessed the association between a preoperative risk management program and postoperative readmissions, discharge location, LOS, and infection incidence	Implementation of this program was associated with lower readmission proportions and lower proportions of discharge to a postacute care facility.	Recommended BMI ≤ 40 kg/m2 and HgbA1c < 8%	No	No mention of race, gender, or insurance type related to disparities in care; Mentioned that SES was not evaluated though it can be associated with discharge disposition
Nussenbaum et al. [51]	995	THA and TKA	Retrospective institutional study	Determined whether implementation of preoperative screening criteria was associated with reduced complications and SSI incidence	Implementation of the preoperative screening criteria was associated with reduced total complications and SSI incidence.	Recommended BMI ≤ 35 kg/m2, HgbA1c $\le$ 7%, hemoglobin ≥ 11 g/dL, and albumin $\ge$ 3.5 g/dL	No	No mention of race, gender, or income related to disparities in care. Only included patients treated at VA facility
Plate et al. [54]	751	THA	Retrospective institutional study	Evaluate implementation of the CJR model and its associations with surgery time, discharge disposition, LOS, and costs	Implementation of the CJR model was associated with reduced LOS and increased home discharges. It was not associated with changes in surgery time, 90-day readmissions, or costs.	Recommended BMI < 40 kg/m2, HgbA1c < 7.5%, and hemoglobin > 11 g/dL	No	Mentioned that increased scrutiny of patient selection may lead to disparities in access; no mention of disparities in care specific to race, gender, income, or insurance type
Ryan et al. [57]	1248	TKA	Retrospective institutional study	Evaluated implementation of CJR bundle and its association with surgery time, LOS, discharge disposition, and costs	Implementation of the CJR bundle was associated with decreased LOS and increased home discharges. It was not associated with surgery time or cost.	Recommended BMI < 40 kg/m2, HgbA1c < 7.5%, and hemoglobin > 11 g/dL	No	Mentioned that no difference in gender of patients receiving TKA before and after implementation of bundle; no mention of disparities in care related to race, gender, income, or insurance type
Ryan et al. [56]	2308	TKA	Retrospective multi-hospital study	Examined association of a preoperative checklist with LOS, discharge disposition, ED visits, and readmissions	Treatment at a CJR center was associated with reduced LOS and fewer discharges to SNFs. It was not associated with ED visits or readmissions.	Recommended BMI ≤ 40 kg/m2 and HgbA1c < 7.5%, hemoglobin > 11 g/dL, albumin $\ge$ 3 g/dL, and others related to smoking and platelets	No	No mention of race, gender, or income related to disparities in care; only included patients with Medicare insurance
Schultz et al. [58]	216	THA and TKA	Retrospective institutional study	Assessed the association between implementation of an accelerated recovery protocol and LOS, complications, discharge disposition, and cost	Implementation of the protocol was associated with reduced LOS, increased home discharges, reduced complications, and reduced costs.	Required HgbA1c < 8.0%; no hard cutoff for BMI	No	Mentioned that lower income is associated with disparities in access to TJA in introduction and that as a county hospital, their patient population often has lower incomes. There was no mention of race, gender, or insurance types related to disparities in care.

HgbA1c = hemoglobin A1c; PJI = prosthetic joint infection; ED = emergency department; CJR = Comprehensive Care for Joint Replacement; SES = socioeconomic status; SSI = surgical site infection; VA = Veterans Affairs; SNF = skilled nursing facility.