Abstract
Aims
The limited documentation on patients’ perspectives on undergoing discharge on the day of surgery impedes its adoption as a standard of care. Hence, the aim of this study was to investigate whether patients were willing to repeat being discharged on the day of surgery if having a future hip or knee arthroplasty procedure.
Methods
This multicentre, prospective consecutive cohort study spanned from 1 September 2022 to 31 January 2024, and was conducted at six public arthroplasty centres adhering to the same published protocol for discharge on the day of surgery following hip and knee arthroplasty. Patients undergoing primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or medial unicompartmental knee arthroplasty (mUKA) were screened for eligibility and discharged when fulfilling predetermined discharge criteria. Patients discharged on the same calendar day of surgery were sent a questionnaire 30 days postoperatively.
Results
Of 9,542 primary hip and knee arthroplasties registered, 3,457 (36%) were eligible for discharge on day of surgery; 58% of eligible patients (n = 2,011) were discharged on day of surgery and therefore received the survey. Baseline characteristics were comparable across all arthroplasty groups. The survey response rate was 88% (n = 1,771). Overall, 90% (95% CI 88 to 91) were willing to repeat discharge on the day of surgery if having a future joint arthroplasty, with 91% (95% CI 88 to 93) after THA, 89% (95% CI 86 to 92) after TKA, and 90% (95% CI 86 to 92) after mUKA. The difference between centres ranged from 84% to 93%. Patients responding ‘no’ to repeat discharge on the day of surgery were more often female (55%, n = 95) compared to patients responding ‘yes’ (47%, n = 744); otherwise, the groups were comparable.
Conclusion
A total of 90% of patients (n = 1,590) discharged on the day of surgery following hip and knee arthroplasty expressed willingness to repeat discharge on the day of surgery. This supports further implementation efforts.
Cite this article: Bone Jt Open 2025;6(9):1156–1163.
Keywords: Hip arthroplasty, Knee arthroplasty, Fast-track, Day-case surgery, Same day discharge, hip and knee arthroplasties, knee arthroplasty procedures, Hip, joint arthroplasty, total knee arthroplasty (TKA), medial unicompartmental knee arthroplasty, primary total hip arthroplasty, cohort study, total hip arthroplasty, fast
Introduction
With the anticipated rise in hip and knee arthroplasty demand due to an ageing and increasingly active population, optimizing the length of hospital stay while ensuring patient safety remains a key focus. This has led to the increased use of fast-track/enhanced recovery protocols in recent years,1-3 also serving as a cost-saving effort.4 The ultimate goal of fast-track surgery may be to discharge patients on the day of surgery without compromising safety and satisfaction.5,6 The feasibility of implementing discharge on the day of surgery in 20% to 25% of all primary hip and knee arthroplasty patients in a public multicentre setting, representing 40% of a Danish nationwide production, is now well established.7,8 However, despite the growing acceptance of discharging patients on the day of surgery, there is a paucity of research dealing with patients’ perspectives on discharge on the day of surgery for these procedures.9
While the clinical efficacy of discharge on the day of surgery is well established, the successful implementation of discharge on the day of surgery depends on more than just medical outcomes—it necessitates a comprehensive understanding of patients’ experiences and preferences. Without thorough documentation of patients’ perspectives, it becomes challenging to advocate for the widespread adoption of discharge on the day of surgery as a standard of care.
Hence, the aim of the study was to investigate whether patients were willing to repeat being discharged on the day of surgery if they were to have a future hip or knee arthroplasty procedure.
Methods
Study design
This was a prospective cohort study following the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) guideline.10
Setting
This study emanated from the multicentre collaboration ‘The Center for Fast-track Hip and Knee Replacement’.11 The collaboration consists of eight public arthroplasty centres covering 40% of a Danish nationwide production of hip and knee arthroplasty procedures. For this study, we only included the six centres that maintained a well-established protocol for discharge on the day of surgery throughout the study period.7 Hence, one centre in the collaboration was excluded as they did not manage to implement the protocol sufficiently during the study period (33 patients discharged on the day of surgery in the study period). Another centre was excluded due to a delayed start of inclusion caused by relocation to a new hospital site. The study period was from 1 September 2022 to 31 January 2024 (Figure 1).
Fig. 1.
Flowchart of patient inclusion in the study. THA, total hip arthroplasty; TKA, total knee arthroplasty; mUKA, medial unicompartmental knee arthroplasty
Study population
The cohort included patients undergoing primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) from a multicentre healthcare setting receiving patients who had not been preselected. The protocol for discharge on the day of surgery within the collaboration has been published.7 Patients’ eligibility for discharge on the day of surgery was evaluated using clearly specified inclusion and exclusion criteria (Supplementary Material). Patients were discharged upon meeting the predetermined discharge criteria (Supplementary Material). For this study, we only included eligible patients who were discharged on the same calendar day as surgery (Figure 1). Some of the patients included in this study cohort have also been reported on in previous publications, but with a shorter study period and a different endpoint.8,12
Data sources
At each centre, dedicated research staff prospectively collected patient data, with the option of physician assistance if necessary. The data were securely stored in an online REDCap database provided by the Open Patient Data Explorative Network (OPEN) at Odense University Hospital. The database comprised patient-reported data as well as information extracted from patient files.7 Eligible patients discharged on day of surgery received a survey 30 days postoperatively with the question: ‘If you were to undergo hip/knee arthroplasty on the opposite side, would you prefer to be discharged on the day of surgery again?’.
Variables
Demographic variables were age (continuous variable), sex (male/female), BMI (kg/m2), cohabitation (cohabiting, living alone), Clinical Frailty Scale (1 to 4),13 alcohol consumption above ten units (yes/no), regular home assistance before surgery (yes/no), previous cerebrovascular accident (yes/no), preoperative psychiatric medication (yes/no), and preoperative opioid use (yes/no).
The primary outcome variable was the proportion of patients discharged on the day of surgery who were willing to repeat being discharged on the day of surgery if undergoing a second hip or knee arthroplasty procedure. This outcome variable was analyzed overall as well as by procedure and centre level. Secondary outcome variables were differences in baseline characteristics between ‘yes’ responders and ‘no’ responders” (Table I). An additional subanalysis also compared ‘responders’ and ‘non responders’ (Supplementary Material).
Table I.
Characteristics of responders.
| Variable | ‘Yes’ responders n = 1,590 | ‘No’ responders n = 174 |
|---|---|---|
| Mean age, yrs (SD) | 66.0 (8.5) | 65.4 (8.7) |
| Sex, n (%) | ||
| Female | 744 (47) | 95 (55) |
| Male | 835 (53) | 77 (44) |
| Missing | 11 (0.7) | 2 (1.1) |
| Mean BMI, kg/m 2 (SD) | 28.9 (4.5) | 27 (4.3) |
| Cohabitation, n (%) | ||
| Cohabiting | 1,404 (88) | 160 (92) |
| Living alone | 176 (11) | 12 (7) |
| Missing | 10 (0.6) | 2 (1.1) |
| Mean CFS (SD) | 2.2 (0.8) | 2.2 (0.7) |
| Alcohol consumption above 10 units, n (%) | 254 (16) | 27 (16) |
| Regular home assistance before surgery, n (%) | 10 (0.6) | 2 (1) |
| Previous cerebral accident, n (%) | 67 (4) | 7 (4) |
| Preoperative psychiatric medication, n (%) | ||
| Yes | 106 (7) | 16 (9) |
| No | 1,477 (93) | 158 (91) |
| Missing | 7 (0.4) | 0 |
| Preoperative opioid use, n (%) | ||
| Yes | 62 (4) | 10 (6) |
| No | 1524 (96) | 164 (94) |
| Missing | 4 (0.3) | 0 |
CFS, Clinical Frailty Scale.
Ethics and registration
Patients were included after informed consent. Since the outpatient surgical treatment for eligible patients adhered to the standard of care at the collaborating centres, as specified in the protocol,7 ethical approval was deemed unnecessary according to Danish law.
The fast-track project was preregistered at ClinicalTrials.gov (NCT05613439) and within the Region of Southern Denmark, with the necessary data processing approval obtained (Journal No. 22/39454).
Statistical analysis
Descriptive statistics were presented as means with SDs for continuous variables that followed a normal distribution. For non-normally distributed continuous variables, medians along with IQRs were presented. Categorical variables were described as proportions with 95% CIs and analyzed using Stata Statistical Software v. 18 (StataCorp, USA).
Results
Among the 9,542 primary hip and knee arthroplasties registered in the database, 3,457 (36%) were eligible for discharge on the day of surgery. Overall, 58% of eligible patients (n = 2,011) were discharged on the day of surgery and hence 2,011 patients received the survey: 786 (39%) THA, 638 (32%) TKA, and 587 mUKA (29%) (Figure 1).
Baseline characteristics were comparable across all three arthroplasty groups (Table II). The overall survey response rate was 88% (n = 1,771). In total, 90% (95% CI 88 to 91) of the respondents were willing to repeat being discharged on the day of surgery, if they were to have a second hip or knee arthroplasty procedure. The proportion of patients willing to repeat being discharged on the day of surgery remained consistent throughout the study period (Figure 2b). Procedure-specific willingness to repeat discharge on the day of surgery was 91% (95% CI 88 to 93) after THA, 89% (95% CI 86 to 92) after TKA, and 90% (95% CI 86 to 92) after mUKA (Figure 3). The proportion of ‘yes’ responders varied between centres (84% to 93%) (Figure 4). Patients not willing to repeat discharge on the day of surgery were more often female (55%, n = 95) compared with patients willing to repeat discharge on the day of surgery (47%, n = 744). Otherwise, the groups were comparable. Additionally, a sensitivity analysis examining differences between age groups stratified by decades was performed, but no notable differences were identified. A greater proportion of patients lived alone among non-responders (78%, n = 187) compared to responders (9%, n = 163) (Supplementary Material).14
Table II.
Patient demographic characteristics of all responders.
| Variable | THA (n = 688) | TKA (n = 557) | mUKA (n = 526) |
|---|---|---|---|
| Mean age, yrs (SD) | 65.0 (9.1) | 66.1 (8.2) | 65.5 (8.2) |
| Sex, n (%) | |||
| Female | 330 (48) | 273 (49) | 237 (45) |
| Male | 355 (52) | 276 (50) | 287 (55) |
| Missing | 3 (0.4) | 8 (1.4) | 2 (0.4) |
| Mean BMI, kg/m 2 (SD) | 27.2 (4.2) | 29.5 (4.5) | 29.7 (4.4) |
| Cohabitation, n (%) | |||
| Cohabiting | 616 (90) | 524 (94) | 456 (87) |
| Living alone | 68 (10) | 29 (5) | 66 (13) |
| Missing | 4 (0.6) | 4 (0.7) | 4 (0.8) |
| Mean CFS (SD) | 2.2 (0.8) | 2.2 (0.8) | 2.1 (0.8) |
| Alcohol consumption above 10 units, n (%) | 117 (17) | 86 (15) | 79 (15) |
| Regular home assistance before surgery, n (%) | 2 (0.3) | 4 (0.7) | 4 (0.8) |
| Previous cerebral accident, n (%) | 18 (3) | 24 (4) | 30 (6) |
| Preoperative psychiatric medication, n (%) | |||
| Yes | 31 (5) | 17 (3) | 19 (4) |
| No | 654 (95) | 538 (97) | 505 (96) |
| Missing | 3 (0.4) | 2 (0.4) | 2 (0.4) |
| Preoperative opioid use, n (%) | |||
| Yes | 35 (5) | 34 (6) | 21 (4) |
| No | 651 (95) | 523 (94) | 503 (96) |
| Missing | 2 (0.3) | - | 2 (0.4) |
CFS, Clinical Frailty Scale; mUKA, medial unicompartmental knee arthroplasty; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Fig. 2.
a) Proportion of patients willing to repeat being discharged on day of surgery compared with those unwilling. b) Proportion of patients willing to repeat being discharged on day of surgery, presented on a timeline.
Fig. 3.
Proportion of patients willing to repeat being discharged on day of surgery divided by surgical procedure. THA, total hip arthroplasty; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty.
Fig. 4.
Proportion of patients willing to repeat being discharged on the day of surgery divided by centre. Overall discharge on the day of surgery represents the proportion of eligible patients discharged on the day of surgery out of all patients. Eligible discharge on day of surgery represents the proportion of eligible patients discharged on day of surgery out of eligible patients. Proportion of 'yes' responders.
Discussion
In this prospective multicentre cohort study, 90% of patients discharged on the day of surgery following primary unilateral hip or knee arthroplasty expressed their willingness to repeat being discharged on the day of surgery if undergoing a future hip or knee arthroplasty procedure. Assessing patients’ willingness to repeat being discharged on the day of surgery serves as a proxy for their satisfaction with the fast-track setup, as it is presumed that patients would not wish to repeat a course of treatment they found unsatisfactory.
Discharge on the day of surgery following hip or knee arthroplasty has generated increasing attention in recent years, especially after the COVID-19 pandemic. Nevertheless, patients’ perspectives on discharge on the day of surgery for these types of procedures remain less known. In a previous single-centre study from the USA,15 patients received a questionnaire prior to hip or knee arthroplasty: 32% of the patients reported feeling either uncomfortable or very uncomfortable being discharged within 23 hours after surgery. In another Danish single-centre study from one of the participating centres prior to the current multicentre collaboration, patients’ attitudes towards discharge on the day of surgery were examined preoperatively, when they were scheduled for surgery.16 It was found that only 42% were interested in discharge on the day of surgery. These findings were concerning just before the broader multicentre implementation of discharge on the day of surgery in Denmark. However, our results, which show a 90% willingness to repeat discharge on the day of surgery, alleviate these concerns. The variability in these findings can likely be attributed to the fact that the patients in the study by Halken et al16 were not preselected, and were asked before undergoing surgery without receiving any structured information about day-case surgery before answering the questionnaires. In contrast, the patients in our study answered the questionnaire after the arthroplasty procedure, and they were selected for discharge on the day of surgery based on well-defined criteria.
Lovasz et al17 presented findings with an even higher satisfaction rate than we report, with 98% of patients selected for discharge on the day of surgery expressing their willingness to repeat same-day discharge if they were to undergo a similar procedure. However, this study was a single-centre study with only 200 patients. Additionally, data collection for this study occurred during a six-week postoperative follow-up visit at the hospital, raising the possibility that some patients may have felt pressured to express satisfaction with their experience.
According to Figure 4, there was a variation in overall discharge on the day of surgery success rates among the participating centres, as well as differences in the proportion of ‘yes’ responders. However, there did not appear to be any obvious correlation between these two variables, suggesting that a higher proportion of patients discharged on the day of surgery did not necessarily lead to more or less satisfied patients.
The strength of our study primarily lies in its comprehensive and well-defined protocol for discharge on the day of surgery after hip and knee arthroplasty.7 ‘The Center for Fast-track Hip and Knee Replacement’ consists of public arthroplasty centres across all regions in Denmark and accounts for approximately 40% of all hip and knee arthroplasties in the country. This setup, combined with a high response rate (88%) and the largest cohort reported on so far, enhances the potential generalizability of our findings. Furthermore, we specifically included centres in this study that maintained a well-established protocol for discharge on the day of surgery. As standard of care, all patients eligible for discharge on the day of surgery were provided with preoperative information regarding the discharged plan, and their expectations were carefully managed.7 This also contributed to a high level of willingness to repeat being discharged on the day of surgery.
Our study is not without limitations. Given its reliance on patient-reported data, there exists a potential for recall bias. Patients were administered a survey 30 days postoperatively, presumed to encompass the timeframe wherein potential complications associated with expedited discharge are accounted for, while still maintaining proximity to the surgical intervention and discharge, thereby minimizing recall bias.
Overall, 10% of the patients were unwilling to repeat discharge on the day of surgery. To further enhance the satisfaction rate for discharge on day of surgery in the future, a closer examination of the reasons behind patients’ responses of ‘no’ is imperative. There are several potential internal and external factors contributing to why some patients do not wish to repeat discharge on the day of surgery if having a future hip or knee arthroplasty procedure. Gathering qualitative data on this aspect may thus offer limited additional insights capable of significantly influencing clinical practice. However, it is plausible that it could contribute to enhance patient selection and refining the day-case pathway. Considering that only 10% of the patients were unwilling to repeat discharge on the day of surgery, ongoing implementation of discharge on the day of surgery is deemed acceptable.
In conclusion, a total of 90% of patients discharged on the day of surgery after hip and knee arthroplasty were willing to repeat this length of time to discharge. This rate is encouraging and acceptable for ongoing implementation.
Take home message
- 90% of patients who were discharged on the day of surgery following hip and knee arthroplasty expressed willingness to repeat discharge on day of surgery.
- This rate is encouraging, and acceptable for ongoing implementation.
Author contributions
O. Danielsen: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing
K. Gromov: Conceptualization, Supervision, Writing – review & editing
C. Varnum: Conceptualization, Supervision, Writing – review & editing
T. H. Jakobsen: Conceptualization, Writing – review & editing
M. R. Andersen: Conceptualization, Writing – review & editing
M. J. Bieder: Conceptualization, Writing – review & editing
C. C. Jørgensen: Conceptualization, Writing – review & editing
H. Kehlet: Conceptualization, Supervision, Writing – review & editing
M. Lindberg-Larsen: Conceptualization, Methodology, Project administration, Supervision, Writing – review & editing
Funding statement
The author(s) disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: in 2021, funding for the collaboration “The Center for Fast-track Hip and Knee Replacement” was secured from the Novo Nordisk Foundation (Grant number: NNF21SA0073760). This funding provided for research staff at all participating centres, data management, and monitoring of complications. O. Danielsen's PhD salary was provided through funding from the Candys Foundation, University of Southern Denmark and Region of Southern Denmark.
ICMJE COI statement
M. R. Andersen is a board member of the Danish Society for Hip and Knee Surgery. All authors are members of the steering committee for the Centre for Fast-track Hip and Knee Arthroplasty and declared no conflicts of interest related to this study. O. Danielsen's PhD salary was provided through funding from the Candys Foundation, University of Southern Denmark and Region of Southern Denmark. K. Gromov reports institutional support and research support from Zimmer Biomet, unrelated to this study. C. C. Jørgensen reports speaker fees and support for attending meetings and/or travel from Pharmacosmos, unrelated to this study, and is Co-chair of the European guidelines on peri-operative venous thromboembolism prophylaxis. M. Lindberg-Larsen is Chairman of the steering committee of the Danish Knee Arthroplasty Register. C. Varnum reports institutional support from Stryker for attending meetings and/or travel, unrelated to this study.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
Acknowledgements
We thank the research staff at the participating hospitals within The Center for Fast-track Hip and Knee Replacement for their assistance with data collection and coordination.
Ethical review statement
Patients were included after informed consent. The management of eligible patients for day-case surgery adhered to the standard of care outlined in the protocol at the participating centres, obviating the necessity for ethical approval.
Open access funding
The open access fee for this article was funded by the Candys Foundation.
Supplementary material
Tables of inclusion and exclusion criteria for discharge on day of surgery, and characteristics between responders and non-responders.
© 2025 Danielsen et al. This article is distributed under the terms of the Creative Commons Attributions (CC BY 4.0) licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original author and source are credited.
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.