Outcomes assessment of total hip and total knee arthroplasty: critical pathways, variance analysis, and continuous quality improvement

Using critical pathways, with variance analysis and continuous quality improvement techniques to refine the pathways, the efficiency of total hip and total knee surgeries in one academic health center was maximized. Using a retrospective cohort study design, complications, readmissions, morbidity/mortality, and function scores were examined in two groups of patients attended by the same surgeon for the year before and the year after the implementation of an outcomes management program. The length of stay was reduced by 57% for knee patients and by 46% for hip patients. Hospital costs were reduced 11% for all knees and 38% for hips. Complications were also significantly reduced. There was no statistically significant difference between pre- or postoperative knee or hip outcome scores. The program resulted in significant savings without adversely affecting overall outcome.     

Early inpatient rehabilitation after elective hip and knee arthroplasty

CONTEXT: Inpatient rehabilitation after elective hip and knee arthroplasty is often necessary for patients who cannot function at home soon after surgery, but how soon after surgery inpatient rehabilitation can be initiated has not been studied. OBJECTIVE: To test the hypothesis that high-risk patients undergoing elective hip and knee arthroplasty would incur less total cost and experience more rapid functional improvement if inpatient rehabilitation began on postoperative day 3 rather than day 7, without adverse consequences to the patients. DESIGN: Randomized controlled trial conducted from 1994 to 1996. SETTING: Tertiary care center. PARTICIPANTS: A total of 86 patients undergoing elective hip or knee arthroplasty and who met the following criteria for being high risk: 70 years of age or older and living alone, 70 years of age or older with 2 or more comorbid conditions, or any age with 3 or more comorbid conditions. Of the 86 patients, 71 completed the study. INTERVENTIONS: Random assignment to begin inpatient rehabilitation on postoperative day 3 vs postoperative day 7. MAIN OUTCOME MEASURES: Total length of stay and cost from orthopedic and rehabilitation hospital admissions, functional performance in hospitals using a subset of the functional independence measure, and 4-month follow-up assessment using the RAND 36-item health survey I and the functional status index. RESULTS: Patients who completed the study and began inpatient rehabilitation on postoperative day 3 exhibited shorter mean (+/-SD) total length of stay (11.7+/-2.3 days vs 14.5+/-1.9, P<.001), lower mean (+/-SD) total cost ($25891+/-$3648 vs $27762+/-$3626, P<.03), more rapid attainment of short-term functional milestones between days 6 and 10 (36.2+/-14.4 m ambulated vs 21.4+/-13.3 m, P<.001; 4.8+/-0.8 mean transfer functional independence measure score vs 4.3+/-0.7, P<.01), and equivalent functional outcome at 4-month follow-up. CONCLUSION: These data showed that high-risk individuals were able to tolerate early intensive rehabilitation, and this intervention yielded faster attainment of short-term functional milestones in fewer days using less total cost.     

Relationship between length of stay and manipulation rate after total knee arthroplasty

We hypothesized that a pattern of decreasing postoperative length of stay (LOS) in the hospital could lead to an increased rate of manipulation after total knee arthroplasty (TKA). The decision to manipulate is based on the patient's ability to perform normal physical activities, which may in large part be dependent on adequate knee flexion (ie, range of motion [ROM]). Decreased exposure to physical therapy (as a result of decreased LOS) may be a contributing factor leading to impaired functional ROM in the 6-week postoperative period. We examined records from 745 patients (2 surgeons) who had a primary TKA from 1993 to 1996. At our institution, development and implementation of clinical pathways resulted in a significant decrease in the average LOS beginning in 1993. The average LOS in 1993 was 6.4 +/- 1.8 days (mean +/- SD) and progressively decreased to 4.4 +/- 1.0 days in 1996 (P < .0001). The rate of manipulation (patients manipulated at 6 weeks/total number of patients receiving TKA) was 6.0% in 1993 and increased to 11.3% (P = .09) in 1994, 13.5% (P = .02) in 1995, and 12.0% (P = .05) in 1996. In the period 1993-1996, patients requiring manipulation consistently had a lower ROM at discharge from the hospital (69.0 +/- 10 degrees, n = 67, P < .0001) compared with patients not requiring manipulation (80.7 +/- 10.6 degrees, n = 542). The relatively low frequency and charge for manipulation may justify the decision to decrease patient exposure to physical therapy through reduction in LOS. As efforts to decrease LOS continue, however, we must aggressively manage patients and provide adequate exposure to inpatient and outpatient physical therapy to ensure optimal ROM results.     

Patient comorbidity: relationship to outcomes of total knee arthroplasty

One hundred six patients treated consecutively with total knee arthroplasty were evaluated to determine whether preoperative comorbidity (as measured by patient class, knee score, short form, anesthesia severity assessment, and number of medical comorbidities) correlated with perioperative and postoperative outcomes, including length of stay, total (and specific) hospital charges, and validated outcome scores. The length of stay for total knee arthroplasty was longer in patients who had lower preoperative knee scores and for patients with greater medical and musculoskeletal morbidity. Greater total hospital costs were associated with Class C patients and patients with poor anesthesia morbidity ratings. Patients who were debilitated medically and had four or more risk factors had decreased postoperative outcome scores. Preoperative medical and musculoskeletal morbidity influence the results of total knee arthroplasty. These findings may be useful to surgeons for optimizing resource utilization and outcomes in patients undergoing total knee arthroplasty. These data must be accounted for when contrasting total knee arthroplasty results between different surgeons and institutions.     

Opportunities for control of hospital cost for total knee arthroplasty

The hospital financial records of 120 consecutive patients who underwent unilateral knee replacement surgery at one hospital during 1995 were reviewed to determine opportunities for control of hospital cost for total knee arthroplasty. The average hospital length of stay for these patients was 4.27 days (range, 3-10 days). The average hospital cost was $10,231. All 120 patients were classified under Diagnosis Related Group 209, principle procedure 81.54 primary total knee arthroplasty. Medicare paid for 70% of the patients. All payers were profitable except Medicaid and one managed care organization. When hospital cost for total knee arthroplasty was allocated to hospital service centers, 78% of the cost was attributed to the operating room, nursing units, recovery room, and pharmacy. When hospital cost for total knee arthroplasty was allocated to hospital days, 80% of the hospital cost occurred during the first 48 hours of hospitalization. Hospital reimbursement for total knee arthroplasty is primarily a prospective case price payment system. After initial cost containment efforts reduce the hospital length of stay for total knee arthroplasty to 4 to 6 days, additional control of hospital cost should focus on these areas of opportunity.     

Outcome of hip and knee arthroplasty in persons aged 80 years and older

Recent studies have established the cost effectiveness and safety of total joint arthroplasties. As the population ages, it is important to determine whether these procedures are equally beneficial in the elderly. The short term safety and efficacy of total hip and knee arthroplasties in subjects 80 years of age and older was evaluated. Between 1988 and 1993, preoperative and postoperative physical and functional information was collected on 99 consecutive elective hip and knee arthroplasties in subjects 80 years of age or older. These data were compared with those derived from a younger otherwise matched control group. Data collected included subject demographics and characteristics, information concerning the acute and postacute hospital stay, comorbid conditions, postoperative complications, discharge disposition, Hospital for Special Surgery knee and Harris hip scores, pain scores, and functional capacity. The average age of the subjects was 83 years; osteoarthritis was the most common diagnosis; and the average followup was 25 months. Complication rates and length of stay in acute care facilities were not significantly different than for the control group. Mean preoperative Hospital for Special Surgery knee and Harris hip scores were 58 and 60, respectively, with postoperative scores of 77 and 88, respectively. Pain dramatically improved with 98% of total knee arthroplasty and 100% of total hip arthroplasty subjects reporting mild or no pain at followup. Preoperatively, none of the knee or hip subjects could walk unlimited distances. Postoperatively 51% of the total knee arthroplasty and 54% of the total hip arthroplasty subjects could walk more than five blocks; 71% of the total knee arthroplasty and 86% of the total hip arthroplasty subjects walked with a cane or no assistive device. The most dramatic postoperative functional gains were seen in the most disabled subjects. Total charges of care for patients 80 years of age and older was slightly greater than for a younger group. It was established that total joint arthroplasty can be performed safely in patients 80 years of age and older, promising excellent pain relief and improved functional outcome.     

High-Resolution Infrared Fourier-Transform Spectroscopy and Rotational Constants of the nu4 Band of BrNO2

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice.     

Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analysis

One hundred consecutive, primary simultaneous bilateral total knee arthroplasties were prospectively compared with 100 consecutive, primary unilateral total knee arthroplasties in reference to relative risk, complications, cost, and need for rehabilitation. All procedures were performed using identical preoperative, intraoperative, and postoperative protocols. Postoperative confusion was approximately four times greater in the simultaneous bilateral total knee arthroplasties group (29% versus 7%), which was thought to represent an increased incidence of fat embolism. Cardiopulmonary complications were approximately three times greater after simultaneous bilateral total knee arthroplasties (14% versus 5%), and most commonly involved arrhythmias. The increased stress on the cardiopulmonary system with simultaneous bilateral total knee arthroplasties may make this procedure contraindicated in certain patients with preexisting disease. There was an approximately 17 times greater need for banked blood in the simultaneous bilateral total knee arthroplasties group (17% versus 1%), which is alarming given the persistent concerns of transfusion related disease transmission. Although the length of hospitalization was similar (6.4 days simultaneous bilateral total knee arthroplasties versus 6 days unilateral total knee arthroplasty), 89% of the patients in the simultaneous bilateral total knee arthroplasties group required a rehabilitation stay versus 45% of the patients in the unilateral total knee arthroplasty group. Total hospital charges averaged $53,168 for simultaneous bilateral total knee arthroplasties versus $32,598 for unilateral total knee arthroplasty. Total rehabilitation charges were similar. The relative cost savings implicit by doing simultaneous bilateral total knee arthroplasties seem to be at least partially offset by the approximately two times greater need for rehabilitation in this group. The true safety, efficacy, relative risk, and total cost analysis of simultaneous bilateral total knee arthroplasties demands further critical evaluation.     

Average thresholds in the 8 to 20 kHz range in young adults

RATIONALE AND OBJECTIVES: The Comprehensive Clinical Assessment (CCA) examination at the University of Michigan Medical School is a series of test stations through which the mastery of clinical skills is evaluated. The purpose of this study was to determine whether student performance on the radiology station improved in years when radiology faculty presented case-of-the-week unknowns to the 3rd-year students. MATERIALS AND METHODS: The authors compared four separate classes of medical students in examination years 1993, 1994, 1995, and 1996 by using the total CCA examination score, the radiology station score, and radiology station pass/fail rates. Radiology case-of-the-week presentations were given by the radiology faculty only in academic years 1993-1994 and 1994-1995 (examination years 1994 and 1995). RESULTS: The means and standard deviations of the radiology station scores for the examination years when case-of-the-week presentations were not given, 1993 and 1996, were 78.92 +/- 13.62 and 79.76 +/- 13.62, respectively. In the years case-of-the-week presentations were given, 1994 and 1995, the radiology station scores averaged 90.83 +/- 8.58 and 89.97 +/- 9.66, respectively (P < .001, global alpha = .05). Total CCA percentage correct scores were similar for all years studied. In 1993 and 1996, 7.6% and 5.3% of students, respectively, failed the radiology station. In 1994 and 1995, 0.4% and 0% of students, respectively, failed (P < .0001). CONCLUSION: Case-of-the-week presentations by radiology faculty increased 3rd-year students' basic radiologic knowledge as evidenced by increased scores on the radiology station of the CCA examination.     

Plasma levels of activated protein C in healthy subjects and patients with previous venous thromboembolism: relationships with plasma homocysteine levels

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.     

How can and do Australian doctors promote physical activity?

We describe a modified technique for the salvage of a total knee arthroplasty after disruption of the extensor mechanism. Between January and December 1992, seven patients had reconstruction of the extensor mechanism with use of a medial or an extended medial gastrocnemius flap. Six of the seven patients were followed for a mean of thirty-three months (range, twenty-six to forty-one months) and were evaluated both preoperatively and postoperatively with regard to the knee and functional scores of The Knee Society as well as the range of motion, extensor lag, walking status, and patellar height. The seventh patient was lost to follow-up six months postoperatively and was excluded from the analysis of the results. Preoperatively, the knee and functional scores were 16 +/- 12.3 points and 12 +/- 12.1 points (mean and standard deviation), respectively; the mean range of motion was 70 +/- 44.0 degrees; and the mean extensor lag was 53 +/- 33.4 degrees. Postoperatively, the mean knee and functional scores improved to 82 +/- 12.4 points and 51 +/- 23.0 points, respectively; the mean range of motion improved to 100 +/- 21.8 degrees; and the mean extensor lag decreased to 24 +/- 18.8 degrees. After the procedure, all patients who previously had been dependent on a walker were able to walk about the community with or without a cane, and those who had been dependent on a wheelchair were able to walk with the assistance of a walker. Patellar height was measured according to the method of Insall and Salvati for the four patients who had a patella. Preoperatively, the patellar heights were grossly abnormal; postoperatively, they more closely approached accepted normal values for three of the four patients. Reconstruction of a complicated rupture of the extensor mechanism with use of a medial gastrocnemius transposition flap after total knee arthroplasty is a reliable option for treatment.     

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

BACKGROUND: Patients with large (> or = 5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures. METHODS: Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. RESULTS: No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44+/-0.88 days versus 14.10+/-2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941+/-$1,933 versus $34,076+/-$2,534; p = 0.003). CONCLUSIONS: A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.     

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90 degrees flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.     

Comparing the effectiveness of different educational programs for patients with total knee arthroplasty

PURPOSE: To compare the effects of preadmission and postadmission educational programs for patients with total knee arthroplasty. DESIGN: Quasiexperimental study. SAMPLE: 60 total knee arthroplasty patients. METHODS: Subjects in the experimental group received preadmission preoperative teaching with an instruction booklet during a preoperative outpatient clinic visit. Upon admission to the hospital, they were presented with an educational video tape. The control group received only postadmission preoperative teaching with the same instruction booklet and no video. PREADMISSION AND POSTADMISSION: Preoperative anxiety level, knowledge about postoperative care, exercise performance and postoperative recovery were used as outcome measures. FINDINGS: The research results found: 1. there was no significant difference between the two groups in reduction of preoperative anxiety score: 2. the experimental group had a significantly higher knowledge level than the control group; 3. the experimental group performed exercise more regularly and correctly than those in the control group; 4. the experimental group had greater flexion of the operative knee joint than the control group. CONCLUSION: Preadmission teaching with a videotape program and a health manual for patients with total knee arthroplasty is recommended. IMPLICATIONS FOR NURSING RESEARCH: More indicators such as postoperative pain and patient satisfaction can be used to investigate the effectiveness of intervention. In addition, increasing the sample size is recommended for future studies.     

Change in anaesthesia practice and postoperative sedation shortens ICU and hospital length of stay following coronary artery bypass surgery

We randomized prospectively 144 patients, undergoing elective coronary artery bypass surgery, to either early or to routine extubation [mechanical ventilatory support for 4-7 h (Group A), or 8-14 h (Group B)]. Anaesthesia was modified for both groups. The groups were well matched in terms of sex, age, NYHA class, preoperative left ventricular ejection fraction, bypass time and aortic cross-clamp time, number of grafts used, and blood units transfused. All patients had normal preoperative respiratory, renal, hepatic and cerebral functions. Mechanical ventilatory support (mean +/- SD) was 6.3 +/- 0.7 h for Group A and 11.6 +/- 1.3 h for Group B. Mean ICU stay was 17 +/- 1.3 h for Group A and 22 +/- 1.2 h for Group B, while the mean hospital stay was 7.3 +/- 0.8 days and 8.4 +/- 0.9, respectively. There were no statistically significant differences in the frequency of all postoperative complications among the two groups. There were no reintubation, readmission to the ICU or death in either group. We concluded that change in anaesthesia practice and early postoperative sedation in patients undergoing elective coronary artery bypass graft (CABG) surgery resulted in earlier tracheal extubation, shorter ICU and hospital length of stay without organ dysfunction or postoperative complications. Early extubation was only possible due to the modification of anaesthesia and ICU sedation regime.     

Agonist action at D2(long) dopamine receptors: ligand binding and functional assays

Clinical pathways are being introduced by hospitals to reduce costs and control unnecessary variation in care. We studied 766 inpatients to measure the impact of a perioperative clinical pathway for patients undergoing knee replacement surgery on hospital costs. One hundred twenty patients underwent knee replacement surgery before the development of a perioperative clinical pathway, and 63 patients underwent knee replacement surgery after pathway implementation. As control groups, we contemporaneously studied 332 patients undergoing radical prostatectomy (no clinical pathway in place for these patients) and 251 patients undergoing hip replacement surgery without a clinical pathway (no clinical pathway and same surgeons as patients having knee replacement surgery). Total hospitalization costs (not charges), excluding professional fees, were computed for all patients. Mean (+/-SD) hospital costs for knee replacement surgery decreased from $21,709 +/- $5985 to $17,618 +/- $3152 after implementation of the clinical pathway. The percent decrease in hospitalization costs was 1.56-fold greater (95% confidence interval 1.02-2.28) in the knee replacement patients than in the radical prostatectomy patients and 2.02-fold greater (95% confidence interval 1.13-5.22) than in the hip replacement patients. If patient outcomes (e.g., patient satisfaction) remain constant with clinical pathways, clinical pathways may be a useful tool for incremental improvements in the cost of perioperative care. Implications: Doctors and nurses can proactively organize and record the elements of hospital care results in a clinical pathway, also known as "care pathways" or "critical pathways." We found that implementing a clinical pathway for patients undergoing knee replacement surgery reduced the hospitalization costs of this surgery.     

Patellofemoral complications in symmetrical total knee arthroplasty

A review of 356 Kinemax (Howmedica, Inc, Rutherford, NJ) cemented posterior cruciate ligament-retaining condylar total knee arthroplasties employing a symmetrical femoral component articulating with a medially offset symmetrical dome patella component was carried out to examine the results and determine the incidence and nature of the patellofemoral complications. Follow-up was from 3 to 8 years, with a mean of 5.1 years. A review of patellofemoral complications in previously reported homogeneous series of symmetrical and asymmetrical implants is presented. Mean postoperative Knee Society scores improved to 91, function scores to 86, and Hospital of Special Surgery scores to 90 yielding 95% good and excellent results. Mean postoperative range of motion was -1.5 degrees extension to 113 degrees flexion. There were five patellofemoral complications (1.4%), including two symptomatic subluxations, two distal pole avulsion fractures, and one lateral facet fracture. There were two reoperations necessary for patellofemoral problems (0.56%), one to correct subluxation and one for excision of the fractured lateral facet. These rates are lower than those previously reported for asymmetrical implants as well as current and phased-out symmetrical designs of total knee arthroplasty in the intermediate term. This review suggests that cemented total knee arthroplasty with symmetrical patellofemoral resurfacing with an offset patella dome and posterior cruciate ligament retention yields low patellofemoral complications and reoperations. The symmetrical femoral component appears to be a satisfactory compromise of "normal" femoral anatomy, which decreases inventory and cost without adversely affecting patellofemoral function and complications.     

Cost effectiveness and quality of life in knee arthroplasty

Few studies quantitate the cost of a quality well being as produced by arthroplasty surgery. The objective was to use the Quality of Well Being Index to calculate the cost per quality of well year in knee arthroplasty surgery. The difference in Quality of Well Being Index scores before and after the intervention was calculated and multiplied by the patient's life expectancy. The procedure cost was divided by this quantity resulting in the cost of a quality well year. One hundred patients underwent a primary knee arthroplasty. There were 30 males (average age, 62 years old) and 70 females (average age, 64 years old). The calculated costs per a quality well year were $30,695 (standard deviation $90,883) at 3 months, $17,804 (standard deviation $25,888) at 6 months, $11,560 (standard deviation $11,874) at 1 year, and $6656 (standard deviation $3567) at 2 years postsurgery. Health economists consider an intervention costing less than $30,000 per quality of well year a bargain to society. Cost effectiveness of knee arthroplasty surgery compares favorably with other surgical interventions such as coronary artery bypass surgery ($5000 per quality of well year) and extremely favorable with medical treatments such as renal dialysis ($50,000.00 for the quality well year). Knee arthroplasty is a cost effective procedure and should be considered an appropriate investment by society.     

Atrial fibrillation after bypass surgery: does the arrhythmia or the characteristics of the patients prolong hospital stay?

STUDY OBJECTIVES: The goal of this study was to determine whether prolonged hospital stay associated with atrial fibrillation or flutter (AF) after coronary artery bypass graft (CABG) surgery is attributable to the characteristics of patients who develop this arrhythmia or to the rhythm disturbance itself. DESIGN: An investigation was conducted through a prospective case series. SETTING: Patients were from a single urban teaching hospital. PARTICIPANTS: Consecutive patients undergoing isolated CABG surgery between December 1994 and May 1996 were included in the study. INTERVENTIONS: No interventions were involved. RESULTS: Of 436 patients undergoing isolated CABG surgery, 101 (23%) developed AF. AF patients were older and more likely to have obstructive lung disease than patients without AF, but both patients with and without AF had similar left ventricular function and extent of coronary disease. ICU and hospital stays were longer in patients with AF. Multivariate analysis, adjusted for age, gender, and race, demonstrated that postoperative hospital stay was 9.2+/-5.3 days in patients with AF and 6.4+/-5.3 days in patients without AF (p<0.001). CONCLUSIONS: Although AF is strongly associated with advanced age, most of the prolonged hospital stay appears to be attributable to the rhythm itself and not to patient characteristics.     

Effect of a patient management system on outcomes of total hip and knee arthroplasty

Five hundred fifty-three patients undergoing hip and knee reconstructive procedures in one institution that used a patient management system were compared with a retrospective group of 340 patients undergoing similar procedures in the same institution. All procedures were performed by one surgeon and the same patient management team. Measures of length of stay, discharge disposition, and hospital charges were recorded for all patients in each subgroup of total hip arthroplasty, revision total hip arthroplasty, total knee arthroplasty, revision total knee arthroplasty, unicompartmental knee arthroplasty, and bilateral procedures. The length of stay and hospital charges were reduced significantly in all groups, whereas the percentage of patients discharged to home was unchanged. There was no significant difference in complication rates between the two groups.