Same Day, Wrong Focus?
Is the drive towards same day knee replacement the wrong response to the wrong challenge? Dave Duffy explains…
Same day knee replacement has become a bit of a ‘thing’ recently. It wasn’t so long ago that the idea of an outpatient knee replacement was so ludicrous as to barely be worth a mention, but as technology, procedures and surgical expertise have improved, so the length of hospital stays for knee replacements have fallen over the past couple of decades, from ten days to five and now, typically, just one or two.
Historically, the push for same day discharge started in the US where there’s a financial incentive for surgeons to complete knee replacements same day because of the way they’re reimbursed. The healthcare market is very different in the UK, yet we’ve followed the same trend and, at the risk of sounding like Jeff Goldblum in Jurassic Park, you could argue that we’ve been so preoccupied with whether we could, we didn’t stop to think whether we should.
This issue was brought into focus recently by a paper in The Bone and Joint Journal entitled ‘Same day and delayed hospital discharges are associated with worse outcomes following total knee arthroplasty’ (knee replacement).
In a nutshell, patients who spend one or two nights in hospital post-knee replacement have better outcomes than those who spend longer. This isn’t surprising, as patients who stay in hospital longer will typically represent a different population compared with those with a shorter length of stay – with more issues surrounding, for example, mobilisation or pain relief.
But patients who spend one or two days in hospital also have better outcomes than those who have same day procedures – and that’s something we really can’t ignore.
Same day the wrong philosophy
In certain cases, given the right support and optimised pain relief, some patients could go home same day following a knee replacement. We don’t yet know exactly how many patients might fit that fairly narrow set of criteria, but certainly there are some.
Yet there’s a big difference between a patient being allowed home same day because their recovery and the available support is such that it makes it the right thing to do, and a philosophy of same day service.
We need to take a step back and ask what is the purpose of the knee replacement surgery? It isn’t to have the patient home same day. It is to ensure a patient receives a trouble-free implant that serves them well for the next 20 years. I would argue that’s worth a night in hospital.
Of course, you could ask why it’s not possible to have both – and it is possible to have both, but not in every case, and not without a large supporting network of 24/7 staff ensuring that there is no adverse reaction to surgery, that pain is optimised and that where there is an issue, there’s someone to pick up the phone and respond immediately.
Some centres do offer that, but as my colleague Nick London posted recently, the safest place to be post-op is in hospital. And to compromise that even fractionally because of a needless drive for same day seems nonsensical.
I’ve no doubt that, over time, we will continue to move towards same day in certain cases, where that is the right and safe choice for the patient. But at the moment, in most instances, and as the above study notes, that’s not the case.
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