The Efficacy of Telemedicine Versus In-Person Education for High-Risk Patients Undergoing Primary Total Joint Arthroplasty.

BACKGROUND: While multiple studies have demonstrated the positive impact of preoperative education on total joint arthroplasty (TJA) outcomes, the traditional method of conducting in-person individualized counseling or group education may limit access to these resources for a subset of the population. This study aimed to evaluate the use of preoperative telemedicine and in-person educational programs for primary TJA patients to determine if the utilization of telemedicine is inferior to in-person education in high-risk populations. METHODS: A retrospective chart review of all "high-risk" patients undergoing primary unilateral TKA or THA by 1 of 10 board-certified surgeons at a single institution over 1 year was performed. Patients were prospectively classified as high-risk based on race/ethnicity, comorbidities, and socioeconomic and psychosocial factors. Demographics, comorbidities, and hospital outcomes were compared between patients receiving preoperative nurse navigator education via telemedicine versus those receiving face-to-face education. RESULTS: When comparing the interventions, telemedicine education was noninferior to face-to-face visits. No significant differences between postoperative length of stay, discharge home, 30-day emergency department return, or 30-day readmission rates were noted. Within the telemedicine group, patients who received video consultations were found to be 6 times more likely to be discharged home after surgery (odds ratio (OR): 5.95, 95% confidence interval (CI): 2.00 to 25.49; P = .004) and less likely to have a 30-day readmission than the phone consultations (OR: 0.36, 95% CI: 0.12 to 0.94: P = .050). CONCLUSION: This study demonstrates that telemedicine is not inferior to in-person preoperative education for patients undergoing unilateral TJA, although video-based consultation may improve outcomes over phone-only education.

Analysis of Risk Factors for High-Risk Patients Undergoing Total Joint Arthroplasty.

Background: The purpose of this study is to evaluate and redefine patients at high risk for increased resource utilization and complications after total joint arthroplasty (TJA), so interventions may focus on patients standing to receive the most benefit. Material and methods: This is a retrospective study of 787 patients undergoing primary unilateral TJA from September 1, 2020, to September 31, 2021. Patients were deemed to be at "high risk" based on criteria derived from published literature and triaged to an enhanced preoperative education program. Patients that were discharged to a skilled nursing facility, had a length of stay ≥ 2 days, returned to the emergency department, or readmitted within 30 days were classified as having a composite outcome. A univariate analysis compared patients who did and did not experience the composite outcome, and multivariate regression was performed to evaluate predictors of this endpoint. Results: Differences in rates of 5 of the 28 risk factors were present between patients who did and did not experience composite outcomes. After controlling for other factors, African American race, planned discharge to skilled nursing facility, mental health conditions or drug use, cardiac, and neurologic conditions were predictive of the composite outcome. Patients who were reclassified as "high risk" with 1 or more of these characteristics, experienced longer length of stay and lower rates of home discharge than the rest of the population. Conclusion: This study presents a profile of high-risk TJA patients that can be incorporated into clinical practice for risk stratification and targeted intervention.

Enhanced Preoperative Education Pathways: A Step Toward Reducing Disparities in Total Joint Arthroplasty Outcomes.

BACKGROUND: Patients with increased comorbidities, lower socioeconomic status, and African American (AA) race have been shown to be at increased risk for suboptimal outcomes after total joint arthroplasty (TJA). Despite the body of evidence highlighting these disparities, few interventions aimed at improving outcomes specifically in high-risk patients have been evaluated. This study evaluates the impact of an enhanced preoperative education pathway (EPrEP) on outcomes after TJA. METHODS: All patients included underwent unilateral primary total hip or knee arthroplasty at a single institution from September 1, 2020 to September 31, 2021. This is a retrospective observational cohort study comparing demographics, comorbidities, and outcomes of patients treated through EPrEP with those receiving routine care. Subgroup analysis of outcome differences by race was performed. RESULTS: In total, 1,716 patients were included in the study: 802 went through the EPrEP and 914 did not. EPrEP patients had a higher comorbidity burden as measured by the Charlson Comorbidity Index (3.54 ± 1.71 vs 3.25 ± 1.75, P < .001). After risk adjustment, there was no significant relationship among EPrEP utilization and length of stay, home discharge, or 30-day readmissions. However, EPrEP patients were less likely to return to the emergency department 30 days postoperatively (odds ratio 0.49, 95% confidence interval 0.27-0.86, P = .016). No significant differences in outcomes between AA and non-AA patients were observed. CONCLUSION: High-risk patients receiving individualized nurse navigator counseling experienced similar outcomes to the broader patient population undergoing TJA. Implementation of EPrEPs may be an effective means of enhancing the equity of care quality across all patients undergoing TJA.

Preoperative Education for Total Joint Arthroplasty: Does Reimbursement Reduction Threaten Improved Outcomes?

BACKGROUND: Nurse navigation programs have been previously shown to reduce cost and improve outcomes after total joint arthroplasty (TJA). Medicare has proposed a 13.7% reduction in professional fee reimbursement for TJA procedures that may adversely impact providers' and health systems' ability to fund ancillary support resources such as nurse navigators. METHODS: A consecutive series of primary TJAs performed between April 2019 and February 2020 was retrospectively reviewed. Clinical and financial outcomes of patients attending a nurse navigator-led preoperative education class were compared with those who did not attend. RESULTS: There were 2057 TJAs identified during the study period. Most patients attended the preoperative education class (82.7%) and were discharged home (92.8%). Controlling for significant differences between groups, class attendance was associated with reduced length of stay (LOS), increased chance of 0- or 1-day LOS, reduced chance of discharge to a skilled nursing facility, and reduced hospital charges. For this patient sample, a proposed 13.7% reduction in nurse navigator-led classes was modeled to increase overall cost to payers by >$400,000 annually. Complete elimination of this class was estimated to increase the total annual cost by >$5,700,000 and cost per TJA by >$2700. CONCLUSION: The use of a nurse navigator-led preoperative education class was associated with shorter LOS, more frequent 0- and 1-day LOS, reduced discharge to skilled nursing facilities, and lower total hospital charges for those patients who attended. Potential reductions proposed by Medicare may interfere with the ability to support such services and negatively impact both clinical and financial outcomes.