Patient evaluation of early discharge after hip arthroplasty: development of a measure and comparison of three centres with differing durations of stay.

OBJECTIVE: We compared patients' evaluation of care between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to those of the comparison sites. DESIGN: Cross-sectional cohort study. SUBJECTS: Consecutive consenting patients undergoing primary hip arthroplasty during 12 months in: a unit that had reduced postoperative stay to median three days; a specialised orthopaedic surgery treatment centre with median stay of five days; a traditional unit with median stay of six days (N = 316, 125, 119, respectively). METHODS: Six weeks postoperatively, patients completed a specially developed questionnaire measuring their evaluation of care and recovery, together with measures of function and quality of life for validation purposes. RESULTS: Factor analysis of questionnaire responses identified two independent components of patients' evaluation: problems in staff care and problems in physical recovery. Neither component was impaired in the unit with rapid discharge: similar proportions of patients reported recovery problems in each site (odds radios (ORs) for the two comparators versus unit with rapid discharge: 0.96, 1.18); and more patients reported care problems in the two comparator sites (ORs 2.97, 2.16). CONCLUSION: Duration of stay after primary hip arthroplasty can be reduced to three days without intensive pre- or postoperative care, without detriment to patient evaluation.

The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay.

OBJECTIVE: To compare outcomes from hip arthroplasty between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to the comparison sites. DESIGN: Prospective cohort study. SUBJECTS: Consecutive consenting patients receiving primary hip arthroplasty during 12 months beginning July 2006 in three UK National Health Service surgical units. One has shortened postoperative stay to median three days; one was a new treatment centre with median stay of five days; the third was a traditional unit with median stay of six days (N = 316, 119, 87, respectively). METHODS: Patients were assessed preoperatively and six weeks postoperatively. The primary indicator of function was the Oxford Hip Score. Additional secondary measures included further self-report indicators of function and quality of life and health service costs. RESULTS: Patient outcome in the unit with rapid discharge was not impaired by comparison with the other sites on any measure: Oxford Hip Score decreased from 49 to 27 in the short-stay unit, from 40 to 30 in the treatment centre and from 43 to 32 in the traditional unit. Cost of arthroplasty was least in the short-stay unit, although there was potential for cost savings in each. CONCLUSION: Short postoperative stay after hip arthroplasty can be achieved without intensive patient preparation or post-discharge care and without compromising short-term patient outcome or increasing health care costs. Longer term follow-up is needed.

Early discharge following hip arthroplasty: patients' acceptance masks doubts and concerns.

OBJECTIVE: To describe patients' experience of accelerated discharge after hip arthroplasty in order to test the acceptability to patients of economically driven shortening of post-operative stay. METHODS: Patients (n = 35) who had received primary total hip replacement up to 12 weeks previously were recruited from two UK orthopaedic units, one of which has pioneered short post-operative stay (3-4 days), and another one of which retains a traditional regimen of discharge after 6-7 days. Patients were interviewed about their experience of care, focusing particularly on their views related to length of stay and with particular attention to patients' well-known tendency to mask critical views of their care. Transcripts were analysed thematically to identify the ways that patients evaluated their care and whether these differed between sites. RESULTS: Patients were primarily concerned with how attentive and informative hospital staff had been and did not refer to length of stay spontaneously. When prompted about this, they did not question their discharge time, although those in the more traditional unit could not countenance more rapid discharge. Patients in the unit with accelerated discharge described concerns about the consequences of early discharge for them or their family, particularly managing pain and mobility problems at home and needing more support. CONCLUSIONS: Patients' traditional beliefs about the necessity of prolonged convalescence are not a barrier to early discharge after hip arthroplasty. Nevertheless, some patients' acceptance of early discharge masks doubts and concerns. More intensive post-operative management may be needed if clinical care is not to suffer.