title: The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.
abstract: The Perioperative Surgical Home (PSH) seeks to remedy the currently highly fragmented and expensive perioperative care in the United States. The 2 specific aims of this health services research study were to assess the association between the preoperative and postoperative elements of an initial PSH model and a set of (1) clinical, quality, and patient safety outcomes and (2) operational and financial outcomes, in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).
  
  
  
  A 2-group before-and-after study design, with a nonrandomized preintervention PSH (PRE-PSH group, N = 1225) and postintervention PSH (POST-PSH group, N = 1363) data-collection strategy, was applied in this retrospective observational study. The 2 study groups were derived from 2 sequential 24-month time periods. Conventional inferential statistical tests were applied to assess group differences and associations, including regression modeling.
  
  
  
  Compared with the PRE-PSH group, there was a 7.2% (95% confidence interval [CI], 4.0%-10.4%, P < .001) increase in day of surgery on-time starts (adjusted odds ratio [aOR] 2.54; 95% CI, 1.70-3.80; P < .001); a 5.8% (95% CI, 3.1%-8.5%, P < .001) decrease in day of surgery anesthesia-related delays (aOR 0.66; 95% CI, 0.52-0.84, P < .001); and a 2.2% (95% CI, 0.5%-3.9%, P = .011) decrease in ICU admission rate (aOR 0.45; 95% CI, 0.31-0.66, P < .001) in the POST-PSH group. There was a 0.6 (95% CI, 0.5-0.7) decrease in the number of ICU days in the POST-PSH group compared with the PRE-PSH group (P = .028); however, there was no significant difference (0.1 day; 95% CI, -0.03 to 0.23) in the total hospital length of stay between the 2 study groups (P = .14). There was also no significant difference (1.2%; 95% CI, -0.6 to 3.0) in the all-cause readmission rate between the study groups (P = .18). Compared with the PRE-PSH group, the entire POST-PSH group was associated with a $432 (95% CI, 270-594) decrease in direct nonsurgery costs for the THA (P < .001) and a $601 (95% CI, 430-772) decrease in direct nonsurgery costs for the TKA (P < .001) patients.
  
  
  
  On the basis of our preliminary findings, it appears that a PSH model with its expanded role of the anesthesiologist as the "perioperativist" can be associated with improvements in the operational outcomes of increased on-time surgery starts and reduced anesthesia-related delays and day-of-surgery case cancellations, and decreased selected costs in patients undergoing THA and TKA.
authors.affiliation: From the Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Vetter
authors.forename: Joydip
authors.initials: J
authors.lastname: Barman
authors.forename: James M
authors.initials: JM
authors.lastname: Hunter
authors.forename: Keith A
authors.initials: KA
authors.lastname: Jones
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Pittet
mesh_terms: D000328:Adult; D000368:Aged; D000758:Anesthesia; D019644:Arthroplasty, Replacement, Hip / Q000191:economics / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000191:economics / Q000379:methods*; D003422:Critical Care; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010351:Patient Discharge; D061214:Patient Safety; D019990:Perioperative Care / Q000191:economics / Q000379:methods*; D011182:Postoperative Care; D011300:Preoperative Care; D012189:Retrospective Studies; D016896:Treatment Outcome