EXECUTIVE SUMMARY

Investigators found that total knee surgery patients experience better outcomes when they live farther away from a hospital.

  • Researchers observed that patients who lived closer to a hospital were seven times more likely to show up at an ED for treatment after surgery vs. patients who lived far from a hospital.
  • These findings suggest that patients are less likely to visit an ED when they experience symptoms of pain and swelling if the clinic or physician’s office has closely communicated with patients after surgery.
  • Technology can make telecommunication even easier for patients. For instance, doctors could review patients’ photos of their surgical site and confirm that it is healing as expected.

Researchers might not always uncover what they expected; however, what they do discover can be even more interesting. This is what happened when investigators studied patients who underwent total knee and hip surgeries at a facility far away from their homes vs. those who underwent such surgeries at a facility close to where they live.

Investigators conducted a study about the relationship between distance away from a medical facility and total knee replacement surgery postoperative events.1 Researchers used data from 2,892 surgeries. They divided patients into groups based on distance between the medical facility and home: short (less than 10 km), medium (10-40 km), and far (more than 40 km).

The results of their investigation revealed that patients who lived closer to a hospital were seven times more likely than patients who lived far from a hospital to show up in an ED for postoperative pain and swelling. Investigators concluded that total knee arthroplasty was an independent risk factor for more ED visits, a higher rate of hospital readmissions, and less communication with the surgeon after the procedure.

“Originally, we thought those who lived farther away would have less access to healthcare and would end up with more readmissions and problems,” says Bradford Waddell, MD, assistant attending at the Hospital for Special Surgery (HSS) in New York City who worked on this research. Patients who lived far away from hospitals were more likely to communicate with their physicians through phone, email, and patient portal use after surgery compared to patients who lived closer.

“What we inferred is those who lived farther away had a lot of pain and swelling and would call to ask, ‘Am I OK?’” Waddell explains. “Those who didn’t live far away would just pop into the emergency room.”

When patients experience pain and swelling after surgery, they could visit the clinic instead of heading to the ED, or they could call someone to ask about their symptoms. Heading to the ED should be a last resort, intended only when symptoms warrant such a visit. The study’s data trend showed a correlation between fewer ED visits and more patient communication with physicians.

Some healthcare institutions treat patients who are covered by alternative reimbursement plans, such as bundled payments, Waddell explains. Bundled payment plans negotiate one payment to cover all of a surgery patient’s needs. These agreements require a surgery center to handle (for one lump sum payment) all of a patient’s care. The one payment covers everything from the initial visit with the physician through 90 days of care after surgery, including all pre-op visits, the surgical procedure, post-op visits, physical therapy, and any hospitalizations or ED visits.

This means the surgery center will lose money if patients experience poor outcomes and become infected or exhibit symptoms that send them to the hospital. This type of arrangement gives surgery centers a financial incentive to call patients after surgery and to take extra steps to help them prevent postsurgery problems, Waddell adds. From an ASC perspective, these results suggest that follow-up phone calls to patients can help. Surgery centers also might ensure patients understand what type of pain and swelling to expect after surgery so they will not be alarmed unnecessarily when these symptoms appear. The clinic could meet with patients who are worried about symptoms and give them another prescription if they need additional help.

Many ASCs already provide follow-up calls and care. Still, based on the study’s findings, ASC leaders also might consider enhancing patient education. “We think we give patients appropriate expectations. But despite rigorous pre-educational classes and joint camp, we had patients hopping into the ER,” Waddell says.

Waddell says the results of this study have provided HSS a template for correcting such issues. “It’s changed the way we educate pre-operatively,” he says. “We have a nurse navigator now who says, ‘Expect to have a lot of pain and swelling. Instead of showing up at the ER where they’ll tell you everything is OK, we’d prefer you to give our office a call.’”

Nurse navigators call within three days, asking patients about their status. Nurses reassure patients and ask them to come into the clinic if they need help. “We call patients more often, and we keep in better contact with them,” Waddell says.

Some patients use electronic medical record portals that allow them to send the clinic a photo of their wound. “I look at three or more wounds a week, on average, through the online patient portal,” Waddell says. “Almost always, it’s totally normal.”

Phone and electronic follow-ups have been more common among ambulatory providers than with hospitals, but that might change, Waddell notes. “While we’re a huge hospital system that doesn’t utilize outpatient surgery, we’re now using some tricks they use in outpatient surgery,” he says.

For ASCs, total knee surgery is a hot topic as it was removed from the list of inpatient of procedures recently, Waddell notes. “Our study, hopefully, will set up better criteria for knowing who might need that extra motivation to call and be educated or to come into the clinic, as opposed to showing up in the emergency room,” Waddell says.

REFERENCE

  1. Kolodychuk NL, Wong M, Adams T, et al. Travel distance impacts patient access to care following total knee arthroplasty. Abstract presented at the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting, March 12-16, 2019, Las Vegas. Abstract:P0143.