Published online Mar 18, 2023. doi: 10.5312/wjo.v14.i3.123
Peer-review started: August 25, 2022
First decision: December 26, 2022
Revised: January 1, 2023
Accepted: February 15, 2023
Article in press: February 15, 2023
Published online: March 18, 2023
With increasing demand for total joint replacement (TJR) procedures, delivering quality surgical care is a challenge to many hospitals, specifically those hospitals located in rural areas. The perioperative surgical home (PSH) developed by American Society of Anesthesiologists has proven successful in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.
Compared to urban hospitals, rural hospitals in the United States can often be overwhelmed by the growing demand for TJR surgeries and factors such as poor coordination among clinicians, lack of patient education, poor patient care transition, and inconsistent care delivery that affect rural orthopedic surgical care negatively. A new PSH system was implemented at a community hospital located in rural Montana to address these issues, which have plagued the rural orthopedic surgery system.
The objective of this research was to evaluate the newly implemented PSH system at a local rural, community hospital by comparing TJR surgical outcomes using a longitudinal case-control study.
A case-control study was performed to compare the PSH and non-PSH cohorts of TJR surgical outcomes performed at a rural community hospital. Statistical tests including the Chi-square test or Fischer's exact test were performed to compare the categorical variables between non-PSH and PSH cohorts. Similarly, for continuous variables, student's t test or Mann-Whitney test was performed, as appropriate. The adjusted analysis was performed using general linear models; Poisson regression for the LOS, and binomial logistic regression for discharge disposition and 90-d readmission.
The LOS was shorter in PSH cohort compared to the control cohorts [median PSH = 34 h, Control-1 PSH (C1-PSH) = 53 h, Control-2 PSH (C2-PSH) = 35 h]. Correspondingly, the PSH cohort had a lower percentage of discharges to other facilities than the control cohorts (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%). No statistically significant difference was observed in 90-d readmission between PSH and control cohorts. However, the implementation of PSH helped to lower the readmission rates after surgery.
Implementing PSH at a community hospital helped to improve the TJR surgical outcomes. The patient-centric physician co-management to ensure continuity of care across all perioperative surgical phases was vital for establishing PSH system at a rural community hospital. The PSH elements including preoperative assessment, patient education, and longitudinal digital engagement were imperative for improving patient satisfaction, shortening the LOS, increasing discharge to home, and reducing readmission after the surgery.
This study contributes to improving surgical outcomes using PSH system for community hospitals that are specifically located in micro-statistical areas. The authors envision that these study results will immensely help researchers and clinicians who are working to enhance surgical care in states similar to Montana demographics and social factors, including Alaska, Idaho, Wyoming, North Dakota, and South Dakota. In the long term, this research will contribute to reducing socio-economic and socio-demographic differences in delivering high-quality surgical care to patients in the United States.