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Blood Management May Have an Impact on Length of Stay After Total Hip Arthroplasty

  • Original Article
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HSS Journal ®

Abstract

Background

The steady rise in demand for total hip arthroplasty constitutes a significant and increasing burden on health care resources. The biggest contributors to the total cost of hip replacement procedures other than the price of the implant are hospital stay and postoperative rehabilitation. Blood management is one of the most adjustable factors that can impact length of stay and cost-efficiency while improving patient safety.

Questions/Purposes

The primary purpose of this retrospective study was to assess the potential impact of blood management interventions on length of hospital stay after primary unilateral total hip arthroplasty. This was achieved by first identifying which patient and surgical factors are associated with an increased risk of prolonged hospital stay. Subsequently, the significant factors were controlled for through a multivariate regression analysis to quantify the association between blood transfusions and increased hospital stay.

Methods

Retrospectively, the study included 2,104 primary total hip replacements. Eight hundred eighty-eight procedures were performed on males and 1,216 on females, with a mean age of 64 years at the time of the surgery (range 18–94 years) and BMI of 28.6 kg/m2 (range 12–51.5 kg/m2). The correlation between each factor and length of stay was analyzed separately using univariate regression analysis. Those variables with p ≤ 0.05 in the univariate model were selected for inclusion in the multivariate logistic regressions. Multiple linear regression was used to analyze the effect of each significant factor and derive odds ratios with adjustment for the other variables.

Results

Multivariate Poisson regression revealed that increased length of stay was significantly correlated to patient age (p = 0.05), the use of coumadin (p = 0.02) or lovenox/heparin (p = 0.007) as opposed to aspirin for anticoagulation, and allogeneic blood transfusion (p < 0.0001). The data shows that allogeneic blood transfusion is associated with a longer hospital stay regardless of absolute drop in hemoglobin level postoperatively or at discharge or the number of units transfused (OR = 1.18, 95% CI = 1.09 to 1.28, p < 0.001).

Conclusion

Transfusion of allogeneic blood is independently associated with increased hospital stay after total hip arthroplasty. Blood management modalities that can significantly reduce transfusion risk could impact length of stay as well as the total cost of hip replacement procedures.

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References

  1. Baumgartner JM, Silliman CC, Moore EE, et al. Stored red blood cell transfusion induces regulatory T cells. J Am Coll Surg. 2009; 208(1): 110-119. doi:10.1016/j.jamcollsurg.2008.08.012.

    Article  PubMed  Google Scholar 

  2. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999; 81(1): 2-10.

    CAS  PubMed  Google Scholar 

  3. Boettner F, Altneu EI, Williams BA, et al. Nonanemic patients do not benefit from autologous blood donation before total hip replacement. HSS J Musculoskelet Hosp Spec Surg. 2009. doi:10.1007/s11420-009-9145-4.

    Google Scholar 

  4. Borghi B, Casati A. Incidence and risk factors for allogenic blood transfusion during major joint replacement using an integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia. Eur J Anaesthesiol. 2000; 17(7): 411-417.

    Article  CAS  PubMed  Google Scholar 

  5. Bozic KJ, Lau E, Kurtz S, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am. 2012; 94(9): 794-800. doi:10.2106/JBJS.K.00072.

    PubMed  Google Scholar 

  6. Bozic KJ, Wagie A, Naessens JM, et al. Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty. J Arthroplast. 2006; 21(6 Suppl 2): 151-156. doi:10.1016/j.arth.2006.04.015.

    Article  Google Scholar 

  7. Callaghan JJ, Spitzer AI. Blood management and patient specific transfusion options in total joint replacement surgery. Iowa Orthop J. 2000; 20: 36-45.

    CAS  PubMed Central  PubMed  Google Scholar 

  8. Dall GF, Ohly NE, Ballantyne JA, et al. The influence of pre-operative factors on the length of in-patient stay following primary total hip replacement for osteoarthritis: a multivariate analysis of 2302 patients. J Bone Joint Surg. 2009; 91(4): 434-440. doi:10.1302/0301-620X.91B4.21505.

    Article  CAS  Google Scholar 

  9. Dawson-Bowling SJ, Jha S, Chettiar KK, et al. A multidisciplinary enhanced recovery programme allows discharge within two days of total hip replacement; three- to five-year results of 100 patients. Hip Int Jof Clin Exp Res Hip Pathol Ther. 2014. doi:10.5301/hipint.5000100.

    Google Scholar 

  10. Epps CD. Length stay, discharge disposition, and hospital charge predictors. AORN J. 2004; 79(5): 975-976. 9-81, 84-97.

    Article  PubMed  Google Scholar 

  11. Fernandez MC, Gottlieb M, Menitove JE. Blood transfusion and postoperative infection in orthopedic patients. Transfusion. 1992; 32(4): 318-322.

    Article  CAS  PubMed  Google Scholar 

  12. Foote J, Panchoo K, Blair P, et al. Length of stay following primary total hip replacement. Ann R Coll Surg Engl. 2009; 91(6): 500-504. doi:10.1308/003588409X432356.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Friedman R, Homering M, Holberg G, et al. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. J Bone Joint Surg Am. 2014; 96(4): 272-278. doi:10.2106/JBJS.L.01268.

    Article  PubMed  Google Scholar 

  14. Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012; 116(6): 1367-1376. doi:10.1097/ALN.0b013e318254d1a3.

    Article  PubMed  Google Scholar 

  15. Guerin S, Collins C, Kapoor H, et al. Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty. Transfus Med. 2007; 17(1): 37-43. doi:10.1111/j.1365-3148.2006.00698.x.

    CAS  PubMed  Google Scholar 

  16. Hayes JH, Cleary R, Gillespie WJ, et al. Are clinical and patient assessed outcomes affected by reducing length of hospital stay for total hip arthroplasty? J Arthroplast. 2000; 15(4): 448-452. doi:10.1054/arth.2000.4346.

    Article  CAS  Google Scholar 

  17. Hunt GR, Crealey G, Murthy BV, et al. The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay. Clin Rehabil. 2009; 23(12): 1067-1077. doi:10.1177/0269215509339000.

    Article  PubMed  Google Scholar 

  18. Husted H, Hansen HC, Holm G, et al. Length of stay in total hip and knee arthroplasty in Danmark I: volume, morbidity, mortality and resource utilization. A national survey in orthopaedic departments in Denmark. Ugeskr Laeger. 2006; 168(22): 2139-2143.

    PubMed  Google Scholar 

  19. Husted H, Hansen HC, Holm G, et al. What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg. 2010; 130(2): 263-268. doi:10.1007/s00402-009-0940-7.

    Article  PubMed  Google Scholar 

  20. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop. 2008; 79(2): 168-173. doi:10.1080/17453670710014941.

    Article  PubMed  Google Scholar 

  21. Ibrahim MS, Twaij H, Giebaly DE, et al. Enhanced recovery in total hip replacement: a clinical review. Bone Joint J. 2013; 95-B(12): 1587-1594. doi:10.1302/0301-620X.95B12.31303.

    Article  CAS  PubMed  Google Scholar 

  22. Jacobs JJ. United States bone and joint decade: the burden of musculoskeletal diseases in the United States. American Academy of Orthopaedic Surgeons 2008.

  23. Jans O, Jorgensen C, Kehlet H, et al. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Transfusion. 2013. doi:10.1111/trf.12332.

    PubMed  Google Scholar 

  24. Kotze A, Carter LA, Scally AJ. Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth. 2012; 108(6): 943-952. doi:10.1093/bja/aes135.

    Article  CAS  PubMed  Google Scholar 

  25. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4): 780-785. doi:10.2106/JBJS.F.00222.

    Article  PubMed  Google Scholar 

  26. Larsen K, Hansen TB, Thomsen PB, et al. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am. 2009; 91(4): 761-772. doi:10.2106/JBJS.G.01472.

    Article  PubMed  Google Scholar 

  27. Larsen K, Sorensen OG, Hansen TB, et al. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop. 2008; 79(2): 149-159. doi:10.1080/17453670710014923.

    Article  PubMed  Google Scholar 

  28. Lenssen AF, de Bie RA. Role of physiotherapy in peri-operative management in total knee and hip surgery. Injury. 2006; 37(Suppl 5): S41-S43. doi:10.1016/S0020-1383(07)70011-6.

    Article  PubMed  Google Scholar 

  29. Martin CT, Pugely AJ, Gao Y, et al. A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplast. 2013; 28(5): 849-854. doi:10.1016/j.arth.2012.10.029.

    Article  Google Scholar 

  30. Martinez V, Monsaingeon-Lion A, Cherif K, et al. Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs. Br J Anaesth. 2007; 99(6): 794-800. doi:10.1093/bja/aem266.

    Article  CAS  PubMed  Google Scholar 

  31. Moller AM, Pedersen T, Villebro N, et al. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg. 2003; 85(2): 178-181.

    Article  Google Scholar 

  32. Newman ET, Watters TS, Lewis JS, et al. Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty. J Bone Joint Surg Am. 2014; 96(4): 279-284. doi:10.2106/JBJS.L.01041.

    Article  PubMed  Google Scholar 

  33. Oldmeadow LB, McBurney H, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arthroplast. 2003; 18(6): 775-779.

    Article  Google Scholar 

  34. Peck CN, Foster A, McLauchlan GJ. Reducing incision length or intensifying rehabilitation: what makes the difference to length of stay in total hip replacement in a UK setting? Int Orthop. 2006; 30(5): 395-398. doi:10.1007/s00264-006-0091-1.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  35. Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplast. 2006; 21(6 Suppl 2): 132-138. doi:10.1016/j.arth.2006.04.017.

    Article  Google Scholar 

  36. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003; 43(4): 459-469.

    Article  PubMed  Google Scholar 

  37. Sigurdsson E, Siggeirsdottir K, Jonsson H Jr, et al. Early discharge and home intervention reduces unit costs after total hip replacement: results of a cost analysis in a randomized study. Int J Health Care Finance Econ. 2008; 8(3): 181-192. doi:10.1007/s10754-008-9036-0.

    Article  PubMed  Google Scholar 

  38. Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010; 113(2): 482-495. doi:10.1097/ALN.0b013e3181e08e97.

    Article  PubMed  Google Scholar 

  39. Sparrow RL. Red blood cell storage and transfusion-related immunomodulation. Blood Transfus Trasfusione Sangue. 2010; 8(Suppl 3): s26-s30. doi:10.2450/2010.005S.

    Google Scholar 

  40. Tahim AS, Stokes OM, Vedi V. The effect of femoral stem length on duration of hospital stay. Hip Int Jof Clin Exp Res Hip Pathol Ther. 2012; 22(1): 56-61. doi:10.5301/HIP.2012.9035.

    Google Scholar 

  41. Vincent HK, Alfano AP, Lee L, et al. Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation. Arch Phys Med Rehabil. 2006; 87(4): 461-467. doi:10.1016/j.apmr.2006.01.002.

    Article  PubMed  Google Scholar 

  42. Wang T, Ackland T, Hall S, et al. Functional recovery and timing of hospital discharge after primary total hip arthroplasty. Aust N Z J Surg. 1998; 68(8): 580-583.

    Article  CAS  PubMed  Google Scholar 

  43. Weber EW, Slappendel R, Prins MH, et al. Perioperative blood transfusions and delayed wound healing after hip replacement surgery: effects on duration of hospitalization. Anesth Analg. 2005; 100(5): 1416-1421. table of contents. doi:10.1213/01.ANE.0000150610.44631.9D.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would like to thank Dr. Michael Alexiades, Dr. Mathias Bostrom, Dr. Charles Cornell, Dr. Alejandro Della Valle, Dr. Mark Figgie, Dr. David Mayman, Dr. Douglas Padgett, Dr. Michael Parks, Dr. Amar Ranawat, Dr. Chitranjan Ranawat, Dr. Thomas Sculco, and Dr. Geoffrey Westrich for enrolling their patients in the Center for Blood Preservation at Hospital for Special Surgery, as well as Michele Prigo, EdD, CHES, the coordinator of the blood center for her help in data collection.

Disclosures

Conflict of Interest: Friedrich Boettner, MD reports personal fees from Ethicon, Ortho Development, DJ Ortho and Smith and Nephew, grants from Smith and Nephew, outside the submitted work. Jad Bou Monsef, MD has declared that he has no conflict of interest.

Human/Animal Rights:

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent:

Informed consent was obtained from all patients for being included in the study.

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Authors and Affiliations

  1. Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Jad Bou Monsef MD & Friedrich Boettner MD

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  1. Jad Bou Monsef MD
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Correspondence to Friedrich Boettner MD.

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Level of Evidence: Therapeutic Study Level IV: Retrospective case series. See Levels of Evidence for a complete description.

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Bou Monsef, J., Boettner, F. Blood Management May Have an Impact on Length of Stay After Total Hip Arthroplasty. HSS Jrnl 10, 124–130 (2014). https://doi.org/10.1007/s11420-014-9384-x

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