Objective Assessment Scores and the Development of Efficient Health-Care Systems in Arthroplasty

The current era of the practice of orthopaedic surgery has had the use of principles of evidence-based medicine at its core, gradually shifting from the era of expert-opinion-based practice over the last few decades. Never has there been a time when orthopaedic surgical practice has been more driven by patient demands and the attainment of good functional results that are sustained for a long duration. Arthroplasty has emerged as one of those subspecialties in orthopaedic surgery that is heavily patient-demand-driven and results-oriented. As a result, surgeons look to the usage of objective clinical tools for the assessment of results rather than clinical judgment, which is subjective. In short, orthopaedic surgery has undergone a paradigm shift from subjective to objective assessment.

The cost efficiency of any surgical treatment depends on the postoperative care as much as on the cost of the surgery itself, if not more. The cost associated with discharge to care facilities remains the major contributor to driving up the cost of care, particularly in orthopaedic surgical practice. A prolonged hospital stay also is a risk factor for readmission, which again drives up costs. By predicting discharge disposition, one can allocate resources more efficiently and earlier. Predicting discharge outcome after arthroplasty thus becomes instrumental in the administration of efficient and result-based orthopaedic surgical practice. Many tools have been used to predict discharge outcomes—i.e., to home or a care facility. As is the case with any widespread practice, non-uniformity and non-reproducibility are seen with the various assessment tools. The fact that knee arthroplasties are the most commonly performed surgery by orthopaedic surgeons the world over only elevates the need for an objective assessment tool, or a methodology that is uniformly applicable and works reproducibly.

Tools used to predict discharge outcomes are of 2 types: those based on preoperative variables and those based on the postoperative capacity of the patient. Recently, 2 tools have been used widely to predict discharge after both total hip and total knee replacements. The Predicting Location after Arthroplasty Nomogram (PLAN) tool is a prediction tool created by Barsoum et al.1 in 2010. It is based on preoperative data and can be used in both primary and revision total joint arthroplasty. The Activity Measure for Post-Acute Care (AM-PAC) “6-Clicks” basic mobility score, on the other hand, is a postoperative prediction tool that is based on a patient’s capacity to mobilize after surgery. The “6-Clicks” score has been shown to be successful in predicting discharge to home or a care facility and enjoys widespread usage.

In their article, Hadad et al. assess the combined use of these preoperative and postoperative assessment tools, seeking to answer the question of whether this would provide greater utility in predicting patient discharge disposition. The authors found that when the PLAN score (determined preoperatively) and the first “6-Clicks” mobility score recorded postoperatively (within the first 48 hours after the procedure) agreed on home discharge, a higher rate of home discharge (98.0% for total hip arthroplasty [THA], 97.7% for total knee arthroplasty [TKA]) and a lower readmission rate (5.1% for THA, 7.0% for TKA) were observed. In contrast, when both scores predicted discharge to a facility, a lower rate of discharge to home (58.7% for THA, 64.8% for TKA) and a higher readmission rate (10.8% for THA, 13.8% for TKA) were observed. When the PLAN score and the first “6-Clicks” mobility score disagreed, intermediate rates of discharge to home and readmission rates were observed.

The article presents a scientifically sound data analysis that adds another perspective with respect to the use of these scores together, which on their own garner considerable usage. Appropriate data analyses are systematically presented to support the main conclusion reached by the study, which is that PLAN and “6-Clicks” basic mobility scores are good to excellent predictors of discharge disposition after primary total joint arthroplasty, suggesting that both preoperative and postoperative variables play a role in determining discharge disposition.

The study has a robust methodology and a large cohort of patients as its strengths. The use of data from a single center makes hospital-admission bias a possibility. Also, this potentially limits the external validity—i.e., the applicability of the results of the study to the general population.

In conclusion, it seems that the use of objective assessment tools to predict discharge should be universally adopted as it provides greater efficiency and outcome-oriented practice. This is undoubtedly a worthwhile goal and a rewarding exercise for patients and surgeons alike. Additional avenues of research into this subject include analysis of the confounding effect of complications and taking into account patient preference. The use of objective assessment tools rather than subjective clinical judgment may well be the standard of care sooner rather than later. Adoption of evidence-based practices will be beneficial to individual patients by all but eliminating a certain degree of uncertainty that is associated with the subjective decision-making process. On a larger scale, it can pave the way for a more goal-oriented and economically sound health-care architecture.