Surgery (St Vincent's) - Theses
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ItemCost effectiveness of reducing length of stay for total joint arthroplasty( 2023-12)Background: The utilisation of total joint arthroplasty (TJA) and incidence of osteoarthritis are both increasing. Globally, marked increases in the rate of arthroplasty being performed are predicted within the next ten years. Reducing length of stay (LOS) has been proposed as a method of increasing throughput and to match demand. However, the cost-effectiveness of reducing LOS from the perspective of patients, clinicians, hospitals, and government stakeholders remains to be understood. Objectives: The overall aim of this thesis is to investigate the cost-effectiveness of reducing LOS for TJA. To comprehensively analyse this broad objective, this thesis aimed to: (1) identify factors that affect LOS for TJA; (2) explore strategies that can be utilised to reduce LOS; (3) understand the clinical and cost-effectiveness of earlier discharge; (4) explore trial characteristics and meta-bias amongst trials investigating enhanced recovery after surgery pathways. Methods: This thesis adopts a mixed-methods approach, incorporating multiple quantitative studies and a qualitative study. The perspective of key stakeholders was engaged through each phase of this thesis. Firstly, a narrative review was performed to identify patient-level, clinical, and hospital-level factors that may inform LOS for TJA. In addition, the effect of complications on economic and clinical outcomes, including LOS, was explored. Patients’ and surgeons’ opinions regarding LOS were engaged to explore barriers and enablers for short stay arthroplasty. The impact of enhanced recovery after surgery pathways on outcomes after TJA was systematically reviewed among randomised clinical trials. Expanding the scope to a hospital and government perspective, a policy-level change targeting a one-day reduction in LOS was simulated using overlap propensity score weighted analysis. Finally, a cross-sectional study was performed using registered randomised clinical trials to understand the trial characteristics and meta-biases amongst trials implementing enhanced recovery after surgery. Findings: A diverse array of patient, hospital, and clinical factors were associated with LOS. Expectations of patients and surgeons, which were reinforced by the healthcare system, helped to inform LOS. When specifically testing shorter stay, earlier discharge did not change odds of complication or readmission. Overall, earlier discharge was cost neutral as cost savings were shifted onto inpatient rehabilitation. Systematic review and meta-analysis of clinical pathways combining several factors thought to individually reduce LOS, in the form of enhanced recovery after surgery pathways, were significantly associated with reduced LOS without a commensurate change in complications, readmission, or mortality after arthroplasty. Very low certainty evidence in this systematic review was reinforced when assessing the broader landscape of randomised trials investigating enhanced recovery after surgery – finding poor registration practices, and evidence of publication bias and selective outcome reporting. Conclusion: This thesis demonstrated LOS is determined by a complex interplay of patient, clinician, hospital, and government factors. In the current model of care for arthroplasty, early discharge was cost neutral. For a true cost saving to be realised with earlier discharge, significant changes are required in patient expectations, practice of arthroplasty, and organisation of services for arthroplasty.