Late-Week Surgeries Impact Practice Costs

By Carlos Higuera-Rueda, MD, Robert Molloy, MD, and Trevor Murray, MD

A look at how scheduling orthopaedic surgery impacts care costs reveals late-week surgeries are more costly.

In an effort to drive down costs, researchers often examine length of stay (LOS) as a variable open to adjustment. We looked at the specific day of the week as it affects cost and LOS for patients undergoing total joint arthroplasty.

Eye opening data

Bundled payments are here to stay and will set the tone for hip and knee arthroplasty. One of the variables included in these bundles is LOS. In our practice, we found that LOS is the most important driver for cost.

We reviewed data from 11 Cleveland Clinic system hospital sites for all primary total knee and total hip admissions performed between Jan. 1, 2010, and Dec.31, 2012 (a total of 14,800 surgeries). What we found was truly eye opening.

Surgeries done late in the week – Thursday and Friday versus Monday and Tuesday – lead to increased LOS and increased charges. Specifically, the mean LOS for late versus early week arthroplasty admissions was 4.01 vs. 3.61 days for knees and 3.7 vs. 3.4 for hips. The total charges for late versus early week arthroplasty admissions were $44,319 vs. $43,522. In addition, after a univariate statistical analysis, we found that older patients as well as those with severe illnesses were more likely to have a longer LOS.

While there is a Medicare study that recently reported similar results, we believe that our study provides more accuracy because large datasets often present inaccuracies (up to 30 percent). Our data is more refined because it is from a single healthcare system, making it more detailed and reliable.

A change in practice

Given these findings, we are beginning to explore something new in our practice. We are hoping that primary case patients within the bundled payment system will opt for surgery on a Monday or Tuesday. While this will require a change in infrastructure, it will ultimately save money and will most likely increase patient satisfaction.

Be aware that you need to have a system in place to deal with this discrepancy between early and late week surgery. Even with the best preoperative planning and infrastructure support from a case management standpoint, delays in patient discharge can occur as insurance companies don’t work over the weekend. This can result in delays in paperwork and authorizations, adding an extra day to LOS.

Keeping a patient for an extra day does not necessarily translate into better care – we may just be wasting resources. Our advice is to change the scheduling and load all of these cases at the beginning of the week. Revision and other cases that do not involve bundled payments can be moved to the end of the week.

Dr. Higuera-Rueda specializes in hip and knee replacement, clinical outcomes research and predictive modeling. Dr. Molloy, Director of the Center for Adult Reconstruction, specializes in hip and knee replacement. Dr. Murray specializes in hip and knee replacement.