BACKGROUND: With the rapidly increasing volume of total joint arthroplasty (TJA) procedures, the incidence of periprosthetic joint infection (PJI) and its associated economic burden are expected to rise. Two-stage reimplantation, a common strategy for PJI management, is costly, as it requires multiple surgeries and hospitalizations, with total costs ranging from $35,000 to $42,000. Given the long hospital stays required for these patients, a quality improvement project was undertaken at the authors' institution to reduce admission costs (COA) and length of stay (LOS).
METHODS: We conducted a retrospective review of patients treated for PJI of the shoulder at a single hospital within a large health system. Patients were included if they had a biopsy-proven shoulder PJI treated with one of two protocols: a conventional, inpatient focused approach, or a new, outpatient focused approach. Conventional management involved prosthesis explantation with intraoperative cultures, antibiotic spacer placement, inpatient infectious disease (ID) consultation, and inpatient peripherally inserted central catheter (PICC) placement. The new protocol consisted of outpatient ID clinic referral and PICC placement prior to explantation and spacer placement. COA and LOS were compared between the two groups.
RESULTS: 16 patients were included, 8 in each group. Patients managed with the outpatient focused protocol had a significantly reduced COA ($17,711 +/- 4078) compared to the conventional protocol ($24,233 +/- 4,967) with a mean difference of $6521, representing a 26.9% cost reduction per patient (p = 0.006). LOS was significantly reduced in the outpatient focused group (Median: 1.35 days, IQR: 1.21-1.89) compared to the conventional protocol group (Median: 2.52 days, IQR: 1.81-3.21) (U = 10.50, Z = -2.26, p = 0.024).
CONCLUSIONS: The pilot quality improvement initiative resulted in a 27% reduction in COA and a significantly reduced LOS for patients with shoulder PJI. This has broad implications across orthopedics for the management of periprosthetic joint replacement and potential for tremendous impact of reducing health care costs.
