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Updated: Jan 31, 2026
Reverse Total Shoulder Arthroplasty
Published on: July 5, 2011
Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased
Sean P Ryan1, Claire B Howell1, Samuel S Wellman1
1Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC.
Insights
An 11-metric checklist for total knee arthroplasty (TKA) patients in the Comprehensive Care for Joint Replacement (CJR) model did not improve postoperative outcomes or reduce readmissions. Further investigation into detailed optimization protocols is needed.
Area of Science:
- Orthopedics
- Health Economics
- Quality Improvement
Background:
- The Comprehensive Care for Joint Replacement (CJR) model incentivizes cost reduction and improved outcomes for joint replacement surgeries.
- Preoperative optimization programs have evolved to meet CJR goals, with some centers implementing an 11-metric checklist to mitigate risks.
- One center, not part of the CJR bundle, had fewer resources dedicated to these optimization efforts.
Purpose of the Study:
- To evaluate the effectiveness of an 11-metric preoperative optimization checklist in improving postoperative outcomes for total knee arthroplasty (TKA) patients within the CJR model.
- To compare outcomes between hospitals participating in the CJR model and those not participating, focusing on metrics impacting costs.
Main Methods:
- Retrospective review of TKA patients from 2014 to 2018, including only those eligible for CJR participation.
- Analysis of outcome variables: length of stay, patient disposition, 90-day emergency department visits, and hospital readmissions.
- Comparison of outcomes between CJR-participating and non-participating hospitals within the same healthcare system.
Main Results:
- 2308 TKA patients were analyzed (1564 CJR, 744 non-CJR).
- No significant differences in age or gender; non-CJR patients had higher BMI and ASA scores.
- CJR sites showed fewer skilled nursing facility discharges and shorter length of stay, but no reduction in ED visits or readmissions.
Conclusions:
- The implemented 11-metric checklist did not significantly alter postoperative outcomes or reduce readmissions for TKA patients.
- A checklist alone appears insufficient for effective risk mitigation in the CJR model.
- Detailed optimization protocols addressing modifiable risk factors require further investigation and implementation.
Background:
The Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks. We hypothesized that this checklist would improve postoperative metrics that impact costs for total knee arthroplasty (TKA) patients eligible for participation in CJR.
Methods:
Patients undergoing TKA from 2014 to 2018 were retrospectively reviewed. Only patients with eligible participation in CJR were included. Outcome variables including length of stay, disposition, 90-day emergency department visits, and hospital readmissions were explored. Analysis was performed to determine differences in outcomes between CJR participating and non-CJR participating hospitals within the healthcare system.
Results:
In total, 2308 TKA patients including 1564 from a CJR participating center and 744 from a non-CJR center were analyzed. There was no significant difference in patient age or gender. Patients at the non-CJR hospital had significantly higher body mass index (P < .001) and American Society of Anesthesiologists scores (P < .001), while those in the CJR network had fewer skilled nursing facility discharges (P = .028) and shorter length of stay (P < .001). However, there was no reduction in 90-day emergency department visits or readmissions.
Conclusion:
The resources utilized at CJR participating hospitals, including patient optimization checklists, did not effectively alter patient outcomes following discharge. Likely, a checklist alone is insufficient for risk mitigation and detailed optimization protocols for modifiable risk factors must be investigated.
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