Impact of an Orthopaedic-Driven Perioperative Protocol to Optimize Social and Medical Risk (SAFE) following Elective Total Joint Arthroplasty in a Health Safety-Net Hospital

Background: Preoperative optimization of medical risk factors before total joint arthroplasty of the hip and knee improves outcomes. Arthroplasty programs in health safety-net hospitals have increased risk of complications because of increased medical complexity and disparities of social determinants of health. We propose a novel, orthopaedic team-driven perioperative optimization protocol to comprehensively and systematically address medical and social risk factors before total joint arthroplasty. We aim to evaluate the effect of optimizing medical and social risk factors on outcomes after hip and knee arthroplasty in a health safety-net hospital. Methods: A retrospective case-control series was done in a single, academic, tertiary-care, urban, safety-net hospital to compare complications (primary outcome) readmissions, length of stay (LOS), discharge disposition and escalation of care to intensive care unit (ICU), revision surgeries, and mortality (secondary outcomes) in patients who underwent hip or knee arthroplasty by a single surgeon before and after implementation of the optimization protocol. Follow-up duration was 12 months. Social determinants of health (SDOH) burden between groups were compared. Results: Of 808 primary total joint arthroplasty patients, 409 had surgery after the optimization protocol was implemented and 399 control subjects had surgery before implementation. Study patients had lower 90-day deep infection rate (0.24% vs 1%; P = 0.017) and 1-year deep infection rate (0.24 vs 2.01%; P = 0.017) compared with control subjects, respectively. Study patients versus control subjects: LOS (3.0 vs 3.5 days, P = 0.012), discharge to skilled nursing facility (SNF) (11.0 vs 17.0%, P = 0.015), escalation to ICU care (0.25 vs 2.5%, P = 0.006), and 1-year mortality (0.24 vs 2.5%, P = 0.074), respectively. SDOH burden was similar between control and study groups. Conclusion: Implementation of an orthopaedic-driven, standardized protocol designed to address modifiable medical and social risk factors before elective primary hip and knee arthroplasty was associated with reduced infection, LOS, discharge to SNF, and escalation of ICU care in a health safety-net hospital. Level of Evidence: Level III.