Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes, Complications, and Healthcare Utilizations (2010 to 2020)

Pedro J Rullán; James R Xu; Ahmed K Emara; Robert M Molloy; Viktor E Krebs; Michael A Mont; Nicolas S Piuzzi

doi:10.1016/j.arth.2023.01.019

Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes, Complications, and Healthcare Utilizations (2010 to 2020)

J Arthroplasty. 2023 Jul;38(7):1209-1216.e5. doi: 10.1016/j.arth.2023.01.019. Epub 2023 Jan 21.

Authors

Pedro J Rullán¹, James R Xu², Ahmed K Emara¹, Robert M Molloy¹, Viktor E Krebs¹, Michael A Mont³, Nicolas S Piuzzi⁴

Affiliations

¹ Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
² School of Medicine, Case Western Reserve University, Cleveland, Ohio.
³ Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
⁴ Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio.

PMID: 36693513
DOI: 10.1016/j.arth.2023.01.019

Abstract

Background: The removal of total knee arthroplasty (TKA) from inpatient-only lists accelerated changes in orthopaedic surgical practices across the United States. This study aimed to (1) quantify the annual volume of inpatient/outpatient primary TKAs; (2) compare patient characteristics before/after the year 2018; and (3) compare annual trends in 30-day readmissions, 30-day complications, and healthcare utilization parameters for inpatient/outpatient TKAs.

Methods: The National Surgical Quality Improvement Program was reviewed (January 2010 to December 2020) for patients who underwent primary TKA (n = 470,456). The primary outcome was annual volumes of inpatient/outpatient TKA. Secondary outcomes included 30-day readmissions, 30-day reoperations, and 30-day major/minor complications. Demographic characteristics and healthcare utilization parameters (hospital lengths of stay and discharge dispositions) were compared between cohorts via Chi-square goodness-of-fit tests.

Results: Overall, 89% had inpatient TKA (n = 416,972) and 11% had outpatient TKA (n = 53,854). Between 2017 and 2020, annual volumes of outpatient TKA increased by 1,925 (1,019 to 20,633), while inpatient TKA decreased by 53% (61,874 to 29,280). Patients who had outpatient TKA after 2018 were older (P < .001), predominantly males (P < .001), more commonly White (P < .001), and had a greater proportion of American Society of Anesthesiologists class III (P < .001). The inpatient cohort had higher rates of 30-day readmissions, reoperations, and complications. Average length of stay and nonhome discharges decreased for both cohorts.

Conclusion: Outpatient TKA increased 20-fold at NSQIP hospitals. The changes in comorbidity profiles and the increase in volumes of outpatient TKA were not associated with a rise in cumulative 30-day readmissions and complications. Further research and policy endeavors should focus on identifying patients who still require or benefit from inpatient TKA.

Keywords: complications; inpatient; outpatient; total knee arthroplasty; volume.

MeSH terms

Arthroplasty, Replacement, Knee* / adverse effects
Comorbidity
Female
Humans
Length of Stay
Male
Outpatients*
Patient Acceptance of Health Care
Patient Readmission
Postoperative Complications / epidemiology
Postoperative Complications / etiology
Retrospective Studies
United States / epidemiology