Abstract
Background
Length of stay (LOS) following total knee arthroplasty (TKA) has decreased over recently years. In 2018, the Centers for Medicare and Medicaid Services removed TKA from Inpatient-Only List (IPO), incentivizing further expansion of outpatient TKA. However, many patients may still require postsurgical hospitalization. The purpose of this study was to assess early outcomes for TKA based on length of stay (LOS).
Methods
We identified patients undergoing elective, primary TKA in the National Surgical Quality Improvement Program database using CPT code 27447 between 2015 and 2018. Patients were stratified by length of stay (LOS) 0 days, 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmission, and reoperation were assessed. Multivariate analysis was performed to adjust for confounding variables.
Results
5,655 (3%) patients underwent outpatient TKA, 130,543 (59%) had LOS 1-2 days, and 84,986 (38%) had LOS ≥3 days. Any complication was experienced in 4.1% of those with LOS 0 days, 4.3% for those with LOS of 1-2 days, and 10.5% for patients with LOS ≥3 days (p<0.0001). Readmission occurred in 2.2%, 2.6%, and 4.0% for the 3 groups, respectively (p<0.0001). After multivariate analysis, there was no significant difference in any outcome measure between patients with LOS 0 and 1-2 days, however those with LOS ≥3 days had higher odds of complications, reoperation, and readmission.
Conclusion
A significant number of patients had LOS ≥3 days following TKA and had more comorbidities and complications. Outpatient TKA was not associated with increased early complication compared to those with LOS of 1-2 days. Despite expansion of outpatient surgery, postsurgical hospitalization remains an integral part of care following TKA.
Level of Evidence: III
Keywords: total knee arthroplasty, complications, length of stay, outpatient surgery
Introduction
There has been an increasing amount of total knee arthroplasty (TKA) procedures performed in the United States and further growth is anticipated, with some projections estimating 1.26 million TKAs occurring annually by 2030.1 Procedural growth has been paralleled by a transformation of the perioperative course from a prolonged hospitalization to shorter length of stay (LOS), with an increasing number of patients undergoing TKA as an outpatient procedure.2-4 Many factors, such as improvements in surgical technique, preoperative optimization of chronic medical conditions, patient education initiatives, increased adoption of multimodal analgesia, and hospital administrative pressures have contributed to this transition.5-9 Development of novel models of reimbursement and bundle payment, such as the Bundled Payments for Care Improvement initiative and Comprehensive Care for Joint Replacement model may have also contributed.10,11 Effective January 1st, 2018, the Centers for Medicare and Medicaid Services (CMS) removed TKA from the Inpatient-Only List (IPO), incentivizing further expansion of outpatient TKA.
Shorter hospitalizations and shifting more care to the home setting after TKA provide clear benefits, including reduction of costs associated with immediate post-surgical hospitalization.12 However, there is concern that shorter hospitalizations and associated reductions in monitoring during the early postoperative period may result in increased complications or readmissions, particularly in those patients at highest risk for postoperative complications.13,14 Additionally, reduction in postsurgical hospitalization may result in increased burden placed upon the patient, their caregivers, and also the surgeon.15,16 Studies assessing the impact of shorter LOS have reported mixed results on complications and, despite movement towards same-day discharge, outpatient TKA may not be feasible or appropriate for all patients with end-stage arthritis.13,17,18 Therefore, the purpose of this study was to assess differences in 30-day complication rates related to LOS following TKA. Additionally, we sought to compare the demographics and comorbidity profiles of those able to discharge on the same-day as TKA with those requiring longer LOS.
Methods
The American College of Surgeons National Quality Improvement Program (ACS NSQIP) database was queried to identify patients who underwent primary TKA between years 2015 and 2018 using Common Procedural Terminology (CPT) code 27447. The ACS NSQIP database includes data from over 600 voluntarily participating hospitals, the majority of which are located within the United States. Hospitals are both academic and private institutions and patients with public and private insurance are included. Data collection is performed by trained nurse abstractors, who document patient demographic information, medical comorbidities, perioperative data, and 30-day complication data. An internal auditing mechanism is in place and a cumulative disagreement rate of <2% has previously been reported.19 All data collected and maintained in the ACS NSQIP database are de-identified and compliant with the Health Insurance Portability and Accountability Act. The ACS NSQIP user guide contains complete details regarding data collection.20 This study was reviewed by our institutional review board and granted a human subjects research exemption.
Eligible patients underwent primary TKA as determined by CPT code. Patients undergoing emergent or non-elective surgery, bilateral TKA, revision TKA, recent chemoradiation treatment, or with active disseminated cancer were excluded. In order to establish a cohort most representative of elective, primary TKA, patients with the following characteristics were also excluded: patients residing in non-home locations prior to surgery, those with a non-clean wound class, and patients with documented preoperative sepsis. All CPT codes billed at time of primary TKA were individually reviewed and patients were excluded if unrelated procedures or those for non-primary indications, such as revision arthroplasty, tumor excision, or arthroscopy of other joints, were performed at time of index primary TKA. A list of concurrent included CPT codes is provided in Appendix 1.
Age, body mass index (BMI), race, sex, and other patient demographic data were collected. Medical comorbidities were also collected, and included diabetes, chronic obstructive pulmonary disease (COPD), dialysis, ascites, congestive heart failure (CHF), preoperative steroid use, and bleeding disorders. Patients were subsequently stratified based on documented length of stay (LOS) into three groups: LOS 0 days, LOS 1-2 days, and LOS ≥3 days. 30-day incidence of wound complications, deep infection, readmission, reoperation, and any complication were assessed. Wound complication was a composite variable, comprised of superficial incisional surgical site infection (SSI), deep incisional SSI, organ space SSI, and wound disruption/dehiscence. Deep infection was also a composite variable, including both deep incisional SSI and organ space SSI. Any complication was defined as the occurrence of any of the following complications: readmission, reoperation, pneumonia, unplanned reintubation, deep vein thrombosis, pulmonary embolism, renal insufficiency, acute renal failure, urinary tract infection, stroke, cardiac arrest, myocardial infarction, allogenic blood transfusion, sepsis, septic shock, clostridium difficile infection, superficial incisional SSI, deep incisional SSI, organ space SSI, and wound disruption/dehiscence. Mean LOS in days and operative time in minutes were also determined for each of the three groups.
Univariate statistical analysis was performed using chi-squared test for categorical variables and Kruskal-Wallis Test for continuous variables. Multivariate logistic regression was then performed to assess for differences in occurrence of complication outcome measures between the three groups adjusting for age, race, sex, BMI, functional status, ASA classification, smoking status, recent weight loss, recent steroid use, diabetes, COPD, CHF, ascites, dialysis, and bleeding disorders. Criteria for inclusion in the multivariate analysis was p<0.1, additionally recent weight loss and ascites were included as potential variables of interest. All statistical analyses were performed with use of SAS 9.4 (SAS Institute, Cary, NC), and the statistically significant level was set at p<0.05.
Results
In total, 221,184 eligible patients undergoing elective, primary TKA between 2015-2018 were identified in the ACS NSQIP database. Of these, 5,655 (2.6%) had LOS 0 days, 130,543 (59.0%) had LOS 1-2 days, and 84,986 (38.4%) had LOS ≥3 days. The mean age was 65.7 (±9.1) years for patients with LOS 0 days, 66.0 (±9.7) years for those with LOS 1-2 days, and 68.4 (±9.1) years for patients with LOS ≥3 days (p<0.0001). Higher mean BMI was associated with increased length of hospitalization. Mean BMI was 31.6 (±6.0) kg/m2 for LOS 0 days, 32.8 (±6.5) kg/m2 for LOS 1-2 days, and 33.5 (±7.2) kg/ m2 for LOS ≥3 days (p<0.0001). Incidence of diabetes was higher with greater LOS, increasing from 14.4% in patients with LOS of 0 days, 16.5% in those with LOS 1-2 days, and 21.2% in patients hospitalized for ≥3 days (p<0.0001). Mean operative time was 82.8 (±28.6) minutes with LOS of 0 days, 87.7 (±31.8) minutes with LOS of 1-2 days, and 91.9 (±37.5) minutes for LOS ≥3 days (p<0.0001). Complete demographic and comorbidity data are provided in Table 1.
Table 1.
Patient Demographics and Comorbidities
| LOS 0 days (n=5,655) | LOS 1-2 days (n=130,543) | LOS ≥3 days (n=84,986) | p-value | |
|---|---|---|---|---|
| Age - years (SD) | 65.7 (9.1) | 66.0 (9.0) | 68.4 (9.7) | <0.0001 |
| <55 | 10.3% | 10.3% | 8.1% | |
| 55-65 | 33.5% | 32.1% | 25.5% | |
| 65-75 | 40.1% | 40.1% | 38.6% | |
| >75 | 16.2% | 17.5% | 27.8% | |
| Female (%) | 53.4% | 58.1% | 67.2% | <0.0001 |
| BMI – kg/m2 (SD) | 31.6 (6.0) | 32.8 (6.5) | 33.5 (7.2) | <0.0001 |
| Race | <0.0001 | |||
| Asian | 4.2% | 2.0% | 2.0% | |
| Black | 6.3% | 7.3% | 8.7% | |
| Other | 7.8% | 12.5% | 24.3% | |
| White | 81.7% | 78.2% | 65.0% | |
| Diabetes (%) | 14.4% | 16.5% | 21.2% | <0.0001 |
| COPD (%) | 2.1% | 2.7% | 4.6% | <0.0001 |
| Smoking | 6.8% | 8.1% | 8.3% | 0.04 |
| Congestive Heart Failure | 0.1% | 0.2% | 0.5% | <0.0001 |
| Weight Loss | 0.2% | 0.1% | 0.1% | 0.009 |
| Dialysis | 0.1% | 0.1% | 0.2% | <0.0001 |
| Ascites | 0.0% | 0.0% | 0.0% | 0.14 |
| Steroid Use | 2.4% | 3.2% | 4.0% | <0.0001 |
| Bleeding Disorder | 1.4% | 1.5% | 2.5% | <0.0001 |
| ASA | <0.0001 | |||
| 1 | 2.0% | 1.9% | 1.6% | |
| 2 | 60.1% | 51.5% | 41.9% | |
| 3 | 37.3% | 45.4% | 54.1% | |
| ≥4 | 0.6% | 1.2% | 2.4% | |
| Functional Status | <0.0001 | |||
| Totally Independent | 99.7% | 99.3% | 98.5% | |
| Partially Dependent | 0.3% | 0.6% | 1.4% | |
| Totally Dependent | 0.0% | 0.1% | 0.1% | |
| Mean LOS – days (SD) | 0 (0) | 1.6 (0.5) | 3.8 (3.1) | <0.0001 |
| Operative Time – minutes (SD) | 82.8 (28.6) | 87.7 (31.8) | 91.9 (37.5) | <0.0001 |
Complete data regarding incidence of complications is provided in Table 2. Wound complications occurred in 0.8% of patients with both LOS of 0 and 1-2 days and 1.3% in patients with LOS ≥3 days (p<0.0001). The rate of deep infection was 0.3% in patients with both 0- and 1-2-day LOS and 0.4% when LOS was ≥3 days (p<0.0001). Readmission occurred for 2.2% of patients with LOS of 0 days, 2.6% of patients with LOS of 1-2 days, and 4.0% of patients whose LOS was ≥3 days (p<0.0001). Any complication was observed in 4.1% of patients with LOS of 0 days, 4.3% in those with LOS of 1-2 days, and 10.5% of those with LOS ≥3 days (p<0.0001).
Table 2.
Incidence of 30-day Postoperative Complications
| LOS 0 days | LOS 1-2 days | LOS ≥3 days | p-value | |
|---|---|---|---|---|
| Wound Complications | 0.8% | 0.8% | 1.3% | <0.0001 |
| Superficial Infection | 0.4% | 0.4% | 0.7% | <0.0001 |
| Wound Infection | 0.1% | 0.1% | 0.2% | <0.0001 |
| Organ Space Infection | 0.2% | 0.2% | 0.2% | 0.13 |
| Wound Dehiscence | 0.2% | 0.2% | 0.3% | <0.0001 |
| Deep Infection | 0.3% | 0.3% | 0.4% | <0.0001 |
| Readmission | 2.2% | 2.6% | 4.0% | <0.0001 |
| Reoperation | 0.9% | 0.8% | 1.5% | <0.0001 |
| Any Complication | 4.1% | 4.3% | 10.5% | <0.0001 |
| Pneumonia | 0.3% | 0.3% | 0.4% | <0.0001 |
| Reintubation | 0.1% | 0.1% | 0.2% | <0.0001 |
| Pulmonary Embolism | 0.4% | 0.2% | 0.9% | <0.0001 |
| Renal Insufficiency | 0.1% | 0.1% | 0.2% | <0.0001 |
| Urinary Tract Infection | 0.7% | 0.5% | 1.0% | <0.0001 |
| Stroke | 0.1% | 0.0% | 0.1% | <0.0001 |
| Cardiac Arrest | 0.0% | 0.1% | 0.1% | <0.0001 |
| Myocardial Infarction | 0.1% | 10.0% | 0.3% | <0.0001 |
| Transfusion | 0.3% | 0.4% | 3.0% | <0.0001 |
| Deep Vein Thrombosis | 0.5% | 0.5% | 1.1% | <0.0001 |
| Sepsis | 0.2% | 0.1% | 0.2% | <0.0001 |
| Septic Shock | 0.0% | 0.0% | 0.1% | <0.0001 |
| Clostridium difficile infection | 0.0% | 0.0% | 0.0% | <0.0001 |
| Failure to wean vent | 0.0% | 0.0% | 0.1% | <0.0001 |
Odds for complications based on LOS are presented in Table 3. There was no difference in odds of wound complications, deep infection, readmission, reoperation, or any complication between patients with LOS of 0 days and 1-2 days, before or after adjustment for potential confounders. Patients with LOS of ≥3 days had significantly higher odds for reoperation (OR: 1.78 [95% Confidence Interval (CI): 2.39-3.12]), readmission (OR: 1.84 [95% CI: 1.54-2.21]), wound complications (OR: 1.62 [95% CI: 1.21-2.21]), and any complication (OR: 2.73 [95% CI: 2.39-3.12]). After multivariate analysis, significant differences remained for reoperation (OR: 1.68 [1.26-2.24]), readmission (OR: 1.56 [1.30-1.87]), and any complication (OR: 2.37 [2.08-2.71]). When compared to patients with LOS of 1-2 days, patients with LOS of ≥3 days had significantly higher odds for wound complications, deep infection, reoperation, readmission, and any complication in both the univariate and multivariate analyses (Table 3).
Table 3.
Odds for Complications Based on Length of Stay
| LOS 1-2 vs LOS 0 (ref) | LOS ≥3 vs LOS 0 (ref) | LOS ≥3 vs LOS 1-2(ref) | |
|---|---|---|---|
| Unadjusted | |||
| Any Complication (OR) | 1.03 [0.90-1.18] | 2.73 [2.39-3.12] | 2.65 [2.56-2.74] |
| Wound Complications (OR) | 0.99 [0.73-1.33] | 1.62 [1.21-2.21] | 1.65 [1.52-1.80] |
| Deep Infection (OR) | 0.91 [0.55-1.50] | 1.32 [0.80-2.19] | 1.46 [1.25-1.70] |
| Reoperation (OR) | 0.96 [0.72-1.28] | 1.78 [1.33-2.36] | 1.85 [1.71-2.01] |
| Readmission (OR) | 1.16 [0.96-1.38] | 1.84 [1.54-2.21] | 1.59 [1.52-1.67] |
| Adjusted* | |||
| Any Complication (OR) | 0.99 [0.86-1.13] | 2.37 [2.08-2.71] | 2.41 [2.32-2.49] |
| Wound Complications (OR) | 0.88 [0.65-1.19] | 1.29 [0.95-1.75] | 1.46 [1.34-1.60] |
| Deep Infection (OR) | 0.83 [0.50-1.37] | 1.14 [0.69-1.89] | 1.37 [1.17-1.61] |
| Reoperation (OR) | 0.91 [0.69-1.22] | 1.65 [1.24-2.21] | 1.81 [1.66-1.97] |
| Readmission (OR) | 1.09 [0.91-1.31] | 1.56 [1.30-1.87] | 1.43 [1.4-1.50] |
Ref = reference. Values presented as OR [95% Confidence interval]
* Adjusting for age, race, sex, BMI, functional status, ASA classification, smoking status, recent weight loss, recent steroid use, diabetes, COPD, CHF, ascites, dialysis, and bleeding disorders.
Discussion
In this study, the majority of patients required some postsurgical hospitalization following TKA< with 59.0% having LOS of 1-2 days and 38.4% requiring LOS of 3 or more days. There were greater odds for reoperation, readmission, and any complication for patients hospitalized for ≥3 days, when compared to patients with LOS 0. Similarly, patients with LOS of ≥3 days were found to have greater odds for complications compared to those with LOS of 1-2 days. Conversely, patients undergoing primary, elective TKA with LOS of 0 days did not have increased odds for wound complications, deep infection, reoperation, readmission, or any complication when compared to patients with LOS of 1-2 days. Increased incidence of complications observed with longer LOS is likely related to significantly higher overall medical comorbidity in these patients, such as greater age, have higher BMI, more diabetes, and higher ASA scores. Despite extensive efforts of modern presurgical optimization, many of these risk factors may be non-modifiable and postsurgical hospitalization may be a part of their postsurgical care.
Similar to the current study, Otero et al. found LOS exceeding 3 days to be independently associated with increased risks for 30-day complications after TKA.18 Conversely, Lovecchio et al. found greater rates of 30-day complications when comparing patients with LOS of 1-2 days compared to those undergoing outpatient surgery.12 As duration of hospitalization increased, the mean BMI, mean age, proportion of patients with higher ASA classification, and prevalence of medical comorbidities, such as CHF, diabetes, COPD, and end-stage renal disease requiring dialysis, also increased. Greater levels of medical comorbidities result in certain patients requiring longer duration of hospitalization following TKA and have a resulting increased risk for early complications. COPD, CHF, coronary artery disease, and cirrhosis have been associated with occurrence of complications at greater than 24 hours following primary TJA.13
Courtney et al. reported no increased risk for readmission, reoperation, and any complication for patients able to undergo outpatient TKA or total hip arthroplasty.13 In a separate study, Courtney et al. found appropriately selected Medicare-aged TKA patients, defined in the study as age greater than or equal to 65 years, may undergo outpatient TKA, however those with a LOS of 1 day had fewer complications than patients undergoing outpatient surgery.17 The lack of difference in odds for complications, reoperation, or readmission observed in the present study may be related to the inclusion of more current data, a larger cohort of patients, and focus on solely TKA patients for analysis. The present study includes data from 2015-2018, which was the most current data available at the time, while prior studies include data from 2015 and earlier. As a result of more current data and recent expansion of outpatient TKA, the current study includes more than 5,500 patients, whereas other recent studies are limited to fewer than 1,300.13,14,17,18
Patients not discharged on postoperative day 0 and requiring longer hospitalization were older and were more often female. Female sex has previously been identified as an independent risk factor for requiring an inpatient stay after TKA.17 Weiner et al. also identified age greater than 75 years, female sex, and non-Hispanic black patients having increased risk for hospitalization greater than 2 days after total hip arthroplasty.21 Further investigation into the impact of sex on duration of hospitalization is needed. It is possible older females are more frail overall and have more difficulty safely mobilizing following TKA. We also found operative time to significantly increase with increasing hospital LOS, which may relate to patient factors or overall surgical complexity. Bradley et al. found each point increase in BMI to be associated with 2.9% longer LOS and 1.46 minutes greater operative time.22 While surgical factors and precise reasons for duration of hospitalization are not captured as part of the ACS NSQIP database, it is possible greater operative time reflects greater surgical complexity and resulting difficulties with mobilization or pain control.
Successful and safe outpatient TKA is dependent on preoperative medical optimization, careful patient selection, and appropriate aligned practice infrastructure.14,17 While formal scoring systems to guide selection of patients for outpatient TKA exist, such as the Outpatient Arthroplasty Risk Assessment, there is not a widely accepted standard for determining what patients may undergo outpatient TKA and surgeons may utilize clinical experience in combination with patient preference to determine appropriateness of same-day discharge.23 While differences in demographics and comorbidities did exist when comparing the three groups in this study, overall size of these differences between patients with LOS 0 and LOS 1-2 was small. It is possible some of the patients with short hospitalization following TKA could undergo outpatient TKA if procedures were in place to facilitate this or their postsurgical hospitalization was related to non-medical factors, such availability of transportation or caregivers. An important aspect of outpatient TKA is ensuring patients have access to adequate support at home, which is not quantified in the ACS NSQIP database.16 Traditional postsurgical care has been provided in the hospital setting. Outpatient surgery requires redeployment of resources to provide these services using a different method and may shift responsibility or burden for providing these to the surgeon.15 Procedures in-place to care for patients unable to discharge on postoperative day 0 are essential. Despite careful patient selection and established protocols, outpatient TJA may remain difficult to successfully execute, as a randomized study found 24% of patients unable to discharge same day as planned.24 Despite pressures from payers and governmental regulations, there remains a portion of patients who are not candidates for same-day discharge following TKA and further study is needed to develop criteria to guide decisions for hospitalization after TKA.
Further study is needed to develop standardized guidelines to determine
This study is not without limitations. This study was retrospective in nature and performed using prospectively collected data in the ACS NSQIP database. While this database does have quality control protocols in-place, the findings of this paper remain dependent on accurate coding and data collection. The ACS NSQIP database reports on 30-day complications and events outside of this window are not reported in this study, although adverse effects from reduced duration of hospitalization seem likely to occur during this early perioperative period. While the ACS NSQIP database does include participating hospitals across the United States, this is a small portion of patients undergoing TKA nationally and this subset may not be representative of all patients. Data available for analysis is limited to variables reported in the ACS NSQIP database, therefore not all patient or socioeconomic factors that may contribute to LOS or complications were considered. Additionally, specific reasons for the occurrence of complications and reasons for readmission or reoperation were not considered as part of this study.
When assessing surgeries occurring between 2015 and 2018, nearly 40% of patients undergoing primary, elective TKA required postsurgical hospitalizations of 3 or more days. These patients were older, had more medical comorbidities, and experienced more complications than patients with LOS of 0 or 1-2 days. Despite regulatory changes and pressures to expand outpatient TKA, successfully performing these procedures with same-day discharge requires careful patient selection, presurgical medical optimization, and care coordination. Despite these advances, a significant number of patients remain at higher risk for perioperative complications and postsurgical inpatient care may continue to be an integral part of their care following TKA.
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