Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS. RESULTS: Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001). CONCLUSION: Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.

The Impact of Solid Organ Transplant History on Inpatient Complications, Mortality, Length of Stay, and Cost for Primary Total Hip Arthroplasty Admissions in the United States.

BACKGROUND: As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history. METHODS: A retrospective cross-sectional analysis was conducted using 1998-2011 Nationwide Inpatient Sample. Primary THA patients were queried (n = 3,175,456). After exclusions, remaining patients were assigned to transplant (n = 7558) or non-transplant groups (n = 2,772,943). After propensity score matching, adjusted for patient and hospital characteristics, logistic regression and paired t-tests examined the effect of transplant history on outcomes. RESULTS: Between 1998 and 2011, THA volume among transplant patients grew approximately 48%. The overall prevalence of one or more complications following THA was greater in the transplant group than in the non-transplant group (32.0% vs 22.1%; P < .001). In-hospital mortality was minimal, with comparable rates (0.1%) in both groups (P = .93). Unadjusted trends show that transplant patients have greater annual and overall mean LOS (4.47 days) and mean admission costs ($18,402) than non-transplant patients (3.73 days; $16,899; P < .001). After propensity score matching, transplant history was associated with increased complication risk (odds ratio, 1.56) after THA, longer hospital LOS (+0.64 days; P < .001), and increased admission costs (+$887; P = .005). CONCLUSION: Transplant patients exhibited increased odds of inpatient complications, longer LOS, and greater admission costs after THA compared with non-transplant patients.

Impact of Cirrhosis on Resource Use and Inpatient Complications in Patients Undergoing Total Knee and Hip Arthroplasty.

BACKGROUND: Cirrhosis is a major cause of morbidity and mortality and is an important risk factor for complications in surgical patients. The purpose of this study was to investigate the association of cirrhosis with postoperative complications, length of stay (LOS), and costs among patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA). METHODS: Using the Nationwide Inpatient Sample between 2000 and 2011, we identified patients who had a primary TKA or primary THA. TKA patients were divided into 2 groups: (1) cirrhosis (n = 41,464) and (2) no cirrhosis (n = 5,721,297) and THA patients were divided into 2 groups: (1) cirrhosis (n = 27,401) and (2) no cirrhosis (n = 2,622,539). Patient demographics, comorbidities, perioperative complications, LOS, and incremental costs were analyzed. An additional subgroup analysis by cirrhosis etiology was performed. RESULTS: Multivariable analysis revealed cirrhosis was associated with 1.55 (95% confidence interval: 1.47-1.63) times higher odds of any complication after TKA and 1.59 (1.50-1.69) higher odds after THA. Adjusted outcomes showed cirrhotic TKA patients had $1857 higher costs and 0.30 days longer LOS and THA cirrhotic patients had $1497 higher costs and 0.48 longer LOS. We found similar results for each cirrhosis subtype but alcohol-related had the highest resource use and complication rate. CONCLUSION: Patients with cirrhosis who are undergoing TKA or THA are at a significantly increased risk for perioperative complications, increased LOS, and higher costs. The perioperative complications and costs were highest among patients with alcohol-related cirrhosis.

Prevalence and Perioperative Outcomes of Off-Label Total Hip and Knee Arthroplasty in the United States, 2000-2010.

"Off-label use" refers to medical device utilization for purposes or subpopulations other than those approved by the United States Food and Drug Administration. The primary goal of this study was to determine the current epidemiology of off-label total hip and knee arthroplasties (THA and TKA, respectively) in the United States and to project further off-label use through 2040. Over the past decade, the prevalence of off-label THA and TKA was 30.4% and 37.0%, respectively, growing ~70% from 2000 to 2010. By 2040, the majority of THAs (86.1%) and TKAs (91.5%) could be off-label. The high prevalence of off-label arthroplasty and the dramatically shifting patient profile illustrated by these results highlight the need for continued medical device surveillance among on- and off label patients.

Early Postoperative Outcomes of Primary Total Knee Arthroplasty After Solid Organ Transplantation in the United States, 1998-2011.

This review of the Nationwide Inpatient Sample (1998-2011) examined trends in solid organ transplant patients who received a total knee arthroplasty (TKA) to determine whether length of stay (LOS), cost, and perioperative complications differed from non-transplant peers. Primary TKA patients (n=5,870,421) were categorized as: (1) those with a history of solid organ transplant (n=6104) and (2) those without (n=5,864,317). Propensity matching was used to estimate adjusted effects of solid organ transplant history on perioperative outcomes. The percentage of TKA patients with a transplant history grew during the study period from 0.069% to 0.103%. Adjusted outcomes showed patients with a transplant had a 0.44 day longer LOS, $962 higher cost of admission, and were 1.43 times more likely to suffer any complication (P=0.0002).

Primary total knee arthroplasty allogenic transfusion trends, length of stay, and complications: nationwide inpatient sample 2000-2009.

Perioperative blood loss leading to blood transfusion continues to be an issue for total knee arthroplasty (TKA) patients. The US Nationwide Inpatient Sample (NIS) was used to determine annual trends in allogenic blood transfusion rates, and effects of transfusion on in-hospital mortality, length of stay (LOS), costs, discharge disposition, and complications of primary TKA patients. TKA patients between 2000 and 2009 were included (n = 4,544,999) and categorized as: (1) those who received a transfusion of allogenic blood, and (2) those who did not. Transfusion rates increased from 7.7% to 12.2%. For both transfused and not transfused groups, mortality rates and mean LOS declined, while total costs increased. Transfused patients were associated with adjusted odds ratios of in-hospital mortality (AOR 1.16; P = 0.184), 0.71 ± 0.01 days longer LOS (P < 0.0001), and incurred ($1777 ± 36; P < 0.0001) higher total costs per admission.

Effect of price capitation on implant selection for primary total hip and knee arthroplasty.

While price capitation strategies may help to control total hip (THA) and knee arthroplasty (TKA) implant costs, its effect on premium implant selection is unclear. Primary THA and TKA cases 6 months before and after capitated pricing implementation were retrospectively identified. After exclusions, 716 THA and 981 TKA from a large academic hospital and 2 midsize private practice community hospitals were reviewed. Academic hospital surgeons increased premium THA implant usage (66.5% to 70.6%; P = 0.28), while community surgeons selected fewer premium implants (36.4%) compared to academic surgeons, with no practice change (P = 0.95). Conversely, premium TKA implant usage significantly increased (73.4% to 89.4%; P < 0.001) for academic surgeons. Community surgeons used premium TKA implants at greater rates in both periods, with all cases having ≥1 premium criterion.