J Knee Surg
DOI: 10.1055/a-2062-0468
Original Article

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011–2020)

Xuankang Pan
1   School of Medicine, Case Western Reserve University, Cleveland, Ohio
James Xu
1   School of Medicine, Case Western Reserve University, Cleveland, Ohio
Pedro J. Rullán
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Ignacio Pasqualini
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Viktor E. Krebs
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Robert M. Molloy
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
2   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
3   Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
› Author Affiliations


Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.


Dr. Piuzzi disclosed serving as a board or committee member for the American Association of Hip and Knee Surgeons, International Society for Cell and Gene Therapy, and Orthopaedic Research Society, serving on the editorial boards for the Journal of Hip Surgery and Journal of Knee Surgery, serving as a paid consultant for Regeneron and Stryker, and receiving research support from Osteal Therapeutics, Signature Orthopaedics, RegenLab, and Zimmer.

Dr. Molloy reports personal fees and grants from Striker, grants from Zimmer, other from American Academy of Hip and Knee Surgeons, outside the submitted work.

Dr. Krebs reports personal fees royalties, and grants from Striker, serving on the editorial boards for the Journal of Arthroplasty,

All other authors have no disclosures.

Publication History

Received: 28 November 2022

Accepted: 13 March 2023

Accepted Manuscript online:
24 March 2023

Article published online:
24 April 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100 (17) 1455-1460
  • 2 Siddiqi A, Warren JA, McLaughlin J. et al. Demographic, comorbidity, and episode-of-care differences in primary total knee arthroplasty. J Bone Joint Surg Am 2021; 103 (03) 227-234
  • 3 Memtsoudis SG, Sun X, Chiu YL. et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118 (05) 1046-1058
  • 4 Khan SK, Malviya A, Muller SD. et al. Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop 2014; 85 (01) 26-31
  • 5 Ripollés-Melchor J, Abad-Motos A, Díez-Remesal Y. et al; Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty (POWER2) Study Investigators Group for the Spanish Perioperative Audit and Research Network (REDGERM). Association between use of enhanced recovery after surgery protocol and postoperative complications in total hip and knee arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2). JAMA Surg 2020; 155 (04) e196024-e196024
  • 6 Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med 2009; 361 (06) 594-604
  • 7 Hunt LP, Whitehouse MR, Howard PW, Ben-Shlomo Y, Blom AW. Using long term mortality to determine which perioperative risk factors of mortality following hip and knee replacement may be causal. Sci Rep 2018; 8 (01) 15026
  • 8 Singh JA, Lewallen DG. Diabetes: a risk factor for poor functional outcome after total knee arthroplasty. PLoS One 2013; 8 (11) e78991
  • 9 Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol 2011; 38 (09) 1824-1834
  • 10 Siddiqi A, Warren JA, Manrique-Succar J, Molloy RM, Barsoum WK, Piuzzi NS. Temporal trends in revision total hip and knee arthroplasty from 2008 to 2018: gaps and opportunities. J Bone Joint Surg Am 2021; 103 (14) 1335-1354
  • 11 Barnett ML, Wilcock A, McWilliams JM. et al. Two-year evaluation of mandatory bundled payments for joint replacement. N Engl J Med 2019; 380 (03) 252-262
  • 12 CMS.gov. Comprehensive Care for Joint Replacement Model. Accessed June 13, 2022 at: https://innovation.cms.gov/innovation-models/cjr
  • 13 Bolz NJ, Iorio R. Bundled payments: our experience at an academic medical center. J Arthroplasty 2016; 31 (05) 932-935
  • 14 CMS.gov. Bundled Payments for Care Improvement (BPCI) initiative: general information. Accessed June 13, 2022 at: https://innovation.cms.gov/innovation-models/bundled-payments
  • 15 Bozic K, Yu H, Zywiel MG. et al. Quality measure public reporting is associated with improved outcomes following hip and knee replacement. J Bone Joint Surg Am 2020; 102 (20) 1799-1806
  • 16 Zeng F, Waldo D. Total knee arthroplasty post acute care costs by discharge status. Value Health 2016; 19 (03) A13-A14
  • 17 Keswani A, Tasi MC, Fields A, Lovy AJ, Moucha CS, Bozic KJ. Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplasty 2016; 31 (06) 1155-1162
  • 18 Adhia AH, Feinglass JM, Suleiman LI. What are the risk factors for 48 or more-hour stay and nonhome discharge after total knee arthroplasty? Results from 151 Illinois hospitals, 2016-2018. J Arthroplasty 2020; 35 (06) 1466-1473.e1
  • 19 Gwam CU, Mohamed NS, Etcheson JI. et al. Changes in total knee arthroplasty utilization since the implementation of ACA: an analysis of patient-hospital demographics, costs, and charges. J Knee Surg 2020; 33 (07) 636-645
  • 20 American College of Surgeons. ACS National Surgical Quality Improvement Program [available at: https://www.facs.org/quality-programs/data-and-registries/acs-nsqip/participant-use-data-file/]
  • 21 Menendez ME, Neuhaus V, van Dijk CN, Ring D. The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res 2014; 472 (09) 2878-2886
  • 22 Reddy NC, Prentice HA, Paxton EW, Hinman AD, Lin AG, Navarro RA. Association between same-day discharge total joint arthroplasty and risk of 90-day adverse events in patients with ASA classification of ≥3. J Bone Joint Surg Am 2021; 103 (21) 2032-2044
  • 23 Mallinson TR, Bateman J, Tseng HY. et al. A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Arch Phys Med Rehabil 2011; 92 (05) 712-720
  • 24 Sharma BS, Swisher MW, Doan CN, Khatibi B, Gabriel RA. Predicting patients requiring discharge to post-acute care facilities following primary total hip replacement: Does anesthesia type play a role?. J Clin Anesth 2018; 51: 32-36
  • 25 Legner VJ, Massarweh NN, Symons RG, McCormick WC, Flum DR. The significance of discharge to skilled care after abdominopelvic surgery in older adults. Ann Surg 2009; 249 (02) 250-255
  • 26 Edgerton JR, Herbert MA, Mahoney C. et al. Long-term fate of patients discharged to extended care facilities after cardiovascular surgery. Ann Thorac Surg 2013; 96 (03) 871-877
  • 27 Winzelberg GS. The quest for nursing home quality: learning history's lessons. Arch Intern Med 2003; 163 (21) 2552-2556
  • 28 Tanuseputro P, Chalifoux M, Bennett C. et al. Hospitalization and mortality rates in long-term care facilities: does for-profit status matter?. J Am Med Dir Assoc 2015; 16 (10) 874-883
  • 29 Bovonratwet P, Tyagi V, Ottesen TD, Ondeck NT, Rubin LE, Grauer JN. Revision total knee arthroplasty in octogenarians: an analysis of 957 cases. J Arthroplasty 2018; 33 (01) 178-184
  • 30 Smith EL, Shahien AA, Chung M, Stoker G, Niu R, Schwarzkopf R. The obesity paradox: body mass index complication rates vary by gender and age among primary total hip arthroplasty patients. J Arthroplasty 2020; 35 (09) 2658-2665
  • 31 Katakam A, Melnic CM, Bragdon CR, Sauder N, Collins AK, Bedair HS. Low body mass index is a predictor for mortality and increased length of stay following total joint arthroplasty. J Arthroplasty 2021; 36 (01) 72-77
  • 32 Tohidi M, Brogly SB, Lajkosz K, Grant HJ, VanDenKerkhof EG, Campbell AR. Ten-year mortality and revision after total knee arthroplasty in morbidly obese patients. J Arthroplasty 2018; 33 (08) 2518-2523
  • 33 Clement ND, Jenkins PJ, Brenkel IJ, Walmsley P. Predictors of mortality after total knee replacement: a ten-year survivorship analysis. J Bone Joint Surg Br 2012; 94 (02) 200-204
  • 34 Azin A, Hirpara DH, Doshi S, Chesney TR, Quereshy FA, Chadi SA. Racial disparities in surgery. Ann Surg Open 2020; 1 (02) e023
  • 35 Schoenfeld AJ, Tipirneni R, Nelson JH, Carpenter JE, Iwashyna TJ. The influence of race and ethnicity on complications and mortality after orthopedic surgery: a systematic review of the literature. Med Care 2014; 52 (09) 842-851
  • 36 Galatz LM, Silva MJ, Rothermich SY, Zaegel MA, Havlioglu N, Thomopoulos S. Nicotine delays tendon-to-bone healing in a rat shoulder model. J Bone Joint Surg Am 2006; 88 (09) 2027-2034
  • 37 Jorgensen LN, Kallehave F, Christensen E, Siana JE, Gottrup F. Less collagen production in smokers. Surgery 1998; 123 (04) 450-455
  • 38 Grits D, Emara AK, Klika AK, Murray TG, McLaughlin JP, Piuzzi NS. Neighborhood socioeconomic disadvantage associated with increased healthcare utilization after total hip arthroplasty. J Arthroplasty 2022; 37 (10) 1980-1986.e2
  • 39 Khlopas A, Grits D, Sax OC. et al. Neighborhood socioeconomic disadvantages associated with prolonged lengths of stay, nonhome discharges, and 90-day readmissions after total knee arthroplasty. J Arthroplasty 2022; 37 (6S): S37, 43.e1
  • 40 Santiago-Torres J, Flanigan DC, Butler RB, Bishop JY. The effect of smoking on rotator cuff and glenoid labrum surgery: a systematic review. Am J Sports Med 2015; 43 (03) 745-751
  • 41 Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth 2020; 125 (04) 492-504
  • 42 Greimel F, Maderbacher G, Zeman F, Grifka J, Meissner W, Benditz A. No clinical difference comparing general, regional, and combination anesthesia in hip arthroplasty: a multicenter cohort-study regarding perioperative pain management and patient satisfaction. J Arthroplasty 2017; 32 (11) 3429-3433
  • 43 Warren J, Sundaram K, Anis H. et al. Spinal anesthesia is associated with decreased complications after total knee and hip arthroplasty. J Am Acad Orthop Surg 2020; 28 (05) e213-e221
  • 44 Donauer K, Bomberg H, Wagenpfeil S, Volk T, Meissner W, Wolf A. Regional vs. general anesthesia for total knee and hip replacement: an analysis of postoperative pain perception from the international PAIN OUT registry. Pain Pract 2018; 18 (08) 1036-1047
  • 45 Hoffmann JD, Kusnezov NA, Dunn JC, Zarkadis NJ, Goodman GP, Berger RA. The shift to same-day outpatient joint arthroplasty: a systematic review. J Arthroplasty 2018; 33 (04) 1265-1274
  • 46 Kolisek FR, McGrath MS, Jessup NM, Monesmith EA, Mont MA. Comparison of outpatient versus inpatient total knee arthroplasty. Clin Orthop Relat Res 2009; 467 (06) 1438-1442