J Knee Surg 2022; 35(12): 1357-1363
DOI: 10.1055/s-0041-1723015
Original Article

Comparative Analysis of Outcomes in Medicare-Eligible Patients with a Hospital Stay Less than Two-Midnights versus Longer Length of Stay following Total Knee Arthroplasty: Implications for Inpatient-Outpatient Designation

1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
,
Katherine A. Lygrisse
1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
,
William Macaulay
1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
,
James D. Slover
1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
,
Ran Schwarzkopf
1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
,
William J. Long
1   Department of Orthopedic Surgery, NYU Langone Health, New York City, New York
› Institutsangaben
Funding R.S. reports grants from Smith & Nephew, grants from Intelijoint, and other from Gauss Surgical outside the submitted work.

Abstract

The Centers for Medicaid and Medicare Services (CMS) removed primary total knee arthroplasty (TKA) from the inpatient-only list in January 2018. This study aims to compare outcomes in Medicare-aged patients who underwent primary TKA and had an in-hospital stay spanning less than two-midnights to those with a length of stay greater than or equal to two-midnights. We retrospectively reviewed 4,138 patients ages ≥65 who underwent primary TKA from 2016 to 2020. Two cohorts were established based on length of stay (LOS), those with an LOS <2 midnights were labeled outpatient and those with an LOS ≥2 midnights were labeled inpatient as per CMS designation. Demographic, clinical data, knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR), and veterans RAND 12 physical and mental components (VR-12 PCS & MCS) were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Clinical data and KOOS, JR and VR-12 PCS and MCS scores were compared by using multilinear regression analysis, controlling for demographic differences. There were 841 (20%) patients with a LOS < 2 midnights and 3,297 (80%) patients with a LOS ≥ 2 midnights. Patients with a LOS < 2 midnights were significantly younger (71.70 vs. 73.06; p < 0.001), more likely male (42.1 vs. 25.7%; p < 0.001), Caucasian (68.8 vs. 57.7%; p <0.001), have lower BMI (30.80 vs. 31.92; p < 0.001), Charlson Comorbidity Index (CCI; 4.62 vs. 4.96; p < 0.001), and American Society of Anesthesiologists (ASA) class II or higher (p < 0.001). These patients were more likely to be discharged home compared to patients with LOS ≥ 2 midnights (95.8 vs. 73.1%; p < 0.001). Patients who stayed ≥ 2 midnights reported lower patient-reported outcome scores at all time-periods (preoperatively, 3 months and 1 year), but these differences did not exceed the minimum clinically important difference. Mean improvement preoperatively to 1 year postoperatively in KOOS, JR (22.53 vs. 25.89; p < 0.001), and VR-12 PCS (12.16 vs. 11.49; p = 0.002) was statistically higher for patients who stayed < 2 midnights, though these differences were not clinically significant. All-cause ED visits (p = 0.167), 90-day all-cause readmissions (p = 0.069) and revision (p = 0.277) did not statistically differ between the two cohorts. TKA patients classified as outpatient had similar quality metrics and saw similar clinical improvement following TKA with respect to most patient reported outcome measures, although they were demographically different. Outpatient classification is more likely to be assigned to younger males with higher functional scores, lower BMI, CCI, and ASA class compared with inpatients. This Retrospective Cohort Study shows level III evidence.



Publikationsverlauf

Eingereicht: 31. August 2020

Angenommen: 17. Dezember 2020

Artikel online veröffentlicht:
05. Februar 2021

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  • References

  • 1 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89 (04) 780-785
  • 2 Lovald ST, Ong KL, Malkani AL. et al. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthroplasty 2014; 29 (03) 510-515
  • 3 Cassard X, Garnault V, Corin B, Claverie D, Murgier J. Outpatient total knee arthroplasty: readmission and complication rates on day 30 in 61 patients. Orthop Traumatol Surg Res 2018; 104 (07) 967-970
  • 4 Schwartz AM, Farley KX, Guild GN, Bradbury Jr TL. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 2020; 35 (6S): S79-S85
  • 5 Berger RA, Cross MB, Sanders S. Outpatient hip and knee replacement: the experience from the first 15 years. Instr Course Lect 2016; 65: 547-551
  • 6 Aggarwal V, Thakkar S, Collins K, Vigdorchik J. Same day discharge after total joint arthroplasty: the future may be now. Bull Hosp Jt Dis (2013) 2017; 75 (04) 252-256
  • 7 Hirschmann MT, Kort N, Kopf S, Becker R. Fast track and outpatient surgery in total knee arthroplasty: beneficial for patients, doctors and hospitals. Knee Surg Sports Traumatol Arthrosc 2017; 25 (09) 2657-2658
  • 8 Center for Medicare and Medicaid Innovation. Internal Medicine News. DOI: 10.1016/s1097-8690(10)70866-0
  • 9 NCHS Health Insurance Data. Centers for Disease Control and Prevention. NCHS Fact Sheet. Accessed July 2018 at: https://www.cdc.gov/nchs/data/factsheets/factsheet_NCHS_health_insurance_data.htm
  • 10 MLN Matters Number: SE19002. Total knee arthroplasty (TKA) removal from the Medicare inpatient-only (IPO) list and application of the 2-midnight rule. Article Release Date: January 8, 2019. Accessed January 1, 2018 at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19002.pdf
  • 11 Courtney PM, Boniello AJ, Berger RA. Complications following outpatient total joint arthroplasty: an analysis of a national database. J Arthroplasty 2017; 32 (05) 1426-1430
  • 12 Nanjayan SK, Swamy GN, Yellu S, Yallappa S, Abuzakuk T, Straw R. In-hospital complications following primary total hip and knee arthroplasty in octogenarian and nonagenarian patients. J Orthop Traumatol 2014; 15 (01) 29-33
  • 13 Lovecchio F, Alvi H, Sahota S, Beal M, Manning D. Is outpatient arthroplasty as safe as fast-track inpatient arthroplasty? A propensity score matched analysis. J Arthroplasty 2016; 31 (9, Suppl): 197-201
  • 14 Otero JE, Gholson JJ, Pugely AJ, Gao Y, Bedard NA, Callaghan JJ. Length of hospitalization after joint arthroplasty: does early discharge affect complications and readmission rates?. J Arthroplasty 2016; 31 (12) 2714-2725
  • 15 Lyman S, Lee YY, Franklin PD, Li W, Cross MB, Padgett DE. Validation of the KOOS, JR: a short-form knee arthroplasty outcomes survey. Clin Orthop Relat Res 2016; 474 (06) 1461-1471
  • 16 Lyman S, Lee YY, McLawhorn AS, Islam W, MacLean CH. What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement?. Clin Orthop Relat Res 2018; 476 (12) 2432-2441
  • 17 Selim A, Qian S, Lee A. et al. The veterans RAND 12 item health survey (VR-12): what it is and how it is used. Qual Life Res 2009; 18 (01) 43-52
  • 18 Selim AJ, Rogers W, Fleishman JA. et al. Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). Qual Life Res 2009; 18 (01) 43-52
  • 19 Kazis LE, Selim A, Rogers W, Ren XS, Lee A, Miller DR. Dissemination of methods and results from the veterans health study: final comments and implications for future monitoring strategies within and outside the veterans healthcare system. J Ambul Care Manage 2006; 29 (04) 310-319
  • 20 Kazis LE, Miller DR, Skinner KM. et al. Patient-reported measures of health: the Veterans Health Study. J Ambul Care Manage 2004; 27 (01) 70-83
  • 21 Huang A, Ryu JJ, Dervin G. Cost savings of outpatient versus standard inpatient total knee arthroplasty. Can J Surg 2017; 60 (01) 57-62
  • 22 Courtney PM, Rozell JC, Melnic CM, Lee GC. Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty. J Arthroplasty 2015; 30 (9, Suppl): 1-4
  • 23 Klingenstein GG, Schoifet SD, Jain RK, Reid JJ, Porat MD, Otegbeye MK. Rapid discharge to home after total knee arthroplasty is safe in eligible medicare patients. J Arthroplasty 2017; 32 (11) 3308-3313
  • 24 Siddiqi A, White PB, Mistry JB. et al. Effect of bundled payments and health care reform as alternative payment models in total joint arthroplasty: a clinical review. J Arthroplasty 2017; 32 (08) 2590-2597
  • 25 Slover JD, Mullaly KA, Payne A, Iorio R, Bosco J. What is the best strategy to minimize after-care costs for total joint arthroplasty in a bundled payment environment?. J Arthroplasty 2016; 31 (12) 2710-2713
  • 26 Ramkumar PN, Gwam C, Navarro SM. et al. Discharge to the skilled nursing facility: patient risk factors and perioperative outcomes after total knee arthroplasty. Ann Transl Med 2019; 7 (04) 65-65
  • 27 Rondon AJ, Tan TL, Greenky MR. et al. Who goes to inpatient rehabilitation or skilled nursing facilities unexpectedly following total knee arthroplasty?. J Arthroplasty 2018; 33 (05) 1348-1351.e1
  • 28 Courtney PM, Froimson MI, Meneghini RM, Lee GC, Della Valle CJ. Can total knee arthroplasty be performed safely as an outpatient in the medicare population?. J Arthroplasty 2018; 33 (7S): S28-S31
  • 29 Barnes CL, Iorio R, Zhang X, Haas DA. An examination of the adoption of outpatient total knee arthroplasty since 2018. J Arthroplasty 2020; 35 (6S): S24-S27
  • 30 Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score”. J Arthroplasty 2017; 32 (08) 2325-2331