Department of Orthopedic Surgery, NYU Langone Health, New York City, New York.
J Knee Surg. 2022 Oct;35(12):1357-1363. doi: 10.1055/s-0041-1723015. Epub 2021 Feb 5.
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 -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; < 0.001), more likely male (42.1 vs. 25.7%; < 0.001), Caucasian (68.8 vs. 57.7%; <0.001), have lower BMI (30.80 vs. 31.92; < 0.001), Charlson Comorbidity Index (CCI; 4.62 vs. 4.96; < 0.001), and American Society of Anesthesiologists (ASA) class II or higher ( < 0.001). These patients were more likely to be discharged home compared to patients with LOS ≥ 2 midnights (95.8 vs. 73.1%; < 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; < 0.001), and VR-12 PCS (12.16 vs. 11.49; = 0.002) was statistically higher for patients who stayed < 2 midnights, though these differences were not clinically significant. All-cause ED visits ( = 0.167), 90-day all-cause readmissions ( = 0.069) and revision ( = 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.
医疗补助和医疗保险服务中心（CMS）于 2018 年 1 月将初次全膝关节置换术（TKA）从仅限住院治疗的清单中移除。本研究旨在比较初次 TKA 且住院时间少于两个午夜与住院时间大于或等于两个午夜的 Medicare 年龄患者的治疗结果。我们回顾性分析了 2016 年至 2020 年间接受初次 TKA 的 4138 名年龄≥65 岁的患者。根据住院时间（LOS）建立了两个队列，住院时间<2 个午夜的患者标记为门诊，住院时间≥2 个午夜的患者标记为住院，符合 CMS 的指定。收集了人口统计学、临床数据、膝关节损伤和骨关节炎膝关节置换评分（KOOS，JR）以及退伍军人 RAND 12 身体和精神成分（VR-12 PCS 和 MCS）。使用卡方检验和独立样本 t 检验评估人口统计学差异。使用多线性回归分析比较临床数据和 KOOS，JR 和 VR-12 PCS 和 MCS 评分，同时控制人口统计学差异。有 841 名（20%）患者的 LOS<2 个午夜，3297 名（80%）患者的 LOS≥2 个午夜。LOS<2 个午夜的患者明显更年轻（71.70 岁比 73.06 岁；<0.001），更可能为男性（42.1%比 25.7%；<0.001），白种人（68.8%比 57.7%；<0.001），体重指数（BMI）更低（30.80 比 31.92；<0.001），Charlson 合并症指数（CCI；4.62 比 4.96；<0.001），以及美国麻醉医师协会（ASA）分级 II 或更高（<0.001）。与 LOS≥2 个午夜的患者相比，这些患者更有可能被直接出院回家（95.8%比 73.1%；<0.001）。住院时间≥2 个午夜的患者在所有时间段（术前、3 个月和 1 年）的患者报告结局评分都较低，但这些差异没有超过最小临床重要差异。术前到术后 1 年，KOOS，JR（22.53 比 25.89；<0.001）和 VR-12 PCS（12.16 比 11.49；=0.002）的平均改善在 LOS<2 个午夜的患者中更高，尽管这些差异没有临床意义。两个队列之间在全因急诊就诊（=0.167）、90 天全因再入院（=0.069）和翻修（=0.277）方面没有统计学差异。与住院患者相比，被归类为门诊的 TKA 患者在大多数患者报告的结果测量中具有相似的质量指标，并且在 TKA 后看到了相似的临床改善，尽管他们在人口统计学上存在差异。与住院患者相比，门诊分类更有可能分配给年轻的男性，这些患者的功能评分更高、BMI、CCI 和 ASA 分级更低。本回顾性队列研究提供了 III 级证据。
