From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.
J Am Acad Orthop Surg. 2021 Jun 15;29(12):537-543. doi: 10.5435/JAAOS-D-20-01038.
Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA.
This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes.
A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery.
Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.
在早期康复方案、基于价值的医疗保健以及医疗保险和医疗补助服务中心将其从仅限住院患者名单中移除的背景下，门诊全膝关节置换术（TKA）越来越普遍。鉴于在全关节置换术的不同方面存在既定的种族差异，我们旨在调查与住院 TKA 相比，门诊 TKA 是否存在种族和民族差异。
这是一项使用美国外科医师学院国家手术质量改进计划的回顾性队列研究。我们调查了 2018 年进行的 TKA。记录了人口统计学、住院（≥2 个午夜）与门诊（≤1 个午夜）状态、合并症和围手术期事件/并发症。我们分析了不同种族/族裔群体之间的差异以及预测门诊与住院手术的因素，并评估了结果。
共纳入 54582 名患者（83.2%为白种人，9.2%为非裔美国人[AA]，4.5%为西班牙裔，2.4%为亚洲人，0.6%为美洲原住民）。AA 的平均体重指数、美国麻醉医师协会评分和合并症负担最高。AA 门诊 TKA 率最低（18.3%），亚洲人门诊 TKA 率最高（31.4%，P<0.0001）。AA 的术后输血率最高（1.8%，P<0.0001），急性康复出院率最高（8.4%）。亚洲人术后心脏骤停和尿路感染的发生率最高。AA 在 30 天内急性肾损伤的发生率最高。回归分析显示，AA 更有可能接受住院手术（优势比[OR]，2.58；置信区间[CI]，1.57-4.23；P=0.001）和出院到康复/熟练护理机构[SNF]（OR，2.86；CI，1.66-4.92；P=0.001）。亚裔患者更有可能接受门诊手术（OR，2.48，CI，1.47-4.18，P=0.001）和出院到康复/SNF（OR，2.41，CI，1.36-4.25，P=0.001）。白种人更有可能接受门诊手术（OR，1.62，CI，1.34-1.97，P=0.001），而不太可能出院到康复/SNF（OR，0.73，CI，0.60-0.88，P=0.001）。在控制合并症后，种族并不是 30 天并发症或门诊与住院手术的独立危险因素。
不同种族/族裔门诊 TKA 的适应证差异似乎与合并症负担和术前基线差异高度相关，而不仅仅与种族有关。对门诊或住院 TKA 的患者进行适当的优化，可能会减少不同治疗环境中群体之间的差异。
