Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
School of Medicine, Case Western Reserve University, Cleveland, Ohio.
J Arthroplasty. 2023 Jul;38(7):1209-1216.e5. doi: 10.1016/j.arth.2023.01.019. Epub 2023 Jan 21.
The removal of total knee arthroplasty (TKA) from inpatient-only lists accelerated changes in orthopaedic surgical practices across the United States. This study aimed to (1) quantify the annual volume of inpatient/outpatient primary TKAs; (2) compare patient characteristics before/after the year 2018; and (3) compare annual trends in 30-day readmissions, 30-day complications, and healthcare utilization parameters for inpatient/outpatient TKAs.
The National Surgical Quality Improvement Program was reviewed (January 2010 to December 2020) for patients who underwent primary TKA (n = 470,456). The primary outcome was annual volumes of inpatient/outpatient TKA. Secondary outcomes included 30-day readmissions, 30-day reoperations, and 30-day major/minor complications. Demographic characteristics and healthcare utilization parameters (hospital lengths of stay and discharge dispositions) were compared between cohorts via Chi-square goodness-of-fit tests.
Overall, 89% had inpatient TKA (n = 416,972) and 11% had outpatient TKA (n = 53,854). Between 2017 and 2020, annual volumes of outpatient TKA increased by 1,925 (1,019 to 20,633), while inpatient TKA decreased by 53% (61,874 to 29,280). Patients who had outpatient TKA after 2018 were older (P < .001), predominantly males (P < .001), more commonly White (P < .001), and had a greater proportion of American Society of Anesthesiologists class III (P < .001). The inpatient cohort had higher rates of 30-day readmissions, reoperations, and complications. Average length of stay and nonhome discharges decreased for both cohorts.
Outpatient TKA increased 20-fold at NSQIP hospitals. The changes in comorbidity profiles and the increase in volumes of outpatient TKA were not associated with a rise in cumulative 30-day readmissions and complications. Further research and policy endeavors should focus on identifying patients who still require or benefit from inpatient TKA.
全膝关节置换术（TKA）从仅限住院患者名单中移除，加速了美国骨科手术实践的变革。本研究旨在：（1）量化每年的住院/门诊初次 TKA 量；（2）比较 2018 年前后患者特征；（3）比较住院/门诊初次 TKA 的 30 天再入院率、30 天并发症和医疗保健利用参数的年度趋势。
回顾国家手术质量改进计划（2010 年 1 月至 2020 年 12 月）中接受初次 TKA 的患者（n=470456）。主要结局是住院/门诊 TKA 的年度量。次要结局包括 30 天再入院率、30 天再手术率和 30 天主要/次要并发症。通过卡方拟合优度检验比较队列间的人口统计学特征和医疗保健利用参数（住院时间和出院处置）。
总体而言，89%的患者行住院 TKA（n=416972），11%的患者行门诊 TKA（n=53854）。2017 年至 2020 年期间，门诊 TKA 的年量增加了 1925 例（1019 例至 20633 例），而住院 TKA 减少了 53%（61874 例至 29280 例）。2018 年后行门诊 TKA 的患者年龄更大（P<.001）、主要为男性（P<.001）、更常见为白人（P<.001），美国麻醉医师协会（ASA）分级 III 级的比例更高（P<.001）。住院组的 30 天再入院率、再手术率和并发症发生率更高。两个队列的平均住院时间和非家庭出院率均降低。
NSQIP 医院的门诊 TKA 增加了 20 倍。合并症谱的变化和门诊 TKA 量的增加与累计 30 天再入院率和并发症的增加无关。进一步的研究和政策努力应侧重于确定仍需要或受益于住院 TKA 的患者。
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