J Knee Surg 2021; 34(12): 1318-1321
DOI: 10.1055/s-0040-1708850
Original Article

Does Increasing Patient Complexity Have an Effect on Medical Outcomes and Lengths-of-Stay after Total Knee Arthroplasty?

Hiba K. Anis
1   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Nipun Sodhi
2   Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
,
Alexander J. Acuña
3   School of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
,
Alexander Roth
1   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Rushabh Vakharia
4   Orthopedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, Florida
,
Jared M. Newman
5   Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
,
Syed H. Mufarrih
6   Department of Orthopedic Surgery, Northwell Hospital Lenox Hill, New York, New York
,
Eric Grossman
7   Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, New York, New York
,
Martin W. Roche
4   Orthopedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, Florida
,
Michael A. Mont
6   Department of Orthopedic Surgery, Northwell Hospital Lenox Hill, New York, New York
› Author Affiliations

Abstract

A greater number of medically complex patients with multiple comorbidities are now more readily considered for total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine whether comorbidity burden, measured with the Elixhauser Comorbidity Index (ECI), correlated with 90-day medical complications and longer in-hospital lengths-of-stay (LOS) in TKA patients. The PearlDiver supercomputer was queried for all primary TKA patients in the Medicare Standard Analytic Files from 2005 to 2014 using International Classification of Disease, 9th edition codes. Patients were included based on ECI scores, ranging from 1 to 5. ECI 1 patients served as the control cohort, while ECI 2, 3, 4, and 5 patients were considered study cohorts. Each study cohort was matched based on age and gender to the control cohort, resulting in a total of 715,398 patients included for analysis (ECI 1, n = 144,072; ECI 2, n = 144,072; ECI 3, n = 144,072; ECI 4, n = 144,072; ECI 5, n = 139,110). Logistic regression analyses were performed to compare 90-day medical complications and Welch's t-tests were performed to compare LOS between the cohorts. Patients with higher ECI scores were more likely to develop medical complications and have longer LOS compared with matched patients in the control cohort. Compared with matched ECI 1 patients, patients with ECI scores of 2 (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.14–1.24), 3 (OR: 1.27, 95% CI: 1.21–1.32), 4 (OR: 1.32, 95% CI: 1.27–1.38), and 5 (OR: 1.33, 95% CI: 1.27–1.39) were significantly more likely to develop 90-day medical complications. Additionally, the mean LOS of patients in the ECI 2 (2.59 ± 1.49 vs. 2.73 ± 1.52 days), ECI 3 (2.59 ± 1.49 vs. 2.88 ± 1.51 days; p < 0.001), ECI 4 (2.59 ± 1.49 vs. 3.01 ± 1.56 days; p < 0.001), and ECI 5 (2.61 ± 1.49 vs. 3.14 ± 1.61 days; p < 0.001) groups were significantly longer than the mean LOS in the control ECI 1 group. In an increasingly complex patient population, associations between comorbidities and outcomes after TKA procedures can guide providers on how to modify their pre- and postoperative care. These results demonstrate that higher ECI scores are associated with a greater likelihood of 90-day medical complications and longer in-hospital LOS.



Publication History

Received: 18 July 2019

Accepted: 07 February 2020

Article published online:
08 April 2020

© 2020. Thieme. All rights reserved.

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

 
  • References

  • 1 Skolarus LE, Meurer WJ, Shanmugasundaram K, Adelman EE, Scott PA, Burke JF. Marked regional variation in acute stroke treatment among Medicare beneficiaries. Stroke 2015; 46 (07) 1890-1896
  • 2 Pugely AJ, Martin CT, Gao Y, Belatti DA, Callaghan JJ. Comorbidities in patients undergoing total knee arthroplasty: do they influence hospital costs and length of stay?. Clin Orthop Relat Res 2014; 472 (12) 3943-3950
  • 3 Jain NB, Guller U, Pietrobon R, Bond TK, Higgins LD. Comorbidities increase complication rates in patients having arthroplasty. Clin Orthop Relat Res 2005; (435) 232-238
  • 4 Sloan M, Sheth NP. Length of stay and inpatient mortality trends in primary and revision total joint arthroplasty in the United States, 2000-2014. J Orthop 2018; 15 (02) 645-649
  • 5 Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998; 36 (01) 8-27
  • 6 Lieffers JR, Baracos VE, Winget M, Fassbender K. A comparison of Charlson and Elixhauser comorbidity measures to predict colorectal cancer survival using administrative health data. Cancer 2011; 117 (09) 1957-1965
  • 7 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
  • 8 Dominick KL, Dudley TK, Coffman CJ, Bosworth HB. Comparison of three comorbidity measures for predicting health service use in patients with osteoarthritis. Arthritis Rheum 2005; 53 (05) 666-672
  • 9 Bedard NA, Pugely AJ, McHugh M. et al. Analysis of outcomes after TKA: do all databases produce similar findings?. Clin Orthop Relat Res 2018; 476 (01) 52-63
  • 10 Knoedler MA, Jeffery MM, Philpot LM. et al. Risk factors associated with health care utilization and costs of patients undergoing lower extremity joint replacement. Mayo Clin Proc Innov Qual Outcomes 2018; 2 (03) 248-256
  • 11 Gonzalez Della Valle A, Chiu YL, Ma Y, Mazumdar M, Memtsoudis SG. The metabolic syndrome in patients undergoing knee and hip arthroplasty: trends and in-hospital outcomes in the United States. J Arthroplasty 2012; 27 (10) 1743-1749.e1
  • 12 Al-Arabi YB. Risk classification for primary knee arthroplasty. J Arthroplasty 2009; 24 (01) 90-95
  • 13 D'Apuzzo M, Westrich G, Hidaka C, Jung Pan T, Lyman S. All-cause versus complication-specific readmission following total knee arthroplasty. J Bone Joint Surg Am 2017; 99 (13) 1093-1103
  • 14 Jain NB, Guller U, Pietrobon R, Bond TK, Higgins LD. ; N.B. J. Comorbidities increase complication rates in patients having arthroplasty. Clin Orthop Relat Res 2005; (435) 232-238
  • 15 Raut S, Mertes SC, Muniz-Terrera G, Khanduja V. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop 2012; 36 (08) 1601-1608
  • 16 Podmore B, Hutchings A, van der Meulen J, Aggarwal A, Konan S. Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis. BMJ Open 2018; 8 (07) e021784