Same Day versus Staged Total Knee Arthroplasty: Do Cost Savings Justify the Risk?

Abstract

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t-tests assessed categorical and continuous variables, respectively. A p-value of <0.05 was set as the threshold for statistical significance. The analysis demonstrated that less same-day patients were readmitted, with statistical but not clinical difference in revisions, and mortality (all p < 0.050). Higher 30-day cost ($33,522 vs. $29,053, p < 0.001), decreased total LOS (4.52 vs. 4.94 days, p < 0.001), and lower rates of PEs (0.3 vs. 1.1%, p < 0.001) and transfusions (2.1 vs. 8.5%, p < 0.001) but similar total complications (p >0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements.

Keywords

total knee arthroplasty - bilateral - unilateral - cost - complications

Publication History

Received: 31 March 2020

Accepted: 24 May 2020

Article published online:
13 July 2020

• References

• 1 Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheum Dis Clin North Am 2013; 39 (01) 1-19
• 2 Parvizi J, Rasouli MR. Simultaneous-bilateral TKA: double trouble—affirms. J Bone Joint Surg Br 2012; 94 (11) , suppl A ): 90-92
• 3 Liu L, Liu H, Zhang H, Song J, Zhang L. Bilateral total knee arthroplasty: Simultaneous or staged? A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98 (22) e15931
• 4 Lee WC, Kwan YH, Yeo SJ. Severe bilateral fixed flexion deformity-simultaneous or staged total knee arthroplasty?. J Arthroplasty 2016; 31 (01) 128-131
• 5 Ponnusamy KE, Vasarhelyi EM, Somerville L, McCalden RW, Marsh JD. Cost-effectiveness of total knee arthroplasty vs nonoperative management in normal, overweight, obese, severely obese, morbidly obese, and super-obese patients: a Markov model. J Arthroplasty 2018; 33 (7S): S32-S38
• 6 Odum SM, Troyer JL, Kelly MP, Dedini RD, Bozic KJ. A cost-utility analysis comparing the cost-effectiveness of simultaneous and staged bilateral total knee arthroplasty. J Bone Joint Surg Am 2013; 95 (16) 1441-1449
• 7 Memtsoudis SG, Hargett M, Russell LA. et al; Consensus Conference on Bilateral Total Knee Arthroplasty Group. Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 2013; 471 (08) 2649-2657
• 8 Boyer B, Bordini B, Caputo D, Neri T, Stea S, Toni A. Unilateral versus bilateral total knee arthroplasty: a registry study on survival and risk factors. Orthop Traumatol Surg Res 2019; 105 (04) 627-631
• 9 Overview of the Nationwide Readmissions Database. Accessed February 5, 2020 at: https://www.hcup-us.ahrq.gov/nrdoverview.jsp
• 10 Overview of the National (Nationwide) Inpatient Sample. (NIS). Published 2019. Accessed January 5, 2020 at: https://www.hcup-us.ahrq.gov/nisoverview.jsp
• 11 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
• 12 Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty 2013; 28 (07) 1141-1147
• 13 Davidson IU, Brigati DP, Faour M, UdoInyang IJ, Ibrahim M, Murray TG. Same-day bilateral total knee arthroplasty candidacy criteria decrease length of stay and facility discharge. Orthopedics 2018; 41 (05) 293-298
• 14 Bohm ER, Molodianovitsh K, Dragan A. et al. Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthop 2016; 87 (Suppl. 01) 24-30
• 15 Chua HS, Whitehouse SL, Lorimer M, De Steiger R, Guo L, Crawford RW. Mortality and Implant survival with simultaneous and staged bilateral total knee arthroplasty experience from the Australian Orthopaedic Association National Joint Replacement Registry. J Arthroplasty 2018; 33 (10) 3167-3173
• 16 Lindberg-Larsen M, Pitter FT, Husted H, Kehlet H, Jørgensen CC. Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement Collaborative Group. Simultaneous vs staged bilateral total knee arthroplasty: a propensity-matched case-control study from nine fast-track centres. Arch Orthop Trauma Surg 2019; 139 (05) 709-716
• 17 Sobh AH, Siljander MP, Mells AJ, Koueiter DM, Moore DD, Karadsheh MS. Cost analysis, complications, and discharge disposition associated with simultaneous vs staged bilateral total knee arthroplasty. J Arthroplasty 2018; 33 (02) 320-323
• 18 Hart A, Antoniou J, Brin YS, Huk OL, Zukor DJ, Bergeron SG. Simultaneous bilateral versus unilateral total knee arthroplasty: a comparison of 30-day readmission rates and major complications. J Arthroplasty 2016; 31 (01) 31-35
• 19 Memtsoudis SG, González Della Valle A, Besculides MC, Gaber L, Sculco TP. In-hospital complications and mortality of unilateral, bilateral, and revision TKA: based on an estimate of 4,159,661 discharges. In Clinical Orthopaedics and Related Research. Vol 466. New York, NY: Springer; 2008: 2617-2627