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HomeAnesthesia & Analgesiaindex/list_12253_1Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing...

Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing Primary Total Hip and Total Knee Replacement

Abstract and Introduction

Abstract

Background: Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system.

Methods: This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR.

Results: Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52–1.76; P < .01) and (OR = 1.58, 95% CI, 1.49–1.67; P < .01), respectively.

Conclusions: Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.

Introduction

Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most commonly performed orthopedic surgical procedures in the United States with increasing incidence. According to the Centers for Disease Control and Prevention (CDC), 332,000 THRs and 719,000 TKRs were performed in 2010.[1,2] Because the demand for these procedures is constantly growing with 600,000 THRs and 1.4 million TKRs predicted by 2030, the potential incremental incurred costs are striking. Post acute care expenses are approximately 40% of primary TKR and THR costs. Health care systems are addressing inpatient costs via programs aimed at decreasing hospital length of stay (LOS) for these surgeries. As a trade-off, use of extended care facilities (ECFs) has become more common in the post acute care period.[3] Within both voluntary and mandated bundled care arrangements, however, the providing hospitals and surgeons become responsible for the cost of the 90 days of care after the index procedures, creating an incentive to decrease post acute care expenses. An improved understanding of the factors that determine a patient’s discharge destination is key to optimize resources and patient satisfaction, speed the resumption of activities of daily living, reduce readmissions, and lead to care processes that are more cost-effective.[4–7]

The anesthetic technique selected for a surgical procedure has been previously shown to impact patients’ ability to meet postanesthesia care unit (PACU) discharge criteria and influence LOS and, as a result, may influence pain management and rehabilitation goals in the postoperative period, impacting discharge destination.[8] In patients with multiple comorbidities undergoing joint replacements, the type of anesthetic approach can have a significant impact on the ability to meet rehabilitation goals and resource utilization for the health care system.[9,10]

In this study, we determined the role of types of anesthetic technique on discharge destinations and investigated secondary outcomes associated with readmissions. We hypothesized that patients who received neuraxial anesthesia would be more likely to go home than to ECFs than those who received general anesthesia. To test our hypothesis, we compared the discharge destinations of patients undergoing THR and TKR following propensity matching within a large, tertiary health care system.

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