What is Associated with the Greatest Effect on Lengths of Stay after Total Knee Arthroplasty: The Hospital, the Surgeon, or the Patient

Abstract

Introduction: Patient-, hospital-, and surgeon-related factors are each associated with the variable nature of length of stay (LOS) after total knee arthroplasty (TKA). However, there is a paucity of literature regarding these intertwined relationships. This study aimed to determine if the hospital, the surgeon, or the patient has the greatest association with LOS after TKA. Materials and Methods: A total of 11,402 patients were identified from a multicenter prospectively collected institutional database between January 01, 2017, and April 01, 2019. Surgeons and hospitals were subdivided into three groups: (1) low volume (<10 and <100 cases, respectively), (2) intermediate volume (10–150 and 100–400 cases, respectively), and (3) high volume (>150 and >400 cases, respectively). Patient demographics, comorbidities, hospital academic status, and LOS were identified. Univariate and multivariate analyses were performed to compare hospital-, surgeon-, and patient-related factors. Results: Neither hospital (P = 0.173) volume nor surgeon (P = 0.413) volume were significantly associated with LOS in multivariate analyses while controlling for patient-, surgeon-, and hospital-related factors. Patient medical factors including diabetes (P < 0.001), congestive heart failure (P < 0.001), peripheral vascular disease (P < 0.001), chronic kidney disease (P < 0.001), chronic obstructive pulmonary disease (P < 0.001), and anemia (P < 0.033), as well as academic teaching hospitals (P < 0.001) were associated with a significant increase in hospital LOS. Conclusion: Patient’s chronic medical conditions and hospital status as an academic teaching hospital were found to be the most important associated risk factors on post-operative hospital LOS after TKA. This study directs the focus onto pre-operative optimization and patient selection and helps demonstrate where to best allocate resources to successfully decrease LOS. Keywords: Lengths of stay, Total knee arthroplasty, Pre-operative optimization, Complications, High volume surgeon.