A Validated Pre-operative Risk Prediction Tool for Extended Inpatient Length of Stay Following Primary Total Hip or Knee Arthroplasty

• Published in: The Journal of arthroplasty 2023-05, Vol.38 (5), p.785-793
• Main Authors: Goltz, Daniel E., Sicat, Chelsea S., Levin, Jay M., Helmkamp, Joshua K., Howell, Claire B., Waren, Daniel, Green, Cynthia L., Attarian, David, Jiranek, William A., Bolognesi, Michael P., Schwarzkopf, Ran, Seyler, Thorsten M.
• Format: Article
• Language: English
• Subjects: Aged; Arthroplasty, Replacement, Hip - adverse effects; Arthroplasty, Replacement, Knee - adverse effects; bundled payment; Humans; Inpatients; Length of Stay; Medicare; Patient Discharge; Patient Readmission; predictive model; Retrospective Studies; Risk Factors; total hip arthroplasty; total knee arthroplasty; United States; value-based reimbursement
• ISSN: 0883-5403; 1532-8406
• DOI: 10.1016/j.arth.2022.11.006

As value-based reimbursement models mature, understanding the potential trade-off between inpatient lengths of stay and complications or need for costly postacute care becomes more pressing. Understanding and predicting a patient’s expected baseline length of stay may help providers understand how best to decide optimal discharge timing for high-risk total joint arthroplasty (TJA) patients. A retrospective review was conducted of 37,406 primary total hip (17,134, 46%) and knee (20,272, 54%) arthroplasties performed at two high-volume, geographically diverse, tertiary health systems during the study period. Patients were stratified by 3 binary outcomes for extended inpatient length of stay: 72 + hours (29%), 4 + days (11%), or 5 + days (5%). The predictive ability of over 50 sociodemographic/comorbidity variables was tested. Multivariable logistic regression models were created using institution #1 (derivation), with accuracy tested using the cohort from institution #2 (validation). During the study period, patients underwent an extended length of stay with a decreasing frequency over time, with privately insured patients having a significantly shorter length of stay relative to those with Medicare (1.9 versus 2.3 days, P < .0001). Extended stay patients also had significantly higher 90-day readmission rates (P < .0001), even when excluding those discharged to postacute care (P < .01). Multivariable logistic regression models created from the training cohort demonstrated excellent accuracy (area under the curve (AUC): 0.755, 0.783, 0.810) and performed well under external validation (AUC: 0.719, 0.743, 0.763). Many important variables were common to all 3 models, including age, sex, American Society of Anesthesiologists (ASA) score, body mass index, marital status, bilateral case, insurance type, and 13 comorbidities. An online, freely available, preoperative clinical decision tool accurately predicts risk of extended inpatient length of stay after TJA. Many risk factors are potentially modifiable, and these validated tools may help guide clinicians in preoperative patient counseling, medical optimization, and understanding optimal discharge timing.