Predicting Inpatient Status After Primary Total Knee Arthroplasty in Medicare-Aged Patients

The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from its inpatient only (IPO) list as of January 1, 2018. The purpose of this study was to establish a risk-stratifying nomogram to aid in determining the need for inpatient admission among Medicare-aged patients undergoing primary TKA.

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients aged ≥65 years who underwent primary TKA between 2006 and 2015. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and perioperative variables were incorporated in a multivariate logistic regression model to yield a risk stratification nomogram.

Sixty-one thousand two hundred eighty-four inpatient and 26,066 outpatient admissions were analyzed. Age >80 years (odds ratio [OR] = 2.27, P < .0001, 95% confidence interval [CI] = 2.13-2.42), simultaneous bilateral TKA (OR = 2.02, P < .0001, 95% CI = 1.77-2.30), dependent functional status (OR = 1.95, P < .0001, 95% CI = 1.62-2.35), metastatic cancer (OR = 1.91, P = .055, 95% CI = 0.99-3.73), and female gender (OR = 1.76, P < .0001, 95% CI = 1.70-1.82) were the greatest determinants of inpatient stay. The resulting predictive model demonstrated acceptable discrimination and excellent calibration.

Our model enabled a reliable and straightforward identification of the most suitable candidates for inpatient admission in Medicare aged–patients undergoing primary TKA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram.