Do Hospitals Performing Frequent Neuraxial Anesthesia for Hip and Knee Replacements Have Better Outcomes?


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Abstract

What We Already Know about This TopicNeuraxial anesthesia is being used more frequently for elective hip and knee replacementsIt is unclear whether increasing rates of hospital-level use of neuraxial anesthesia are associated with beneficial medical or economic outcomesWhat This Article Tells Us That Is NewNational administrative data demonstrate that increasing frequency of neuraxial anesthesia use is not associated with improved clinical outcomesHowever, hospitals using neuraxial anesthesia frequently did observe a decrease in inpatient costs compared to hospitals that did not use neuraxial anesthesia at allBackground:Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.Methods:National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines’ R2 statistics reported.Results:Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study’s clinical outcomes. However, significant reductions of up to –14.1% (95% CI, –20.9% to –6.6%) and –15.6% (95% CI, –22.8% to –7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R2 0.13 and 0.41 for hip and knee replacements, respectively.Conclusions:Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality.

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