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

• Neuraxial anesthesia is being used more frequently for elective hip and knee replacements

• It is unclear whether increasing rates of hospital-level use of neuraxial anesthesia are associated with beneficial medical or economic outcomes

What This Article Tells Us That Is New:

• National administrative data demonstrate that increasing frequency of neuraxial anesthesia use is not associated with improved clinical outcomes

• However, hospitals using neuraxial anesthesia frequently did observe a decrease in inpatient costs compared to hospitals that did not use neuraxial anesthesia at all

Background: 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’ R²statistics 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.