• Stavros G Memtsoudis, Jashvant Poeran, Nicole Zubizarreta, Ashley Olson, Crispiana Cozowicz, Eva E Mörwald, Edward R Mariano, and Madhu Mazumdar.
• From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York (S.G.M., C.C., E.E.M.) Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (S.G.M., C.C., E.E.M.) Institute for Healthcare Delivery Science, Departments of Population Health Science and Policy (J.P., N.Z., A.O., M.M.) Departments of Orthopedic Surgery (J.P.) Medicine (J.P.) Icahn School of Medicine at Mount Sinai, New York, New York; Department of Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (E.R.M.) Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California (E.R.M).
• Anesthesiology. 2018 Sep 1; 129 (3): 428-439.

BackgroundNeuraxial 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.MethodsNational 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' R statistics reported.ResultsAnnual 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, R 0.13 and 0.41 for hip and knee replacements, respectively.ConclusionsIncreased 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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