{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T04:08:30Z","timestamp":1778731710984,"version":"3.51.4"},"reference-count":63,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2021,4,25]]},"published-print":{"date-parts":[[2021,8]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Total knee arthroplasty (TKA) is among the most common surgical procedures performed in the USA and comprises an outsized proportion of Medicare expenditures. Previous work-associated higher safety-net burden hospitals with increased morbidity and in-hospital mortality following total hip arthroplasty. Here, we examine the association of safety-net burden on postoperative outcomes after TKA.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We retrospectively analyzed 1\u2009141\u2009587 patients aged \u226518\u2009years undergoing isolated elective TKA using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York and Washington from 2007 through 2018. Hospitals were grouped into tertiles by safety-net burden status, defined by the proportion of inpatient cases billed to Medicaid or unpaid (low: 0%\u201316.83%, medium: 16.84%\u201330.45%, high: \u226530.45%). Using generalized estimating equation models, we assessed the association of hospital safety-net burden status on in-hospital mortality, patient complications and length of stay (LOS). We also analyzed outcomes by anesthesia type in New York State (NYS), the only state with this data.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Most TKA procedures were performed at medium safety-net burden hospitals (n=6\u200916\u2009915, 54%), while high-burden hospitals performed the fewest (n=2\u200904\u2009784, 17.9%). Overall in-patient mortality was low (0.056%), however, patients undergoing TKA at medium-burden hospitals were 40% more likely to die when compared with patients at low-burden hospitals (low: 0.043% vs medium: 0.061%, adjusted OR (aOR): 1.40, 95%\u2009CI 1.09 to 1.79, p=0.008). Patients who underwent TKA at medium or high safety-net burden hospitals were more likely to experience intraoperative complications (low: 0.2% vs medium: 0.3%, aOR: 1.94, 95%\u2009CI 1.34 to 2.83, p&lt;0.001; low: 0.2% vs high: 0.4%, aOR: 1.91, 95%\u2009CI 1.35 to 2.72, p&lt;0.001). There were no statistically significant differences in other postoperative complications or LOS between the different safety-net levels. In NYS, TKA performed at high safety-net burden hospitals was more likely to use general rather than regional anesthesia (low: 26.7% vs high: 59.5%, aOR: 4.04, 95%\u2009CI 1.05 to 15.5, p=0.042).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Patients undergoing TKA at higher safety-net burden hospitals are associated with higher odds of in-patient mortality than those at low safety-net burden hospitals. The source of this mortality differential is unknown but could be related to the increased risk of intraoperative complications at higher burden centers.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/rapm-2020-101731","type":"journal-article","created":{"date-parts":[[2021,5,14]],"date-time":"2021-05-14T11:18:19Z","timestamp":1620991099000},"page":"663-670","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":10,"title":["Hospital safety-net burden is associated with increased inpatient mortality after elective total knee arthroplasty: a retrospective multistate review, 2007\u20132018"],"prefix":"10.1136","volume":"46","author":[{"given":"Deirdre Clare","family":"Kelleher","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ryan","family":"Lippell","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9402-2141","authenticated-orcid":false,"given":"Briana","family":"Lui","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiaoyue","family":"Ma","sequence":"additional","affiliation":[{"name":"Population Health Sciences, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9631-6389","authenticated-orcid":false,"given":"Tiffany","family":"Tedore","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roniel","family":"Weinberg","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert S","family":"White","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,5,14]]},"reference":[{"key":"2025101112130975000_46.8.663.1","doi-asserted-by":"crossref","first-page":"963","DOI":"10.2106\/00004623-200405000-00012","article-title":"Health-Related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature","volume":"86","author":"Ethgen","year":"2004","journal-title":"J Bone Joint Surg Am"},{"key":"2025101112130975000_46.8.663.2","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.ocl.2019.11.003","article-title":"Global perspectives on arthroplasty of hip and knee joints","volume":"51","author":"Abdelaal","year":"2020","journal-title":"Orthop Clin North Am"},{"key":"2025101112130975000_46.8.663.3","doi-asserted-by":"publisher","DOI":"10.1002\/art.21420"},{"key":"2025101112130975000_46.8.663.4","unstructured":"Agency for Healthcare Research and Quality . Most frequent operating room procedures performed in u.S. Hospitals, 2003-2012. Hcup statistical brief #186. Rockville, MD, 2012. http:\/\/www.hcup-us.ahrq.gov\/reports\/statbriefs\/sb186-Operating-Room-Procedures-United-States-2012.pdf"},{"key":"2025101112130975000_46.8.663.5","doi-asserted-by":"publisher","DOI":"10.3899\/jrheum.170990"},{"key":"2025101112130975000_46.8.663.6","doi-asserted-by":"crossref","first-page":"1064","DOI":"10.2106\/JBJS.17.00249","article-title":"Mortality after total knee arthroplasty: a systematic review of incidence, temporal trends, and risk factors","volume":"100","author":"Berstock","year":"2018","journal-title":"J Bone Joint Surg Am"},{"key":"2025101112130975000_46.8.663.7","doi-asserted-by":"crossref","first-page":"1575","DOI":"10.1016\/j.arth.2019.04.027","article-title":"Trends in length of stay and 30-day complications after total knee arthroplasty: an analysis from 2006 to 2016","volume":"34","author":"Sarpong","year":"2019","journal-title":"J Arthroplasty"},{"key":"2025101112130975000_46.8.663.8","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1097\/SLA.0b013e3181e8fd75","article-title":"Primary payer status affects mortality for major surgical operations","volume":"252","author":"LaPar","year":"2010","journal-title":"Ann Surg"},{"key":"2025101112130975000_46.8.663.9","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.E.00629"},{"key":"2025101112130975000_46.8.663.10","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.N.00133"},{"key":"2025101112130975000_46.8.663.11","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2013-203494"},{"key":"2025101112130975000_46.8.663.12","doi-asserted-by":"publisher","DOI":"10.3928\/01477447-20121120-27"},{"key":"2025101112130975000_46.8.663.13","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2018-000020"},{"key":"2025101112130975000_46.8.663.14","doi-asserted-by":"publisher","DOI":"10.1177\/1077558708315440"},{"key":"2025101112130975000_46.8.663.15","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1016\/j.surg.2013.12.006","article-title":"The quality of surgical care in safety net hospitals: a systematic review","volume":"155","author":"Mouch","year":"2014","journal-title":"Surgery"},{"key":"2025101112130975000_46.8.663.16","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1001\/jamasurg.2016.0986","article-title":"Challenges in surgical quality at safety-net hospitals","volume":"151","author":"Macht","year":"2016","journal-title":"JAMA Surg"},{"key":"2025101112130975000_46.8.663.17","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1001\/jamasurg.2015.3209","article-title":"Effect of hospital safety-net burden on cost and outcomes after surgery","volume":"151","author":"Hoehn","year":"2016","journal-title":"JAMA Surg"},{"key":"2025101112130975000_46.8.663.18","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1353\/hpu.2016.0018","article-title":"Hip and knee replacement in safety-net hospitals: recognizing the challenges","volume":"27","author":"Arlas","year":"2016","journal-title":"J Health Care Poor Underserved"},{"key":"2025101112130975000_46.8.663.19","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1016\/j.jvs.2016.12.146","article-title":"Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery","volume":"66","author":"Rosero","year":"2017","journal-title":"J Vasc Surg"},{"key":"2025101112130975000_46.8.663.20","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2018-100305"},{"key":"2025101112130975000_46.8.663.21","doi-asserted-by":"crossref","DOI":"10.2106\/JBJS.20.00597","article-title":"Demographic, comorbidity, and episode-of-care differences in primary total knee arthroplasty","volume":"103","author":"Siddiqi","year":"2021","journal-title":"J Bone Joint Surg Am"},{"key":"2025101112130975000_46.8.663.22","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000002453"},{"key":"2025101112130975000_46.8.663.23","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1097\/ALN.0000000000001004","article-title":"Anesthetic care for orthopedic patients: is there a potential for differences in care?","volume":"124","author":"Memtsoudis","year":"2016","journal-title":"Anesthesiology"},{"key":"2025101112130975000_46.8.663.24","unstructured":"HCUP . Overview of the state inpatient databases (sid). Available: https:\/\/www.hcup-us.ahrq.gov\/sidoverview.jsp [Accessed 30 Aug 2020]."},{"key":"2025101112130975000_46.8.663.25","doi-asserted-by":"publisher","DOI":"10.1097\/00005650-199801000-00004"},{"key":"2025101112130975000_46.8.663.26","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1016\/j.jclinane.2017.09.008","article-title":"Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and new York","volume":"43","author":"Xu","year":"2017","journal-title":"J Clin Anesth"},{"key":"2025101112130975000_46.8.663.27","unstructured":"Rabe-Hesketh S , Skrondal A . Multilevel and longitudinal modeling using stata. STATA press, 2008."},{"key":"2025101112130975000_46.8.663.28","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa050672"},{"key":"2025101112130975000_46.8.663.29","article-title":"Persistent racial disparities in utilization rates and perioperative metrics in total joint arthroplasty in the U.S.: a comprehensive analysis of trends from 2006 to 2015","author":"Amen","journal-title":"J Bone Joint Surg Am"},{"key":"2025101112130975000_46.8.663.30","doi-asserted-by":"crossref","first-page":"e340","DOI":"10.3928\/01477447-20180226-07","article-title":"Insurance status affects in-hospital complication rates after total knee arthroplasty","volume":"41","author":"Veltre","year":"2018","journal-title":"Orthopedics"},{"key":"2025101112130975000_46.8.663.31","doi-asserted-by":"crossref","first-page":"1474","DOI":"10.1016\/j.arth.2020.02.002","article-title":"The association of race\/ethnicity and total knee arthroplasty outcomes in a universally insured population","volume":"35","author":"Hinman","year":"2020","journal-title":"J Arthroplasty"},{"key":"2025101112130975000_46.8.663.32","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.jamcollsurg.2016.04.042","article-title":"Vulnerable hospitals and cancer surgery readmissions: insights into the unintended consequences of the patient protection and Affordable care act","volume":"223","author":"Hong","year":"2016","journal-title":"J Am Coll Surg"},{"key":"2025101112130975000_46.8.663.33","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1097\/JHQ.0000000000000122","article-title":"Breast cancer: does type of hospital where you get surgery affect survival?","volume":"41","author":"Lin","year":"2019","journal-title":"J Healthc Qual"},{"key":"2025101112130975000_46.8.663.34","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2008.02.014"},{"key":"2025101112130975000_46.8.663.35","doi-asserted-by":"publisher","DOI":"10.1177\/1077558712458158"},{"key":"2025101112130975000_46.8.663.36","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1007\/s11605-017-3549-0","article-title":"Equivalent treatment and survival after resection of pancreatic cancer at safety-net hospitals","volume":"22","author":"Dhar","year":"2018","journal-title":"J Gastrointest Surg"},{"key":"2025101112130975000_46.8.663.37","doi-asserted-by":"crossref","first-page":"754","DOI":"10.1016\/j.arth.2015.10.031","article-title":"Early complications in hip and knee arthroplasties in a safety net Hospital vs a university center","volume":"31","author":"Jergesen","year":"2016","journal-title":"J Arthroplasty"},{"key":"2025101112130975000_46.8.663.38","doi-asserted-by":"crossref","DOI":"10.21037\/atm.2019.01.64","article-title":"A comparison of peri-operative outcomes between elective and non-elective total hip arthroplasties","volume":"7","author":"Anis","year":"2019","journal-title":"Ann Transl Med"},{"key":"2025101112130975000_46.8.663.39","doi-asserted-by":"crossref","first-page":"990","DOI":"10.1001\/jamasurg.2015.1239","article-title":"Comparison of US and Canadian perioperative outcomes and hospital efficiency after total hip and knee arthroplasty","volume":"150","author":"Hart","year":"2015","journal-title":"JAMA Surg"},{"key":"2025101112130975000_46.8.663.40","doi-asserted-by":"crossref","first-page":"2232","DOI":"10.1111\/jocs.14738","article-title":"The impact of hospital safety-net burden on mortality and readmission after CABG surgery","volume":"35","author":"Hoyler","year":"2020","journal-title":"J Card Surg"},{"key":"2025101112130975000_46.8.663.41","doi-asserted-by":"publisher","DOI":"10.1016\/j.arth.2008.01.307"},{"key":"2025101112130975000_46.8.663.42","article-title":"Comparison of ICD-9-based, retrospective, and prospective assessments of perioperative complications: assessment of accuracy in reporting","author":"Campbell","journal-title":"J Neurosurg Spine"},{"key":"2025101112130975000_46.8.663.43","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1007\/s10754-013-9124-7","article-title":"Responding to financial pressures. The effect of managed care on hospitals' provision of charity care","volume":"13","author":"Mas","year":"2013","journal-title":"Int J Health Care Finance Econ"},{"key":"2025101112130975000_46.8.663.44","article-title":"Medicaid program; state disproportionate share Hospital allotment reductions. final rule","volume":"78","year":"2013","journal-title":"Fed Regist"},{"key":"2025101112130975000_46.8.663.45","unstructured":"CMS . Hospital readmissions reduction program (hrrp). Available: https:\/\/www.cms.gov\/Medicare\/Medicare-Fee-for-Service-Payment\/AcuteInpatientPPS\/Readmissions-Reduction-Program [Accessed 16 Jul 2019]."},{"key":"2025101112130975000_46.8.663.46","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2015.11.008"},{"key":"2025101112130975000_46.8.663.47","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.jss.2018.04.047","article-title":"Failure to rescue and disparities in emergency general surgery","volume":"231","author":"Metcalfe","year":"2018","journal-title":"J Surg Res"},{"key":"2025101112130975000_46.8.663.48","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000000190"},{"key":"2025101112130975000_46.8.663.49","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1136\/rapm-2019-100748","article-title":"Disparities in care, public health and the role of the anesthesiologist","author":"Memtsoudis","year":"2019","journal-title":"Reg Anesth Pain Med"},{"key":"2025101112130975000_46.8.663.50","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1213\/ANE.0000000000002582","article-title":"Antiemetic prophylaxis as a marker of health care disparities in the National anesthesia clinical outcomes registry","volume":"126","author":"Andreae","year":"2018","journal-title":"Anesth Analg"},{"key":"2025101112130975000_46.8.663.51","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.bjae.2017.10.002","article-title":"Regional anaesthesia and outcomes","volume":"18","author":"Hutton","year":"2018","journal-title":"BJA Educ"},{"key":"2025101112130975000_46.8.663.52","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1097\/ALN.0000000000002299","article-title":"Do hospitals performing frequent neuraxial anesthesia for hip and knee replacements have better outcomes?","volume":"129","author":"Memtsoudis","year":"2018","journal-title":"Anesthesiology"},{"key":"2025101112130975000_46.8.663.53","doi-asserted-by":"crossref","first-page":"554","DOI":"10.1001\/jamasurg.2016.0014","article-title":"Setting a national agenda for surgical disparities research: recommendations from the National Institutes of health and American College of surgeons Summit","volume":"151","author":"Haider","year":"2016","journal-title":"JAMA Surg"},{"key":"2025101112130975000_46.8.663.54","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1016\/j.suc.2018.07.015","article-title":"Enhanced recovery after surgery and surgical disparities","volume":"98","author":"Marques","year":"2018","journal-title":"Surg Clin North Am"},{"key":"2025101112130975000_46.8.663.55","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1213\/ANE.0000000000003663","article-title":"Evidence review conducted for the agency for healthcare research and quality safety program for improving surgical care and recovery: focus on anesthesiology for total hip arthroplasty","volume":"128","author":"Soffin","year":"2019","journal-title":"Anesth Analg"},{"key":"2025101112130975000_46.8.663.56","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-00115550-200811000-00002"},{"key":"2025101112130975000_46.8.663.57","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0000000000000588"},{"key":"2025101112130975000_46.8.663.58","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0000000000000673"},{"key":"2025101112130975000_46.8.663.59","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1016\/j.surg.2015.08.025","article-title":"Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net Hospital: a provider and patient perspective","volume":"159","author":"Alawadi","year":"2016","journal-title":"Surgery"},{"key":"2025101112130975000_46.8.663.60","doi-asserted-by":"crossref","first-page":"908","DOI":"10.1001\/jamasurg.2016.1776","article-title":"Addressing the high costs of pancreaticoduodenectomy at safety-net hospitals","volume":"151","author":"Go","year":"2016","journal-title":"JAMA Surg"},{"key":"2025101112130975000_46.8.663.61","doi-asserted-by":"publisher","DOI":"10.1097\/00000658-200109000-00011"},{"key":"2025101112130975000_46.8.663.62","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2009.01.003"},{"key":"2025101112130975000_46.8.663.63","unstructured":"Census bureau reports . Utah is nation\u2019s fastest-growing state,census bureau reports. Available: https:\/\/www.census.gov\/newsroom\/press-releases\/2016\/cb16-214.html"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2020-101731","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T19:13:24Z","timestamp":1760210004000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2020-101731"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,14]]},"references-count":63,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2021,7,20]]},"published-print":{"date-parts":[[2021,8]]}},"alternative-id":["10.1136\/rapm-2020-101731"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2020-101731","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,14]]}}}