Area Deprivation Index, Institutional Practice, and Utilization of Neuraxial Anesthesia in Total Knee Arthroplasty

Access to healthcare contributes to challenges in controlling postoperative pain in patients of lower socioeconomic status (SES) undergoing total knee arthroplasty (TKA). Neuraxial anesthesia (NA) reduces pain and opioid use after TKA. This study used the Area Deprivation Index (ADI) to evaluate associations between SES and NA utilization in primary TKA.

A retrospective review was conducted of TKAs performed between August 15, 2023, and April 12, 2024, at four hospitals. Revision TKA and bilateral TKA were excluded. The ADI was used to stratify patients into quintiles by address. There were 340 patients included: 25.3% in the first state-level quintile, 19.7% in the second, 25.9% in the third, 16.9% in the fourth, and 12.4% in the fifth. Multivariable logistic regressions controlling for age, sex, race, language, insurance, body mass index, surgeon, and hospital site assessed differences in NA utilization between the least disadvantaged state ADI quintile (first quintile) and more disadvantaged quintiles (second to fifth). Lengths of stay, office phone calls, 90-day emergency department (ED) visits, 90-day readmissions, complications, and reoperations were compared by anesthesia type and ADI.

Multivariable regression analysis demonstrated that hospital site explained differences in rates of NA (P < 0.0001), while ADI did not (P = 0.53). Neuraxial anesthesia was associated with fewer 90-day ED visits compared to general anesthesia (5.0 versus 13.7%, P = 0.0048). The ADI was not associated with ED visits, but was associated with shorter lengths of stay (1.9 ± 1.7 versus 2.5 ± 2.6, P = 0.048) and fewer reoperations (0 versus 5.5%, P = 0.025). Neither anesthesia type nor ADI was associated with office phone calls, 90-day readmissions, or complications.

The hospital site, not ADI, explained the variation in rates of NA during TKA in this cohort. Larger, more geographically diverse studies are warranted to further evaluate the relationship between SES, institutional practice, and perioperative anesthesia in TKA.