Measure Information Form

Measure Set: Total Hip and Total Knee Replacement Outpatient (THKR-OP)

Set Measure ID: THKR-OP-1

Set Measure ID	Performance Measure Name
THKR-OP-1a	Regional Anesthesia - Hip and Knee Overall
THKR-OP-1b	Regional Anesthesia - Hip
THKR-OP-1c	Regional Anesthesia - Knee

Performance Measure Name: Regional Anesthesia

Description: Patients undergoing a total hip or total knee replacement with regional anesthesia attempted or performed. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks.

Rationale: Regional anesthesia is associated with fewer postoperative complications and deaths than general anesthesia. Research shows that patients who received neuraxial anesthesia had statistically significant decreases in 30-day mortality and in-hospital complications including pneumonia, kidney failure and the need for mechanical ventilation.¹ Additional studies show decrease in operative blood loss and need for blood transfusions.^2-3 Additionally, evidence supports the overall beneficial effects of neuraxial anesthesia versus general anesthesia in decreasing the development of surgical site infections after total hip and knee arthroplasty.⁴ Several factors, such as compromised cardiopulmonary function, anticoagulative therapy, or anatomical deformity, may prevent general anesthesia and neuraxial blockade from being conducted in total joint replacement surgery.⁵ Peripheral nerve blocks (PNBs) can be used as the primary anesthetic for total knee replacement facilitating faster postoperative recovery than general anesthesia.⁶

In December, 2015, The American Academy of Orthopaedic Surgeons (AAOS) published Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guidelines. Per the guidelines, evidence supports that neuraxial anesthesia could be used to improve select perioperative outcomes and complication rates compared to general anesthesia.⁷ In March, 2017, AAOS published Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guidelines. These guidelines state evidence supports the use of neuraxial anesthesia compared to general anesthesia to reduce complications in patients undergoing total hip arthroplasty.⁸ According to the National Surgical Quality Improvement Project database, from 2005-2011, 52% of knee replacements and 60% of hip replacements were performed under general anesthesia.

Some surgeons avoid using regional anesthesia due to concerns that regional anesthesia may cause motor weakness, making patients more likely to fall when they are walking postoperatively. Peripheral nerve blockade did not alter the risk of inpatient fall, whereas use of neuraxial anesthesia reduced the risk by 30% compared with general anesthesia. The type of anesthesia may represent a modifiable risk factor and the use of neuraxial over general anesthesia may be considered in the context of a fall-prevention program.⁹

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients undergoing a total hip or total knee replacement with regional anesthesia attempted or performed.

Included Populations: Patients receiving any of the following or documentation of a failed attempt of any of the following during the operative episode:

Epidural anesthesia

Epidural block

Peripheral nerve block (single injection or continuous infusion)

Spinal anesthesia

Spinal block

Subarachnoid block

Excluded Populations: None
Data Elements:

Regional Anesthesia

Denominator Statement: Patients undergoing a total hip or total knee replacement.

Included Populations:

Patients with a CPT® Code with Modifier as defined in Appendix A: Table 14.01b (Total Hip Replacements-OP), or Table 14.02b (Total Knee Replacements-OP), or Table 14.03b (Bilateral Hip Replacements-OP) or Table 14.04b (Bilateral Knee Replacements-OP)

Excluded Populations:

Patients less than 18 years of age

Patients with a CPT® Code with Modifier as defined in Appendix A: Table 14.05b (partial hip and partial knee replacements-OP), or Table 14.06b (revision and resurfacing procedures-OP), or Table 14.07b (removal of implanted devices/prostheses-OP)

Patients with an ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes as defined in Appendix A: Table 14.08 (complication of internal fixation device/prosthesis, or Table 14.09 (malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a disseminated malignant neoplasm)

Documented contraindication by physician/APN/PA (e.g. anticoagulated patients, coagulopathies, neurologic condition, previous spinal fusion) clearly indicated as reason for no regional anesthesia

Data Elements:

Birthdate

CPT® Codes with Modifier

ICD-10-CM Other Diagnosis Codes

ICD-10-CM Principal Diagnosis Code

Outpatient Encounter Date

Reason for No Regional Anesthesia

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and CPT procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 and CPT codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Proportion for hip replacements, proportion for knee replacements and aggregated proportion for hip & knee replacements.

Selected References:

¹ Memtsoudis SG, Xuming S.; Ya-Lin Chiu, et al. Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology 05 2013, Vol.118, 1046-1058.
² Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a metaanalysis. Anesth. Analg. 2006; 103: 1018–25.
³ Hu S, Zhang Z-Y, Hua Y-Q, Li J, Cai Z-D. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a metaanalysis. J. Bone Joint Surg. Br. 2009; 91: 935–42.
⁴ Zorrilla-Vaca A, Grant MC, Mathur V, Li J, Wu CL. The Impact of Neuraxial Versus General Anesthesia on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty: A Meta-Analysis. Regional Anesthesia & Pain Medicine: September/October 2016 - Volume 41 - Issue 5 - p 555–563.
⁵ Kim JH, Cho MR, et al. A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean J Anesthesiol 2012 May 62(5): 448-453.
⁶ Liu JL, Yuan WX, et al. Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery. Clinical Interventions in Aging 2014:9 341-350.
⁷ Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.
⁸ Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 3.13.17.
⁹ Memtsoudis SG, Thomas Danninger, Rehana Rasul, Jashvant Poeran, Philipp Gerner, Ottokar Stundner, Edward R. Mariano, Madhu Mazumdar. Inpatient Falls after Total Knee Arthroplasty. Anesthesiology, 2014; 120 (3): 551-563.
Nielsen PT, Jørgensen LN, Albrecht-Beste E, LeffersA, RasmussenLS. Lower thrombosis risk with epidural blockade in knee arthroplasty. Acta Orthopaedica Scandinavica, 1990,61:1, 29-31
Mitchell D, Friedman, RJ, Baker DJ, Cooke JE, Darcy, MD, Miller MC. Prevention of thromboembolic disease following total knee arthroplasty: Epidural versus general anesthesia. Clinical Orthopaedics & Related Research, August 1991; 269:109-112.
Jorgensen LN, Rasmussen LS, Nielsen PT, Leffers A, Albrecht-Beste E. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth. 1991/1; 1: 8-12
Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
Basques BA, Toy JO, Bohl, DD, Golinvaux, NS, Grauer, JN. General Compared with Spinal Anesthesia for Total Hip Arthroplasty. The Journal of Bone and Joint Surgery 2015;97:455-61
Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 90 day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis, Lancet. 2013 Sep 28;382(9898):1097-104
Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
Williams-Russo P, Sharrock NE, Haas SB, et al. Randomized Trial of Epidural Versus General Anesthesia: Outcomes After Primary Total Knee Replacement. Clinical Orthopaedics & Related Research. 331:199-208, October, 1996.
National Surgical Quality Improvement Project database
FORCE-Total Joint Registry database
Warren, F., Sundaram, A., Anis, A., Kamath, S., Mont, S., Higuera, S., & Piuzzi, S. (2020). Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 28(5), e213–e221.

Measure Algorithm:

Specifications Manual for Joint Commission National Quality Measures (v2022B2)
Discharges 10-01-22 through 12-31-22 (4Q22)

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