We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Comparison of US and Canadian Perioperative Outcomes and Hospital Efficiency After Total Hip and Knee Arthroplasty

Adam Hart, MSc, MD1; Stephane G. Bergeron, MD, MPH1,2; Laura Epure, MSc1,2; Olga Huk, MSc, MD1,2; David Zukor, MD1,2; John Antoniou, PhD, MD1,2
[+] Author Affiliations
1Department of Orthopaedic Surgery, Jewish General Hospital, Montréal, Québec, Canada
2Division of Orthopaedic Surgery, McGill University, Montréal, Québec, Canada
JAMA Surg. 2015;150(10):990-998. doi:10.1001/jamasurg.2015.1239.
Text Size: A A A
Published online

Importance  The combination of an aging population, growing number of medical interventions, and surging economic burden of health care has renewed interest in reevaluating and exploring new health care models.

Objectives  To compare the performance of the US and Canadian health care systems by assessing major complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to measure the efficiency of both health care models by comparing the postoperative length of stay.

Design, Setting, and Participants  With patients grouped according to the country where they underwent surgery, we queried the National Surgical Quality Improvement Program database to identify 55 335 Canadian and US patients who underwent primary elective THA or TKA between January 1, 2011, and December 31, 2012.

Main Outcomes and Measures  Differences in patient demographics, as well as the rate of 30-day major complications and length of stay, were compared between patients hospitalized in the United States and Canada.

Results  Baseline characteristics were similar between the groups. Most US patients underwent general anesthesia (THA, 61.8%; TKA, 59.4%); Canadian patients received more regional anesthesia (THA, 78.7%; TKA, 81.0%). Patients in the United States received more transfusions postoperatively (THA, 9.0% more; TKA, 6.4% more; P < .001) and had shorter hospitalizations (THA, 1.4 days less; TKA, 1.3 days less; P < .001) with a greater proportion of patients discharged to rehabilitation facilities (THA, 21.6% more; TKA, 26.6% more; P < .001). With results reported as incidence rate ratios (95% CIs), after adjusting for all other variables, risk factors, and adverse outcomes, having surgery in Canada increased the postoperative length of stay by 57% (1.57 [1.53-1.61]) for THA and 49% (1.49 [1.46-1.52]) for TKA. With results reported as odds ratios (95% CIs), major complications were significantly more common in Canada following TKA (1.65 [1.31-2.07]) but not THA (1.09 [0.79-1.51]).

Conclusions and Relevance  The rate of major complications was significantly higher in Canada following TKA, but there was no significant difference following THA. Patients undergoing the procedures in US hospitals also had substantially shorter lengths of hospital stay, perhaps reflecting more efficient postoperative care and discharge planning in those facilities.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Place holder to copy figure label and caption
Predicted Postoperative Length of Stay

Length of stay in healthy women with mean baseline characteristics (mean body mass index and preoperative creatinine hematocrit levels) undergoing uncomplicated total hip and total knee arthroplasty of typical duration and discharged home. Diagonal lines indicate the incidence rate ratio; shaded area on either side of each line, 95% CI.

Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

4 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles