Occurrence of never events after total joint arthroplasty in the United States

  • Allen J. TsaiEmail author
Orthopaedic Surgery



Total joint arthroplasty (TJA) is a major orthopedic procedure associated with substantial morbidity and mortality. Never events (NEs) are harmful hospital-acquired conditions (HACs) that are preventable.


Information on hospital admissions with TJA was collected from the National Inpatient Sample (NIS) from 2003 to 2012. NIS was queried to identify NE applicable to TJA patients based on the HAC definition listed by the Centers for Medicare and Medicaid Services (CMS). NEs were further compared before and after 2008 to evaluate the effect of the new CMS non-reimbursement policy on their incidence.


A total of 8,176,774 patients were admitted with TJA from 2003 to 2012. 108,668 patients of these (1.33%) had ≥ 1 NE. The most prevalent NE was fall and trauma (0.7%). Significant multivariable predictors with higher odds of developing at least one NE included weekend admission [odds ratio (99.9% CI), 4.3 (3.1, 5.8), p < 0.001] and weight loss [odds ratio (99.9% CI), 2.8 (2.2, 3.5), p < 0.001]. A temporal comparison of NE before and after 2008 revealed a decrease in total NE occurrence after 2008 when the CMS announced discontinuing payment for NE (1.39% vs. 1.25%, p < 0.001). After adjustment for potential confounding risk factors, NE after TJA was significantly associated with an increased mortality (p < 0.001), a longer hospital stay (p < 0.001), and higher total hospitalization charges (p < 0.001).


These data demonstrated that NE in TJA patients was predictive of an increased mortality, length of hospital stay, and hospitalization costs. This study established baseline NE rates in the TJA patient population to use as benchmarks and identified target areas for quality improvement in US.


Never events Total joint arthroplasty Hospital-acquired condition National Inpatient Sample Total hip arthroplasty Total knee arthroplasty Medical quality 



The paper was presented in abstract form at the Annual Conference of American College of Medical Quality in Washington DC 2018. The author AJT is supported by the National Quality Scholarship funded by the American College of Medical Quality. We thank Rocio Lopez, MS for the expert help in the statistical analysis.


There is no funding source.

Compliance with ethical standards

The study was granted an exempt status by the institutional review board because of the de-identified quality of the data from the national database

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.College of MedicineNortheast Ohio Medical University College of MedicineRootstownUSA

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