Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program

Do Quality Measures or Hospital Characteristics Predict Readmission Penalties for Hip and Knee Arthroplasty?

BACKGROUND

Quality rating systems exist to grade the value of care provided by hospitals, but the extent to which these rating systems correlate with patient outcomes is unclear. The association of quality rating systems and hospital characteristics with excess readmission penalties for total hip arthroplasty (THA) and total knee arthroplasty (TKA) was studied.

METHODS

The fiscal year 2022 Inpatient Prospective Payment System final rule was used to identify 2,286 hospitals subject to the Hospital Readmissions Reduction Program. Overall, 6 hospital quality rating systems and 5 hospital characteristics were obtained. These factors were analyzed to determine the effect on hospital penalties for THA and TKA excess readmissions.

RESULTS

Hospitals that achieved a higher Medicare Overall Hospital Quality Star Rating demonstrated a significantly lower likelihood of receiving THA and TKA readmission penalties (Cramer's V = 0.236 and Rp = -0.233; P < .001 for both). Hospitals ranked among the US News & World Report's top 50 best hospitals for orthopaedics were significantly less likely to be penalized (V = 0.042; P = .043). The remaining 4 quality rating systems were not associated with readmission penalties. Penalization was more likely for hospitals with fewer THA and TKA discharges (Rp = -0.142; P < .001), medium-sized institutions (100 to 499 beds; V = 0.075; P = .002), teaching hospitals (V = 0.049; P = .019), and safety net hospitals (V = 0.043; P = .039). Penalization was less likely for West and Midwest hospitals (V = 0.112; P < .001).

CONCLUSIONS

A higher Overall Hospital Quality Star Rating and recognition among the US News & World Report's top 50 orthopaedic hospitals were associated with a reduced likelihood of THA and TKA readmission penalties. The other 4 widely accepted quality rating systems did not correlate with readmission penalties. Teaching and safety net hospitals may be biased toward higher readmission rates.

Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA.

METHODS

Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests.

RESULTS

Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01).

CONCLUSIONS

Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA.

TYPE OF STUDY

Level III retrospective cohort study.

Frailty Is Associated With Increased 30-Day Adverse Events and Hospitalization Costs After Primary Total Hip Arthroplasty

BACKGROUND

Frailty can predict adverse outcomes for multiple medical conditions and surgeries but is not well studied in total hip arthroplasty (THA). We evaluate the association between Hospital Frailty Risk Score and postoperative events and costs after primary THA.

METHODS

Using the National Readmissions Database, we identified primary THA patients for osteoarthritis, osteonecrosis, or hip fracture from January to November 2017. Using Hospital Frailty Risk Score, we compared 30-day readmission rate, hospital course duration, and costs between frail and nonfrail patients for each diagnosis, controlling for covariates. Thirty-day complication and reoperation rates were compared using univariate analysis.

RESULTS

We identified 167,700 THAs for osteoarthritis, 5353 for osteonecrosis, and 7246 for hip fractures. Frail patients had increased 30-day readmission rates (5.3% vs 2.5% for osteoarthritis, 7.1% vs 3.3% for osteonecrosis, 8.4% vs 4.3% for fracture; P < .01), longer hospital course (3.4 vs 1.9 days for osteoarthritis, 4.1 vs 2.1 days for osteonecrosis, 6.3 vs 3.9 days for fracture; P < .01), and increased costs ($18,712 vs $16,142 for osteoarthritis, $19,876 vs $16,060 for osteonecrosis, $22,185 vs $19,613 for fracture; P < .01). Frail osteoarthritis patients had higher 30-day complication (4.4% vs 1.9%; P < .01) and reoperation rates (1.6% vs 0.93%; P < .01). Frail osteonecrosis patients had higher 30-day complication rates (5.3% vs 2.6%; P < .01). Frail hip fracture patients had higher 30-day complication (6.6% vs 3.8%; P < .01) and reoperation rates (2.9% vs 1.8%; P < .01).

CONCLUSION

Frailty is associated with increased healthcare burden and postoperative events after primary THA. Further research can identify high-risk patients and mitigate complications and costs.

Which Factors Predict 30-Day Readmission After Total Hip and Knee Replacement Surgery?

Background

The Centers for Medicare and Medicaid Services enacted the Hospital Readmissions Reduction Program to impose penalties for diagnoses with high readmission rates. Despite several elective orthopedic procedures being included in this program, readmission rates have not declined, and associated costs have reached critical levels for total knee and total hip arthroplasty. Readmissions drastically impact patient outcomes. There are many known contributors to patient readmission rates, including infection, pain, and hematomas. However, evidence is inconclusive regarding other aspects, such as demographics, insurance, and discharge disposition. The purpose of this manuscript is to 1) measure hospital readmission rates for total knee and total hip arthroplasty, 2) evaluate the causes of readmissions, and 3) provide a predictive profile of risk factors associated with hospital readmissions.

Methods

Patients who underwent total knee or total hip arthroplasty were identified through a retrospective database review. An electronic chart review extracted data concerning patient demographics, comorbidities, surgical information, 30-day outcomes, and reasons for 30-day readmissions. Continuous and categorical variables were assessed with the Wilcoxon rank-sum test and the Chi-square test, respectively.

Results

A total of 6,065 patients were included, with 269 (4.4%) having at least one surgery-related 30-day readmission. No differences in readmission were noted with age, sex, or ethnicity; however, differences were found in weight and body mass index. Statistically significant comorbidities were heart failure, chronic obstructive pulmonary disease, dialysis, and alcohol use or abuse.

Conclusion

Our research indicated that surgery type, length of stay, and heart failure most significantly impacted 30-day readmission rates. By assessing readmission rates, we can take steps to optimize care for non-elective surgeries that will improve patient outcomes and cost-effectiveness.

Predictors for Telephone Outreach Post-hospital Discharge

PURPOSE OF STUDY

The specific aims of this study were to examine whether sociodemographic variables and medical-surgical diagnoses were associated with telephone follow-up (TFU) reach rates, emergency department visits, and hospital readmissions.

PRIMARY PRACTICE OF SETTING

Acute care inpatient units in an academic medical center.

METHODOLOGY AND SAMPLE

A correlational design was utilized, and a prospective medical record review of patients was conducted while implementing face-to-face prehospital discharge meeting interventions. The study sample (N = 176) included adult patients in two neurosurgical wards who were admitted between June 2016 and September 2016. Parametric and nonparametric tests were used to explore the balance between the intervention group receiving a face-to-face prehospital discharge meeting and comparison group receiving standard prehospital discharge care. Bivariate statistics were employed to determine associations between variables.

RESULTS

A total of 15 sociodemographic and medical-surgical variables were used to correlate TFU reach rates, emergency department (ED) visits, and readmission rates. Educational attainment (p = .002), employment status (p = .014), parental status (p = .010), and hospital service (p = .039) had significant differences between the intervention and comparison groups. Results demonstrated an improved reach rate for the intervention group but despite the differences in the groups, phi and Cramer's V coefficients did not correlate any associations with TFU reach rate, ED visits, and readmission rates with sociodemographic and surgical variables. This outcome affirmed that despite the similarities and differences in the sample, a face-to-face meeting prehospital discharge is an effective intervention to improve telephone outreach.

IMPLICATIONS TO CASE MANAGEMENT PRACTICE

There is a need to determine the most cost-effective way to increase TFU reach rates to prevent subsequent ED visits and hospital readmissions. There is also a need to develop a tool that can predict the hardest-to-reach patients posthospital discharge, so that case managers can meet those patients before leaving the hospital. In addition, it is important to identify alternative methods of "face-to-face" interactions during the COVID-19 pandemic crises. Case managers must explore ways with caution to leverage secured digital technology to bridge the gap of communicating with patients and family members when hospital visitations are limited.

Risk Factors for Readmissions After Total Joint Replacement: A Meta-Analysis

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We performed a systematic review and meta-analysis of predictive modeling studies examining the risk of readmission after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in order to synthesize key risk factors and evaluate their pooled effects. Our analysis entailed 15 compliant studies for qualitative review and 17 compliant studies for quantitative meta-analysis.

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A qualitative review of 15 predictive modeling studies highlighted 5 key risk factors for risk of readmission after THA and/or TKA: age, length of stay, readmission reduction policy, use of peripheral nerve block, and type of joint replacement procedure.

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A meta-analysis of 17 studies unveiled 3 significant risk factors: discharge to a skilled nursing facility rather than to home (approximately 61% higher risk), surgery at a low- or medium-procedure-volume hospital (approximately 26% higher risk), and the presence of patient obesity (approximately 34% higher risk). We demonstrated clinically meaningful relationships between these factors and moderator variables of procedure type, source of data used for model-building, and the proportion of male patients in the cohort.

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We found that many studies did not adhere to gold-standard criteria for reporting and study construction based on the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and NOS (Newcastle-Ottawa Scale) methodologies.

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We recommend that these risk factors be considered in clinical practice and future work alike as they relate to surgical, discharge, and care decision-making. Future work should also prioritize greater observance of gold-standard reporting criteria for predictive models.

Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review

Background

The aim of this systematic review is to assess if penalty-based pay-for-performance (P4P) programs are more effective in improving quality and cost outcomes compared to two other payment strategies (i.e., rewards and a combination of rewards and penalties) for surgical care in the United States. Penalty-based programs have gained in popularity because of their potential to motivate behavioral change more effectively than reward-based programs to improve quality of care. However, little is known about whether penalties are more effective than other strategies.

Materials and methods

A systematic literature review was conducted according to the PRISMA guideline to identify studies that evaluated the effects of P4P programs on quality and cost outcomes for surgical care. Five databases were used to search studies published from 2003 to March 1, 2020. Studies were selected based on the PRISMA guidelines. Methodological quality of individual studies was assessed based on ROBINS-I with GRADE approach.

Results

This review included 22 studies. Fifteen cross-sectional, 1 prospective cohort, 4 retrospective cohort, and 2 case-control studies were found. We identified 11 unique P4P programs: 5 used rewards, 3 used penalties, and 3 used a combination of rewards and penalties as a payment strategy. Five out of 10 studies reported positive effects of penalty-based programs, whereas evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.

Conclusions

This review highlights that P4P programs with a penalty design could be more effective than programs using rewards or a combination of rewards and penalties to improve quality of surgical care.

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Evidence on the effectiveness of pay-for-performance programs in quality improvement is mixed.

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Five out of 10 studies reported positive effects of penalty-based programs.

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Evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.

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The increasing use of penalty-based pay-for-performance programs has the potential to improve surgical care quality.

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Penalties may induce stronger provider and hospital behavioral change than other payment strategies.

In-hospital interventions for reducing readmissions to acute care for adults aged 65 and over: An umbrella review

PURPOSE

The aim of this umbrella review was to synthesize existing systematic review evidence on the effectiveness of in-hospital interventions to prevent or reduce avoidable hospital readmissions in older people (≥65 years old).

DATA SOURCES

A comprehensive database search was conducted in May 2019 through MEDLINE, EMBASE, CINAHL, the JBI Database of Systematic Reviews, DARE and Epistemonikos.

STUDY SELECTION

Systematic reviews and other research syntheses, including meta-analyses, exploring the effectiveness of hospital-based interventions to reduce readmissions for people aged 65 and older, irrespective of gender or clinical condition, were included for review. If a review did not exclusively focus on this age group, but data for this group could be extracted, then it was considered for inclusion. Only reviews in English were included.

DATA EXTRACTION

Data extracted for each review included the review objective, participant details, setting and context, type of studies, intervention type, comparator and findings.

RESULTS OF DATA SYNTHESIS

Twenty-nine reviews were included for analysis. Within these reviews, 11 intervention types were examined: in-hospital medication review, discharge planning, comprehensive geriatric assessment, early recovery after surgery, transitional care, interdisciplinary team care, in-hospital nutrition therapy, acute care geriatric units, in-hospital exercise, postfall interventions for people with dementia and emergency department-based palliative care. Except for discharge planning and transitional care, none of the interventions significantly reduced readmissions among older adults.

CONCLUSION

There is limited evidence to support the effectiveness of existing hospital-based interventions to reduce readmissions for people aged 65 and older.

Staphylococcus aureus Osteomyelitis: Bone, Bugs, and Surgery

Osteomyelitis, or inflammation of bone, is most commonly caused by invasion of bacterial pathogens into the skeleton. Bacterial osteomyelitis is notoriously difficult to treat, in part because of the widespread antimicrobial resistance in the preeminent etiologic agent, the Gram-positive bacterium Staphylococcus aureus Bacterial osteomyelitis triggers pathological bone remodeling, which in turn leads to sequestration of infectious foci from innate immune effectors and systemically delivered antimicrobials. Treatment of osteomyelitis therefore typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infection or sustain disease comorbidities. A better mechanistic understanding of how bacteria invade, survive within, and trigger pathological remodeling of bone could therefore lead to new therapies aimed at prevention or treatment of osteomyelitis as well as amelioration of disease morbidity. In this minireview, we highlight recent developments in our understanding of how pathogens invade and survive within bone, how bacterial infection or resulting innate immune responses trigger changes in bone remodeling, and how model systems can be leveraged to identify new therapeutic targets. We review the current state of osteomyelitis epidemiology, diagnostics, and therapeutic guidelines to help direct future research in bacterial pathogenesis.