Do illness rating systems predict discharge location, length of stay, and cost after total hip arthroplasty?

Why Do Patients Choose Skilled Nursing Facilities After Total Hip and Knee Arthroplasty?

BACKGROUND

Current research indicates that total joint arthroplasty patients who are discharged to skilled nursing facilities (SNFs) have higher complication rates as compared to home. Many factors like age, sex, race, Medicare status, and past medical history have been shown to influence discharge destination. The present study sought to gather patient-indicated reasons for SNF discharge and identify potentially modifiable factors influencing the decision.

METHODS

Primary total joint arthroplasty patients were asked to complete surveys at their presurgical and 2-week postsurgical follow-up appointments. The surveys included home access and social support questions as well as patient-reported outcome measures: Patient-Reported Outcomes Measurement and Information System, Risk Assessment and Prediction Tool, Knee injury and Osteoarthritis Outcome Score for Joint Replacement, or Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement.

RESULTS

Of 765 patients who met inclusion criteria, 3.9% were discharged to an SNF and these were more frequently post-THA, women, older, Black, and persons living alone. Regression analyses indicated that lower Risk Assessment and Prediction Tool score, higher age, no caregiver presence, and Black race were significantly associated with SNF discharge. Patients discharged to an SNF most commonly reported social concerns rather than medical or home access concerns as the main factor for SNF discharge.

CONCLUSIONS

While age and sex are nonmodifiable factors, the availability of a caregiver and social support represents an important modifiable factor in regard to discharge destination. Dedicated attention during the preoperative planning period may help augment social support and avoid unnecessary discharges to SNFs.

Machine Learning Models Based on a National-Scale Cohort Identify Patients at High Risk for Prolonged Lengths of Stay Following Primary Total Hip Arthroplasty

BACKGROUND

Existing machine learning models that predicted prolonged lengths of stay (LOS) following primary total hip arthroplasty (THA) were limited by the small training volume and exclusion of important patient factors. This study aimed to develop machine learning models using a national-scale data set and examine their performance in predicting prolonged LOS following THA.

METHODS

A total of 246,265 THAs were analyzed from a large database. Prolonged LOS was defined as exceeding the 75th percentile of all LOSs in the cohort. Candidate predictors of prolonged LOS were selected by recursive feature elimination and used to construct four machine learning models-artificial neural network, random forest, histogram-based gradient boosting, and k-nearest neighbor. The model performance was assessed by discrimination, calibration, and utility.

RESULTS

All models exhibited excellent performance in discrimination (area under the receiver operating characteristic curve [AUC] = 0.72 to 0.74) and calibration (slope: 0.83 to 1.18, intercept: -0.01 to 0.11, Brier score: 0.185 to 0.192) during both training and testing sessions. The artificial neural network was the best performer with an AUC of 0.73, calibration slope of 0.99, calibration intercept of -0.01, and Brier score of 0.185. All models showed great utility by producing higher net benefits than the default treatment strategies in the decision curve analyses. Age, laboratory tests, and surgical variables were the strongest predictors of prolonged LOS.

CONCLUSION

The excellent prediction performance of machine learning models demonstrated their capacity to identify patients prone to prolonged LOS. Many factors contributing to prolonged LOS can be optimized to minimize hospital stay for high-risk patients.

Medicaid Payer Status Is Associated With Increased 90-Day Resource Utilization, Reoperation, and Infection Following Aseptic Revision Total Hip Arthroplasty

Background

Prior literature has demonstrated increased resource utilization and perioperative complications in patients with a Medicaid payor status undergoing primary total hip and knee arthroplasty. This relationship has yet to be explored in patients undergoing revision total hip arthroplasty (rTHA).

Methods

The National Readmissions Database was queried from 2010 to 2015 for all patients undergoing aseptic rTHA. 90-day complication data were collected, and patients were separated into two cohorts based on insurance payor type: Medicaid and non-Medicaid. Patients were propensity score matched 2:1 on a number of comorbid and operative characteristics. The relationship between Medicaid payor status and postoperative outcomes was then assessed using binomial logistic regression analysis.

Results

3,110 Medicaid patients were identified and matched to 6,175 non-Medicaid patients. Medicaid patients had increased odds of an early prosthetic joint infection (Odds Ratio [OR] 1.29, p=0.019), superficial surgical site infection (OR: 1.48, p=0.003), and early reoperation (OR: 1.18, p=0.045). Medicaid patients also experienced higher odds of readmissions, extended length of stay, non-home discharge status, and medical complications. Finally, the Medicaid cohort had a $3,332 (95% CI: 2,412-4,253, p<0.001) increased adjusted total cost of care when compared to the non-Medicaid cohort.

Conclusion

This study identifies the Medicaid payor status as an independent risk factor for increased resource utilization, reoperation, and infection in the early postoperative period for patients undergoing rTHA. This relationship is likely due to an interplay of multiple variables, including socioeconomic status and access to care. Level of Evidence: IV.

Obesity and perioperative outcomes in older surgical patients undergoing elective spine and major arthroplasty surgery

STUDY OBJECTIVE

To determine whether obesity status is associated with perioperative complications, discharge outcomes and hospital length of stay in older surgical patients.

DESIGN

Secondary analysis of five independent study cohorts (N = 1262).

SETTING

An academic medical center between 2001 and 2017 in the United States.

PATIENTS

Patients aged 65 years or older who were scheduled to undergo elective spine, knee, or hip surgery with an expected hospital stay of at least 2 days.

MEASUREMENTS

Body mass index (BMI) was stratified as nonobese (BMI ≤ 30 kg/m2), obesity class 1 (30 kg/m2 ≤ BMI < 35 kg/m2) or obesity class 2-3 (BMI ≥ 35 kg/m2). Primary outcomes included predefined intraoperative and postoperative complications, hospital length of stay (LOS), and discharge location. Univariate and multivariate logistic regression was performed.

MAIN RESULTS

Obesity status was not associated with intraoperative adverse events. However, obesity class 2-3 significantly increased the risk for postoperative complications (IRR 1.43, 95% CI 1.03-1.95, P = 0.03), hospital LOS (IRR 1.13, 95% CI 1.02-1.25, P = 0.02) and non-home discharge destination (OR 1.95, 95% CI 1.35-2.81, P < 0.001) after accounting for patient related factors and surgery type.

CONCLUSIONS

Obesity class 2-3 status has prognostic value in predicting an increased incidence of postoperative complications, increased hospital LOS, and non-home discharge location. These results have important clinical implications for preoperative informed consent and provide areas to target for care improvement for the older obese individual.

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BACKGROUND

The Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.

METHODS

This is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.

RESULTS

Controlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.

CONCLUSION

For patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty

BACKGROUND

With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA.

METHODS

At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites.

RESULTS

Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient.

CONCLUSION

Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital

Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.

Methods

In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.

Results

In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).

Conclusions

Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

The Influence of Modifiable, Postoperative Patient Variables on the Length of Stay After Total Hip Arthroplasty

BACKGROUND

Many studies have examined strategies to reduce length of stay (LOS) after total hip arthroplasty (THA), but few have focused on modifiable patient-specific information in the acute postoperative period. This study investigates the determinants of LOS after THA, with a focus on potentially modifiable factors.

METHODS

A total of 1278 patients undergoing elective THA from 2012 to 2014 were extracted from our institutional data warehouse at our academic orthopedic specialty hospital. Data were collected on patient demographics, comorbidities, inpatient opioid use, hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1. The main outcome was hospital LOS. Multivariate regression analysis was performed to identify independent risk factors for LOS over 3 days.

RESULTS

The average age of patients undergoing primary total hip arthroplasty in our cohort was 62.3 (standard deviation 10.7) years, and 52.7% were women. Eighty-one (6.3%) of 1278 patients had a LOS more than 3 days. Multivariate regression analysis demonstrated several statistically significant nonmodifiable and modifiable risk factors that influence LOS after THA. Nonmodifiable risk factors included nonwhite race (odds ratio [OR], 1.497), single marital status (OR, 1.724), increasing age (OR, 1.330), and increasing Charlson Comorbidity Index (OR, 1.411). Potentially modifiable risk factors included every 10 mg oral morphine equivalent consumption (1.069), every 5 postoperative hypotensive events (OR, 1.232), low hemoglobin (OR, 3.265), high glucose levels (OR, 1.887), and a high creatinine (OR, 2.874).

CONCLUSION

This study identifies potentially modifiable factors that are associated with increased LOS after THA, including postoperative opioid use and hypotensive events. Efforts to control narcotic use and initiatives aimed to reduce early postoperative hypotension could aid in reducing LOS. Furthermore, attempts should be made to correct postoperative anemia, high glucose levels, and a high creatinine level when possible.

Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty

BACKGROUND

With increased restraints and efforts to contain costs in total hip arthroplasty (THA), an emphasis has been placed on risk stratification. The purpose of this study was to determine whether Medicaid patients have increased resource utilization (including 90-day emergency department [ED] visits and readmissions) compared to Medicare or commercial insurance carriers. The study hypothesized that the Medicaid population would represent a high-risk cohort with increased resource utilization.

METHODS

The institutional database was retrospectively queried for primary THAs from 2013 to 2017 based on Current Procedural Terminology codes and patients undergoing revision surgery were excluded. Demographic information including age, sex, and body mass index (BMI) and medical comorbidities including American Society of Anesthesiologists (ASA) scores were evaluated. Patients were stratified by insurance type and length of stay (LOS), and 90-day ED visits and 90-day readmissions were assessed in univariable and multivariable analysis.

RESULTS

A total of 3674 primary THA patients were included in the analysis (including 116 with Medicaid, 1713 with Medicare, and 1845 with other insurance providers). Medicaid patients had significantly higher ASA scores (P < .001) and BMI (P < .001), with corresponding increase in procedure duration (115 vs 99 vs 105 minutes; P < .001). They had a prolonged LOS (2.5 vs 2.5 vs 1.5 days; P < .001) compared with other insurances, but similar to Medicare patients. Following discharge, in multivariable analysis controlling for age, BMI, and ASA score, Medicare patients were significantly more likely to return to the ED (odds ratio, 3.15; 95% confidence interval, 1.88-5.27; P < .001) and be readmitted (odds ratio, 2.46; 95% confidence interval, 1.26-4.81; P = .009).

CONCLUSION

Medicaid patients represent a higher risk cohort with increased resource utilization perioperatively, including longer LOS, and more 90-day ED visits and readmissions. This should be considered in outcome assessments and alternative expectations for the episode of care should be set for this population.