Predictive risk factors for 30-day readmissions following primary total joint arthroplasty and modification of patient management

Epidemiological Characteristics and Trends of Primary Hip Arthroplasty in Five Tertiary Hospitals: A Multicenter Retrospective Study

OBJECTIVE

The number of primary hip arthroplasty (PHA) has increased sharply in recent years. Whether the epidemiological characteristics and trends of PHA have changed are unknown. This study aims to analyze the epidemiological characteristics and trends of those patients are urgent for public health institutions.

METHODS

The data of patients who underwent PHA in five tertiary hospitals from January 2011 to December 2020 were retrospectively reviewed. A total of 21,898 patients were included, most of whom were aged 60-69 years (25.1% males and 31.5% females). According to the hospitalization date, the patients were divided into two groups (Group A and Group B). The patients admitted between January 2011 and December 2015 were designated as Group A (7862), and those admitted between January 2016 and December 2020 were designated as Group B (14036). The patient data of the two groups, including sex, age, disease causes, body mass index (BMI), comorbidities, surgical procedures, hospital stay duration, and hospitalization costs, were analyzed by Pearson chi-Square test, Student t test or Mann-Whitney U test.

RESULTS

More women were included in Group B than in Group A (58.5% vs 52.5%, P < 0.001). The mean age of Group B was less than that of Group A (62.27 ± 14.77 vs 60.69 ± 14.44 years, P < 0.001). Femoral head necrosis was the primary pathogenic factor in both groups, with a higher proportion in Group B than in Group A (55.5% vs 45.5%, P < 0.001). Significant differences were found between the two groups in BMI, comorbidities, surgical procedures, hospital stay duration, and hospitalization costs. Total hip arthroplasty (THA) was the most common surgical procedure in both groups, with a higher proportion in Group B than in Group A (89.8% vs 79.3%, P < 0.001). The proportion of patients with one or more comorbidities was significantly higher in Group B than in Group A (69.2% vs 59.9%, P < 0.001). In addition, Group B had a shorter hospital stay duration and higher hospitalization costs than Group A.

CONCLUSION

Femoral head necrosis was the primary etiology for PHA in this study, followed by femoral neck fracture and hip osteoarthritis. Patients who underwent PHA exhibited a higher percentage of femoral head necrosis; underwent THA more often; and had larger BMIs, more comorbidities, higher medical costs, and younger age in the past decade.

Hospital Readmissions After Total Joint Arthroplasty: An Updated Analysis and Implications for Value-Based Care

BACKGROUND

While risk factors have been published for readmissions following primary total joint arthroplasty, little is known about the etiology of those costly adverse events. In this study, we sought to identify the reasons for 30-day readmission following primary total joint arthroplasty in a contemporary national patient sample.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify 367,199 patients who underwent primary total knee (TKA) or hip arthroplasty (THA) between 2011 and 2018. The primary outcomes were the annual rates of 30-day readmissions and the causes of those readmissions.

RESULTS

The 30-day readmission rate trended downward from 4.5% in 2011 to 3.3% in 2018. Medical complications accounted for 52.6% and 38.5% of readmissions following TKA and THA, respectively. Diseases of the circulatory system, abnormal laboratory values, and diseases of the digestive system were the leading causes of medical readmissions. Surgical complications accounted for 37.7% and 50.7% of readmissions following TKA and THA, respectively. Surgical site infections/wound disruption and venous thromboembolism were the leading two causes of surgical readmissions for THA and TKA. Prosthetic complications-namely dislocations and periprosthetic fractures-were the third leading cause of surgical readmissions for THA. For TKA, musculoskeletal conditions-namely pain and hematoma-were the third leading cause of surgical readmissions.

CONCLUSION

Medical complications accounted for half of all TKA readmissions and more than a third of THA readmissions. This could penalize institutions participating in value-based payment programs or dissuade others who are considering participation in such programs.

Changes in epidemiological characteristics of knee arthroplasty in eastern, northern and central China between 2011 and 2020

OBJECTIVE

To explore changes in the epidemiological and clinical characteristics of patients who underwent knee arthroplasty (KA) over a 10-year period in China.

METHODS

Medical records of patients with knee osteoarthritis (KOA), who underwent primary unilateral KA in 5 level I center hospitals in China between January 2011 and December 2020, were retrospectively reviewed and analyzed. To more clearly define changes over the years, patients were divided into two groups according to time of admission at 5-year intervals. Age, sex, body mass index (BMI), Kellgren-Lawrence (K-L) classification, comorbid diseases, surgical procedures, hospital stay, and hospitalization costs were compared between the two groups.

RESULTS

A total of 23,610 patients with KOA (5400 male and 18,210 females; mean age: 65.7 ± 7.6 years) who underwent primary unilateral KA were included. The number of KAs increased in recent years (group A, n = 7606 vs. group B, n = 16,004). Significant differences were noted in age, sex, BMI, K-L classification, comorbidities, surgical procedures, hospital stay, and hospitalization costs between the two periods (P < 0.05). More than three-quarters of KA cases involved females, and the age at surgery tended to be younger than that reported in foreign countries. In group B, the proportion of overweight and grade III, number of comorbidities, and unicompartmental knee arthroplasty patients increased compared to that in group A; however, hospitalization costs and length of hospital stay decreased.

CONCLUSIONS

Results suggested that the epidemiological characteristics of patients undergoing KA have changed over time. An analysis of the epidemiological characteristics of patients undergoing KA treatment may provide a scientific basis for the prevention and control of KOA.

Enhanced Preoperative Education Pathways: A Step Toward Reducing Disparities in Total Joint Arthroplasty Outcomes

BACKGROUND

Patients with increased comorbidities, lower socioeconomic status, and African American (AA) race have been shown to be at increased risk for suboptimal outcomes after total joint arthroplasty (TJA). Despite the body of evidence highlighting these disparities, few interventions aimed at improving outcomes specifically in high-risk patients have been evaluated. This study evaluates the impact of an enhanced preoperative education pathway (EPrEP) on outcomes after TJA.

METHODS

All patients included underwent unilateral primary total hip or knee arthroplasty at a single institution from September 1, 2020 to September 31, 2021. This is a retrospective observational cohort study comparing demographics, comorbidities, and outcomes of patients treated through EPrEP with those receiving routine care. Subgroup analysis of outcome differences by race was performed.

RESULTS

In total, 1,716 patients were included in the study: 802 went through the EPrEP and 914 did not. EPrEP patients had a higher comorbidity burden as measured by the Charlson Comorbidity Index (3.54 ± 1.71 vs 3.25 ± 1.75, P < .001). After risk adjustment, there was no significant relationship among EPrEP utilization and length of stay, home discharge, or 30-day readmissions. However, EPrEP patients were less likely to return to the emergency department 30 days postoperatively (odds ratio 0.49, 95% confidence interval 0.27-0.86, P = .016). No significant differences in outcomes between AA and non-AA patients were observed.

CONCLUSION

High-risk patients receiving individualized nurse navigator counseling experienced similar outcomes to the broader patient population undergoing TJA. Implementation of EPrEPs may be an effective means of enhancing the equity of care quality across all patients undergoing TJA.

The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty

BACKGROUND

Frailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically.

RESULTS

A total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001).

CONCLUSION

Chronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.

ACT Transition from Hospital to Home Orthopaedic Survey: a cross-sectional survey of unplanned 30-day readmissions for patients having total hip arthroplasty

OBJECTIVES

The aim of this study was to identify patient, hospital and transitional factors associated with unplanned 30-day readmissions in patients who had a total hip arthroplasty (THA).

DESIGN

A cross-sectional survey was performed. All patients attending a 6-week follow-up after a THA in the Australian Capital Territory (ACT) at four public and private clinics in the ACT from 1 February 2018 to 31 January 2019, were invited to complete an ACT Transition from Hospital to Home Orthopaedic Survey.

PARTICIPANTS

Within the ACT, 431 patients over the age of 16 attending their 6-week post-surgery consultation following a THA entered and completed the survey (response rate 77%).

PRIMARY OUTCOME MEASURE

The primary outcome measure was self-reported readmissions for any reason within 30 days of discharge after a THA. Multiple logistic regression was used to estimate ORs of factors associated with unplanned 30-day readmissions.

RESULTS

Of the 431 participants (representing 40% of all THAs conducted in the ACT during the study period), 27 (6%) were readmitted within 30 days of discharge. After controlling for age and sex, patients who did not feel rested on discharge were more likely to be readmitted within 30 days than those who felt rested on discharge (OR=5.75, 95% CI: (2.13 to 15.55), p=0.001). There was no association between post-hospital syndrome (ie, in-hospital experiences of pain, sleep and diet) overall and readmission. Patients who suffered peripheral vascular disease (PVD) were significantly more likely to have an unplanned 30-day readmission (OR=16.9, 95% CI: (3.06 to 93.53), p=0.001). There was no significant difference between private and public patient readmissions CONCLUSIONS: Hospitals should develop strategies that maximise rest and sleep during patients' hospital stay. Diagnosis and optimum treatment of pre-existing PVD prior to THA should also be a priority to minimise the odds of subsequent unplanned readmissions.

The Impact of Pre-Operative Healthcare Utilization on Complications, Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty

BACKGROUND

Identifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized.

METHODS

This is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU.

RESULTS

The 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events.

CONCLUSION

Patients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU.

LEVEL OF EVIDENCE

Level III.

Readmissions after elective orthopedic surgery in a comprehensive co-management care system-a retrospective analysis

Background

No surgical intervention is without risk. Readmissions and reoperations after elective orthopedic surgery are common and are also stressful for the patient. It has been shown that a comprehensive ortho-medical co-management model decreases readmission rates in older patients suffering from hip fracture; but it is still unclear if this also applies to elective orthopedic surgery. The aim of the current study was to determine the proportion of unplanned readmissions or returns to operating room (for any reason) across a broad elective orthopedic population within 90 days after elective surgery. All cases took place in a tertiary care center using co-management care and were also assessed for risk factors leading to readmission or unplanned return to operating room (UROR).

Methods

In this observational study, 1295 patients undergoing elective orthopedic surgery between 2015 and 2017 at a tertiary care center in Switzerland were investigated. The proportion of reoperations and readmissions within 90 days was measured, and possible risk factors for reoperation or readmission were identified using logistic regression.

Results

In our cohort, 3.2% (42 of 1295 patients) had an UROR or readmission. Sixteen patients were readmitted without requiring further surgery—nine of which due to medical and seven to surgical reasons. Patient-related factors associated with UROR and readmission were older age (67 vs. 60 years; p = 0.014), and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3 (43% vs. 18%; p < 0.001). Surgery-related factors were: implantation of foreign material (62% vs. 33%; p < 0.001), duration of operation (76 min. vs. 60 min; p < 0.001), and spine surgery (57% vs. 17%; p < 0.001). Notably, only spine surgery was also found to be independent risk factor.

Conclusion

Rates of UROR during initial hospitalization and readmission were lower in the current study than described in the literature. However, several comorbidities and surgery-related risk factors were found to be associated with these events. Although no surgery is without risk, known threats should be reduced and every effort undertaken to minimize complications in high-risk populations. Further prospective controlled research is needed to investigate the potential benefits of a co-management model in elective orthopedic surgery.

Early Discharge After Total Hip Arthroplasty at an Urban Tertiary Care Safety Net Hospital: A 2-Year Retrospective Cohort Study

INTRODUCTION

Previous studies have shown that shorter inpatient stays after total hip arthroplasty (THA) are safe and effective for select patient populations with limited medical comorbidity and perioperative risk. The purpose of our study was to compare the postoperative complications because they relate to the length of hospital stay at a safety net hospital in the urban area of the United States.

METHODS

We retrospectively reviewed the medical records of 236 patients who underwent primary THA in 2017 at an urban safety net hospital. We collected data on demographics, medical comorbidities, and surgical admission information. Patients were categorized as "early discharge" if they were discharged on postoperative day 0 to 1 and "standard discharge" if they were discharged on postoperative day 2 to 5. The outcomes of interest were 90-day and 2-year postoperative complications, emergency department visit, readmissions, and revision surgeries. Data were analyzed using t-test or chi-square test for univariate analysis and linear logistic regression for controlled analysis.

RESULTS

Compared with the standard discharge group, there were markedly more male patients in the early discharge group (44.5% versus 80%). Early discharge patients were markedly younger (53.3 versus 59.5 years old), more likely to be White/non-Hispanic (64.4% versus 42.4%) and less likely to have heart disease and diabetes (2.2% versus 15.2% and 2.2% versus 19.9%, respectively). With adjustment for these potential confounders, no notable difference was observed in all-type complications, emergency department visits, readmission, or revision surgery between the two groups.

DISCUSSION

This study confirmed that early discharge after THA is as safe as standard discharge in a safety net hospital with appropriate preoperative risk screening. Increased perioperative counseling and optimization of social and medical risk factors mitigated possible risk factors for increased length of stay and surgical complication.

Nationwide analysis on the impact of peripheral vascular disease following primary total knee arthroplasty: A matched-control analysis

BACKGROUND

As the prevalence of peripheral vascular disease (PVD) continues to increase nationwide, studies demonstrating its effects following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study was to evaluate whether patients with PVD have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) medical complications; 4) implant-related complications; and 5) costs of care.

METHODS

Using a nationwide database, patients with PVD undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 1,547,092 between the cohorts. Outcomes analyzed included: in-hospital LOS, readmission rates, complications, and costs of care. A p-value less than 0.004 was considered statistically significant.

RESULTS

PVD patients had significantly longer in-hospital LOS (4-days vs. 3-days, p < 0.0001). Additionally, the study cohort had a higher incidence and odds (OR) of readmissions (20.5 vs. 15.2%; OR: 1.43, 95% CI: 1.42-1.45, p < 0.0001), medical complications (2.46 vs. 1.32%; OR: 1.88, CI: 1.83-1.94, p < 0.0001), and implant-related complications (3.82 vs. 2.18%; OR: 1.78, CI: 1.26-1.58, p < 0.0001). Additionally, the study found patients with PVD had higher day of surgery (p < 0.0001) and 90-day costs of care (p < 0.0001).

CONCLUSIONS

After adjusting for confounding variables the results of the study show patients with PVD undergoing primary TKA have longer in-hospital LOS; in addition to higher rates of complications, readmissions, and costs of care. The study can be utilized by orthopaedists to adequately counsel patients of the potential complications following their procedure.

Body Mass Index, American Society of Anesthesiologists Score, and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty

BACKGROUND

Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable.

METHODS

A retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS.

RESULTS

In total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption.

CONCLUSION

Although ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Reimbursement Penalties and 30-Day Readmissions Following Total Joint Arthroplasty

The U.S. Patient Protection and Affordable Care Act created the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition Reduction Program (HACRP). Under these programs, hospitals face reimbursement reductions for having high rates of readmission and hospital-acquired conditions. This study investigated whether readmission following total joint arthroplasty (TJA) under the HRRP was associated with reimbursement penalties under the HACRP.

Comparison of readmission and early revision rates as a quality metric in total knee arthroplasty using the Nationwide Readmission Database

Background

After release of the Comprehensive Care for Joint Replacement bundle, there has been increased emphasis on reducing readmission rates for total knee arthroplasty (TKA). The potential for a separate, clinically-relevant metric, TKA revision rates within a year following surgery, has not been fully explored. Based on this, we compared rates and payments for TKA readmission and revision procedures as metrics for improving quality and cost.

Methods

We utilized the 2013 Nationwide Readmission Database (NRD) to examine national readmission and revision rates, the reasons for revision procedures, and associated costs for elective TKA procedures. As data are not linked across years, we examined revision rates for TKA completed in the month of January by capturing revision procedures in the subsequent following 11-month period to approximate a 1-year revision rate. Diagnosis and procedure codes for revision procedures were collected. Average readmission and revision procedure costs were then calculated, and the cost distributed across the entire TKA population.

Results

We identified 20,851 patients having TKA surgery. The mean unadjusted 30- and 90-day TKA readmission rates were 3.4% and 5.8%, respectively. In contrast, the mean unadjusted 3-month and approximate 1-year reoperation rates were 1.0% and 1.6%, respectively. The most common cause for revision was periprosthetic joint infection, which accounting for 62% of all reported revision procedures. The mean payment for 90-day readmission was roughly half ($10,589±$11,084) of the mean inpatient payment for single reoperation procedure at 90 days ($20,222±$17,799). Importantly, nearly half (46%) of all 90-day readmissions were associated with a reoperation event within the first year.

Conclusions

Readmission following TKA is associated with a 1-year reoperation in approximately half of patients. These reoperations represent a significant patient burden and have a higher per episode cost. Early reoperation may represent a more clinically relevant target for quality improvement and cost containment.

Predictors of extended length of stay after unicompartmental knee arthroplasty

PURPOSE

To identify factors that independently predict extended length of stay after unicompartmental knee arthroplasty (UKA) surgery (defined as length of stay longer than 3 days), and to identify factors predicting early post-operative complications.

METHODS

A retrospective analysis of all patients undergoing UKA from January 2016-January 2019 at our institution was performed. Clinical notes were reviewed to determine the following information: Patient age (years), gender, American Society of Anesthesiologists (ASA) grade, weight (kg), height (meters), body mass index (BMI), co-morbidities, indication for surgery, surgeon, surgical volume, surgical technique (navigated or patient-specific instrumentation), implant manufacturer, estimated blood loss (ml), application of tourniquet during the surgery, application of drain, hospital length of stay (days) and surgical complications.

RESULTS

Multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 4.4 (CI; 1.8-10.8, p = 0.001)] and a history of cardiovascular disease [OR 2.8 (CI; 1.4-5.5), p = 0.004)] were significant independent predictors of prolonged length of stay. Hosmer-Lemeshow goodness of fit of the model showed a p-value of 0.214. Nagelkerke R-Square was 0.2. For complications, multivariate regression analysis showed that ASA 3-4 vs. ASA 1-2 [OR 5.8 (CI; 1.7-20.7)] and high BMI (BMI >30) [OR 4.3 (CI; 1.1-17.1)] were significant independent predictors of complications. Hosmer-Lemeshow goodness of fit was 0.89 and Nagelkerke R-Square was 0.2. Patients treated with robotics (Navio) techniques had shorter length of stay median 51 h (IQR; 29-96) when compared to other techniques 72 h (IQR; 52-96), p = 0.008.

CONCLUSION

Based on the results of our study, high ASA grade (≥3) appears to be the most important factor excluding eligibility for fast-track UKA. Any number of co-morbidities may increase ASA, but in and of themselves, apart from a history of cardiovascular disease, they should not be seen as contraindications. Appropriate patient selection, technical tools and details during the surgery could facilitate fast track surgery.

RATeS (Re-Admissions in Trauma and Orthopaedic Surgery): a prospective regional service evaluation of complications and readmissions

INTRODUCTION

All the surgeries carry risks, which may lead to readmission at a later date. At present, there is limited Trauma and Orthopaedic (T&O) specific data in the literature. As a result, a prospective regional service evaluation aimed to discover the current complication and readmission rates across all T&O procedures and identify any factors associated with these outcomes.

METHODS

Data were collected at six sites across Yorkshire and Humber for all T&O procedures during October 2016. Patient demographics and procedure-specific data were collected. Post-operative complications and length of stay were recorded. All the patients were then followed up for 30 days post-discharge to determine if they experienced complications which resulted in readmission and further surgical intervention.

RESULTS

1411 patients having a total of 64 operations were recorded with 1391 completing follow-up (98.5%). Overall in-patient complication rate was 8.4% with the readmission rate being 4.4%. An ASA grade of three or more was found to be associated with readmission. Procedure-related factors such as the use of VTE prophylaxis and prophylactic antibiotics, as well as the elective nature of certain operations were negatively associated with readmission. The largest subgroup of patients was those undergoing total hip (THR) or knee replacements (TKR). For these 234 patients, the readmission rate for TKR and THR being 3.77% and 3.13%, respectively.

CONCLUSIONS

This large, multi-centre project describes readmission rates following trauma and orthopaedic surgery. In the presented study, the elective nature of the procedure was associated with a reduced risk of readmission.

Patient-related risk factors for unplanned 30-day readmission following total knee arthroplasty: a protocol for a systematic review and meta-analysis

BACKGROUND

Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty is an effective treatment for advanced stages of disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. The objective is to perform a systematic review of patient-related factors associated with unplanned 30-day readmission following total knee arthroplasty. This information will inform future strategies to improve health outcomes after knee arthroplasty surgery.

METHODS

MEDLINE and EMBASE will be systematically searched using a comprehensive search strategy. Studies of higher quality than case series will be included, in order to optimise the quality of the findings of this review. We will include studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision total knee arthroplasty for any indication. Case series will be excluded, as will studies reporting exclusively on intraoperative, clinician, hospital, and health system risk factors. The reference lists of selected papers will then be screened for any additional literature. Two reviewers will independently apply stringent eligibility criteria to titles, abstracts, and full texts of studies identified in the literature search. They will then extract data from the final list of selected papers according to an agreed-upon taxonomy and vocabulary of the data to be extracted. Assessment of risk of bias and quality of evidence will then take place. Finally, the effect size of each identified risk factor will be determined; meta-analysis will be performed where adequate data is available.

DISCUSSION

The findings of this review and subsequent meta-analysis will aid clinicians as they seek to understand the risk factors for 30-day readmission following total knee arthroplasty. Clinicians and patients will be able to use this information to align expectations of the postoperative course, which will enhance the recovery process, and aid in the development of strategies to mitigate identified risks. Another purpose of this review is to assist policy-makers in developing quality indicators for care and provide insights into the drivers of health costs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019118154.

Emergency Department Visit Within One Year Prior to Elective Total Joint Arthroplasty Is Predictive of Postoperative Return to Emergency Department Within 90 Days

BACKGROUND

The Comprehensive Care for Joint Replacement Model, developed by Centers for Medicare and Medicaid Services, aims to improve the quality of joint replacement. Metrics including emergency room visit rates after primary total knee and total hip arthroplasty (TKA and THA) are of particular interest. The purpose of this study is to determine if preoperative emergency department (ED) visits are predictive of postoperative ED visits among patients undergoing elective THA or TKA.

METHODS

In a retrospective analysis of 6996 patients who underwent elective primary arthroplasty (2453 hips, 4543 knees), we identified all patients who had an ED visit from up to 1 year prior to their surgical date to 90 days after. We assessed if preoperative visit frequency or temporality is predictive of a return to the ED visit within 90 days.

RESULTS

TKA and THA patients with a single preoperative ED visit had an odds ratio of 1.9 and 2.0, respectively, of returning to the emergency room postoperatively (P < .001). Increasing preoperative visit frequency correlated with increasing odds ratios (1.9-16.7, P < .001). The proximity of the most recent preoperative visit prior to surgery had a positive trend toward a larger effect, but did not clearly demonstrate a dose-dependent effect.

CONCLUSION

Presentation to the ED is common prior to total joint arthroplasty and is predictive of a postoperative visit within 90 days. Increasing preoperative visit frequency further increases a patient's risk of a postoperative visit within 90 days.

A Weighted Index of Elixhauser Comorbidities for Predicting 90-day Readmission After Total Joint Arthroplasty

BACKGROUND

Evolving reimbursement models increasingly compel hospitals to assume costs for 90-day readmission after total joint arthroplasty. Although risk assessment tools exist, none currently reach the predictive performance required to accurately identify high-risk patients and modulate perioperative care accordingly. Although unlikely to perform adequately alone, the Elixhauser index is a set of 31 variables that may lend value in a broader model predicting 90-day readmission.

METHODS

Elixhauser comorbidities were examined in 10,022 primary unilateral total joint replacements, of which 4535 were hip replacements and 5487 were knee replacements, all performed between June 2013 and January 2018 at a single tertiary referral center. Data were extracted from electronic medical records using structured query language. After randomizing to derivation (80%) and validation (20%) subgroups, predictive models for 90-day readmission were generated and transformed into a system of weights based on each parameter's relative performance.

RESULTS

We observed 497 90-day readmissions (5.0%) during the study period, which demonstrated independent associations with 14 of the 31 Elixhauser comorbidity groups. A score created from the sum of each patient's weighted comorbidities did not lose substantial predictive discrimination (area under the curve: 0.653) compared to a comprehensive multivariable model containing all 31 unweighted Elixhauser parameters (area under the curve: 0.665). Readmission risk ranged from 3% for patients with a score of 0 to 27% for those with a score of 8 or higher.

CONCLUSIONS

The Elixhauser comorbidity score already meets or exceeds the predictive discrimination of available risk calculators. Although insufficient by itself, this score represents a valuable summary of patient comorbidities and merits inclusion in any broader model predicting 90-day readmission risk after total joint arthroplasty.

LEVEL OF EVIDENCE

III.

Safety of Outpatient Single-level Cervical Total Disc Replacement: A Propensity-Matched Multi-institutional Study

STUDY DESIGN

A retrospective cohort comparison study.

OBJECTIVE

The aim of this study was to investigate the perioperative adverse event profile of cervical total disc replacement (CTDR) performed as an outpatient relative to inpatient procedure.

SUMMARY OF BACKGROUND DATA

Recent reimbursement changes and a push for safe reductions in hospital stay have resulted in increased interest in performing CTDRs in the outpatient setting. However, there has been a paucity of studies investigating the safety of outpatient CTDR procedures, despite increasing frequency.

METHODS

Patients who underwent single-level CTDR were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Outpatient versus inpatient procedure status was defined by length of stay, with outpatient being less than 1 day. Patient baseline characteristics and comorbidities were compared between the two groups. Propensity score matched comparisons were then performed for 30-day perioperative complications and readmissions between the two cohorts. In addition, perioperative outcomes of outpatient single-level CTDR versus matched outpatient single-level anterior cervical discectomy and fusion (ACDF) cases were compared.

RESULTS

In total, 373 outpatient and 1612 inpatient single-level CTDR procedures were identified. After propensity score matching was performed to control for potential confounders, statistical analysis revealed no significant difference in perioperative complications between outpatient versus matched inpatient CTDR. Notably, the rate of readmissions was not different between the two groups. In addition, there was no difference in rates of perioperative adverse events between outpatient single-level CTDR versus matched outpatient single-level ACDF.

CONCLUSION

The perioperative outcomes evaluated in the current study support the conclusion that, for appropriately selected patients, single-level CTDR can be safely performed in the outpatient setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient CTDR or outpatient single-level ACDF.

LEVEL OF EVIDENCE

3.

Unlike Native Hip Fractures, Delay to Periprosthetic Hip Fracture Stabilization Does Not Significantly Affect Most Short-Term Perioperative Outcomes

BACKGROUND

The incidence of periprosthetic hip fractures is increasing due to higher numbers of total hip arthroplasties being performed. Unlike native hip fractures, the effect of time to surgery of periprosthetic hip fractures is not well established. This study evaluates the effect of time to surgery on perioperative complications for patients with periprosthetic hip fractures.

METHODS

Patients who underwent surgery for periprosthetic hip fracture were identified in the 2005-2016 National Surgical Quality Improvement Program database and stratified into 2 groups: <2 and ≥2 days from hospital admission to surgery. Multivariate regressions were used to compare risk for perioperative complications between the 2 groups. Independent risk factors for postoperative serious adverse events were characterized.

RESULTS

In total, 409 (<2 days from admission to surgery) and 272 (≥2 days from admission to surgery) patients were identified. Multivariate analysis revealed only higher risk of extended postoperative stay for patients who had delays of ≥2 days to surgery compared to those who had <2 days from admission to surgery. Independent risk factors for serious adverse events included increasing age, dependent preoperative functional status, and preoperative congestive heart failure, but not time to surgery.

CONCLUSION

Unlike for native hip fractures, time to surgery for periprosthetic hip fractures does not appear to affect most 30-day perioperative complications. However, it is worth noting that this study was unable to control for all potential confounders and therefore the results may not be generalizable to all types of periprosthetic hip fractures.

Elective Total Shoulder Arthroplasty in Octogenarians: A Safe Procedure

INTRODUCTION

There has been a lack of studies investigating the perioperative course of total shoulder arthroplasty (TSA) performed in the increasingly octogenarian (≥80 years old) population in a large sample size. The purpose of this study was to compare perioperative complications between primary TSA performed in octogenarians and that performed in younger populations (<70 and 70 to 79 years old) from the National Surgical Quality Improvement Program database.

METHODS

Patients who underwent primary TSA between January 2005 and December 2015 were identified from the National Surgical Quality Improvement Program database and stratified into three age groups: <70, 70 to 79, and ≥80 years old. Patient characteristics and comorbidities were compared between the three groups. Propensity score-matched comparisons were then performed for length of hospital stay, 30-day perioperative complications, and readmissions. Risk factors and reasons for readmission in the octogenarians were characterized.

RESULTS

This study included 3,007 patients who were <70 years old, 2,155 patients who were 70 to 79 years old, and 900 octogenarian patients. Statistical analysis was carried out after matching for propensity score. While no significant differences in perioperative complications were observed between the octogenarians and 70- to 79-year-olds, significantly higher rates of readmission (4.2% versus 1.7%; P = 0.002), pneumonia (1.1% versus 0.0%; P = 0.002), and urinary tract infection (1.8% versus 0.2%; P = 0.001) were found in the octogenarians compared with <70-year-olds. In addition, the octogenarians also had a slightly longer length of hospital stay compared with the younger populations (0.6 days longer than <70-year-olds and 0.4 days longer than 70- to 79-year-olds; both P < 0.001).

CONCLUSION

These data suggest that primary TSA can safely be considered for octogenarians with only mildly increased morbidities. However, greater preoperative optimization or post-discharge care for octogenarians may be warranted to reduce the rates of readmission.

Is Discharge Within a Day of Total Knee Arthroplasty Safe in the Octogenarian Population?

BACKGROUND

Reduced hospital stay programs for total knee arthroplasty (TKA) are being implemented in order to increase patient satisfaction and reduce healthcare costs. Although elderly patients are often included in these pathways, there have been limited data on whether older patients can safely be discharged within a day after TKA. The purpose of this study is to compare perioperative complications following primary TKA with ≤1 day in the hospital in patients aged ≥80 compared to <80 years old in the National Surgical Quality Improvement Program database.

METHODS

Patients who underwent primary TKA with hospital length of stay ≤1 day were identified in the 2005-2016 National Surgical Quality Improvement Program database. These patients were separated into 2 age groups: <80 and ≥80 years old. Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for perioperative adverse events and readmission. Independent risk factors for serious adverse events following such TKAs were identified.

RESULTS

In total, 17,191 (<80 year olds) and 1005 (≥80 year olds) cases were identified. Of these patients, 1750 cases were discharged the same day. Multivariate analysis revealed only higher risk for 30-day readmission and nonhome discharge in ≥80 compared to <80 year olds. Notably, the octogenarians had a significantly higher rate of nonsurgical site-related readmissions. Independent risk factors for serious adverse events include only American Society of Anesthesiologists score ≥3 and not patient age.

CONCLUSION

These data suggest that, although octogenarians can safely be discharged in ≤1 day, greater postdischarge care may be warranted to reduce the rate of nonsurgical site-related readmissions.

G, Shah A, Godoy-Santos AL, Naranje S. RISK FACTORS FOR EARLY HOSPITAL READMISSION FOLLOWING TOTAL KNEE ARTHROPLASTY

Objective

To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty.

Methods

Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission.

Results

137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations.

Conclusions

Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study.

Postdischarge Unscheduled Care Burden After Lower Limb Arthroplasty

BACKGROUND

In contrast to postdischarge arthroplasty readmission rates, the unscheduled reattendance burden to primary care is under-reported. Understanding reasons for reattendance would allow for implementation of strategies to reduce this burden. The present study aims to quantify the out-of-hours (OOH) general practitioner and emergency department (ED) service reattendance burden and readmission rate after primary total hip arthroplasty and total knee arthroplasty, with estimation of the associated costs.

METHODS

This is a prospective consecutive cohort study. A prospective audit of all total hip arthroplasty and total knee arthroplasty patients in 2016 in a single high-volume UK arthroplasty unit was performed. Incidence and reasons for reattendance to OOH and ED service, as well as readmission rates, at both 30 and 90 days following discharge are reported. A multivariate analysis was performed to determine patient characteristics, which results in increased reattendance and readmission rates.

RESULTS

A total of 2351 procedures resulted in 374 attendances of OOH service and 665 to ED with a total estimated cost of £190,000 within 90 days. The readmission rate was 6.8%. Risk factors for reattendance and readmission were increasing age and a prolonged length of stay. The use of a 5-day postdischarge phone call and a dedicated Arthroplasty Care Practitioner favors reduced reattendances but not the readmission rate, with the additional benefit of being cost-effective.

CONCLUSION

The postdischarge arthroplasty reattendance burden is associated with significant costs, and strategies to reduce this should be developed. Further research is required to assess the effectiveness and cost-effectiveness of multicomponent strategies to reduce reattendance operating at scale.

Predictors and Cost of Readmission in Total Knee Arthroplasty

BACKGROUND

The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost.

METHODS

We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population.

RESULTS

We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost.

CONCLUSIONS

A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.

Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1)

In the face of escalating costs and variations in quality of care, bundled payment models for total joint arthroplasty procedures are becoming increasingly common, both through the Centers for Medicare & Medicaid Services and private payer organizations. The effective implementation of these payment models requires cooperation between multiple service providers to ensure economic viability without deterioration in care quality. This article introduces a stepwise model for the financial analysis of bundled contracts for use in negotiations between hospitals and private payer organizations.

Comorbidities Have a Greater Impact Than Age Alone in the Outcomes of Octogenarian Total Knee Arthroplasty

BACKGROUND

Increasing age and various comorbidities are known risk factors for complications after total knee arthroplasty (TKA), but data on the impact of total comorbidity burden is scarce. We investigated the effect of age and total comorbidity burden on outcomes after primary TKA in octogenarians (OGs).

METHODS

A matched-pair comparison study was conducted using prospectively collected TKA registry data in a large tertiary institution. Between 2006 and 2011, consecutive OGs undergoing primary unilateral TKA, with minimum 2-year follow-up, were matched 1:1 with younger controls based on demographic and surgical variables. We compared the Charlson comorbidity index (CCI), complication rate, length of stay (LOS), 30-day readmission, and 2-year reoperation rate. Multivariate analysis was performed to determine the effects of age and CCI on each outcome.

RESULTS

There were 209 OGs and 209 controls. OGs were significantly older (mean age 82.1 vs 66.1 years, P < .001) and had higher CCI. OGs had longer mean LOS (6.3 vs 5.4 days, P = .001), and a trend for more complications and readmissions. The complication rate increased from 7.5% for CCI = 0, to 33.3% for CCI ≥3 (P = .005). The LOS increased from 5.4 days for CCI = 0, to 9.6 days for CCI ≥3 (P < .001). Multivariate analysis showed that higher CCI was an independent risk factor for complications and longer LOS, whereas age was not.

CONCLUSION

Comorbidity burden has a greater impact than age alone on TKA outcomes in OGs. Well-selected OGs remain good candidates for TKA.

Effect of Spinal Fusion Surgery on Total Hip Arthroplasty Outcomes: A Matched Comparison Study

BACKGROUND

Studies regarding postoperative outcomes after primary total hip arthroplasty (THA) in patients who have comorbid factors tend to focus on medical diseases. However, there is a paucity of literature examining the effect of a patient's orthopedic surgical history on outcomes after THA. Significantly, there are currently no studies on the effect of spinal fusion surgery on THA outcomes.

METHODS

A review of 82 consecutive patients who had prior spinal fusion surgery who underwent elective THA from January 1, 2006 to December 31, 2015, was conducted. A matching cohort of 82 patients was selected from the remaining THA patients to maintain a 1:1 ratio control group. This cohort of 82 patients was matched for age, gender, body mass index ±5, preoperative Oxford score ±10, total Short Form-36 score ±10, and total Western Ontario and McMaster Universities Arthritis Index (WOMAC) score ±50. Data on the same functional outcomes were prospectively collected at 6-month and 2-year follow-up for comparison.

RESULTS

Patients without spinal fusion had better outcome scores than patients with prior spinal fusion, specifically in their 6-month WOMAC scores (253.33-225.07; P = .046), their 2-year Short Form-36 total scores (79.71-69.21; P = .041), and their 2-year WOMAC scores (213.5-267.41; P = .054).

CONCLUSION

This study demonstrates that patients with prior spinal fusion had worse outcomes after THA than patients without prior spinal fusion. This has clinical significance in counseling patients with previous spinal fusion undergoing THA.

All-Cause Versus Complication-Specific Readmission Following Total Knee Arthroplasty

BACKGROUND

Unplanned readmissions have become an important quality indicator, particularly for reimbursement; thus, accurate assessment of readmission frequency and risk factors for readmission is critical. The purpose of this study was to determine (1) the frequency of and (2) risk factors for readmissions for all causes or procedure-specific complications within 30 days after total knee arthroplasty (TKA) as well as (3) the association between hospital volume and readmission rate.

METHODS

The Statewide Planning and Research Cooperative System (SPARCS) database from the New York State Department of Health was used to identify 377,705 patients who had undergone primary TKA in the period from 1997 to 2014. Preoperative diagnoses, comorbidities, and postoperative complications were determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Readmission was defined as all-cause, due to complications considered by the Centers for Medicare & Medicaid Services (CMS) to be TKA-specific, or due to an expanded list of TKA-specific complications based on expert opinion. Multivariable logistic regression analysis was utilized to determine the independent predictors of readmission within 30 days after surgery.

RESULTS

There were 22,076 all-cause readmissions-a rate of 5.8%, with a median rate of 3.9% (interquartile range [Q1, Q3] = 1.1%, 7.2%]) among the hospitals-within 30 days after discharge. Of these, only 11% (0.7% of all TKAs) were due to complications considered to be TKA-related by the CMS whereas 31% (1.8% of all TKAs) were due to TKA-specific complications on the expanded list based on expert opinion. Risk factors for TKA-specific readmissions based on the expanded list of criteria included an age of >85 years (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.15 to 1.52), male sex (OR = 1.41, 95% CI = 1.34 to 1.49), black race (OR = 1.24, 95% CI = 1.14 to 1.34), Medicaid coverage (OR = 1.40, 95% CI = 1.26 to 1.57), and comorbidities. Several comorbid conditions contributed to the all-cause but not the TKA-specific readmission risk. Very low hospital volume (<90 cases per year) was associated with a higher readmission risk.

CONCLUSIONS

The frequency of readmissions for TKA-specific complications was low relative to the frequency of all-cause readmissions. Reasons for hospital readmission are multifactorial and may not be amenable to simple interventions. Health-care-quality measurement of readmission rates should be calculated and risk-adjusted on the basis of procedure-specific criteria.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unplanned readmissions after primary total knee arthroplasty in Korean patients: Rate, causes, and risk factors

BACKGROUND

Unplanned hospital readmissions are indicators of the quality and performance of a health care system, but data on early readmission after primary total knee arthroplasty (TKA) in the Asian population are limited. The purpose of this study was to determine the causes, risk factors, and rate of unplanned readmission after primary TKA at a single institution in Korea.

METHODS

We analyzed all primary TKAs from 2004 to 2013 using the data from our institutional electronic database. A total of 4596 TKAs were performed on 3049 patients. All unplanned readmissions within 30 and 90days of discharge were identified, categorized into arthroplasty-related, medical, and other orthopedic causes.

RESULTS

The overall unplanned readmission rate was 1.9% (n=59) within 30days and 3.3% (n=101) within 90days, and both the 30 and 90day readmission rates remained stable over the entire study period. The majority of readmissions involved arthroplasty-related causes; the most common cause being wound problems, accounting for 22% (13/59) within 30days and 24% (24/101) within 90days. Age (P=0.029) and hypertension (P=0.021) were identified as risk factors for unplanned readmissions after TKA.

CONCLUSION

This study demonstrates that unplanned readmissions after TKA are not infrequent in Korean patients and has identified wound complication as the most frequent cause of unplanned readmissions. Optimized care systems should be established to minimize unplanned readmissions, particularly for patients with high risk factors.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital

BACKGROUND

Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.

METHODS

Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013.

RESULTS

In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period.

CONCLUSION

Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Patient and Perioperative Variables Affecting 30-Day Readmission for Surgical Complications After Hip and Knee Arthroplasties: A Matched Cohort Study

BACKGROUND

Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital.

METHODS

Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission.

RESULTS

Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 [1.4-8.5]; P < .01).

CONCLUSION

Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.

Patterns of Ninety-Day Readmissions Following Total Joint Replacement in a Bundled Payment Initiative

BACKGROUND

Alternative payment models aim to improve quality and decrease costs associated with total joint replacement. Postoperative readmissions within 90 days are of interest to clinicians and administrators as there is no additional reimbursement beyond the episode bundled payment target price. The aim of this study is to improve the understanding of the patterns of readmission which would better guide perioperative patient management affecting readmissions. We hypothesize that readmissions have different timing, location, and patient health profile patterns based on whether the readmission is related to a medical or surgical diagnosis.

METHODS

A retrospective cohort of 80 readmissions out of 1412 total joint replacement patients reimbursed through a bundled payment plan was analyzed. Patients were grouped by readmission diagnosis (surgical or medical) and the main variables analyzed were time to readmission, location of readmission, and baseline Perioperative Orthopaedic Surgical Home and American Society of Anesthesiologists scores capturing pre-existing state of health. Nonparametric tests and multivariable regressions were used to test associations.

RESULTS

Surgical readmissions occurred earlier than medical readmissions (mean 18 vs 33 days, P = .011), and were more likely to occur at the hospital where the surgery was performed (P = .035). Perioperative Orthopaedic Surgical Home and American Society of Anesthesiologists scores did not predict medical vs surgical readmissions (P = .466 and .879) after adjusting for confounding variables.

CONCLUSION

Readmissions appear to follow different patterns depending on whether they are surgical or medical. Surgical readmissions occur earlier than medical readmissions, and more often at the hospital where the surgery was performed. The results of this study suggest that these 2 types of readmissions have different patterns with different implications toward perioperative care and follow-up after total joint replacement.

Unplanned 90-day readmissions in a specialty orthopaedic unit-A prospective analysis of consecutive 12729 admissions

INTRODUCTION

Unplanned readmissions are an undesirable and expensive outcome of clinical practice. Previous reported literature is limited by retrospective study designs and 30 day study intervals. We analyzed causes for 90-day unplanned readmission, temporal occurrence of major causes, possible predisposing factors, bed days lost and economic impact.

MATERIALS & METHODS

A prospective analysis of 12729 admissions was performed over 1 year in an Orthopaedic unit. Consecutive readmissions for unplanned circumstances within 90-days of discharge following the index procedure were included. Open injuries, polytrauma, primary osseous infections and planned readmissions were excluded.

RESULTS

We noted an overall readmission rate of 2.07% and subspecialty rate of 1.43%, 3.32%, 2.9% in trauma, spine and total joint arthroplasty (TJA) respectively. The leading cause was wound complications accounting for 49.62%, followed by medical causes (trauma -18.37%; TJA -27.5%) and aseptic pain (spine-31.6%). Though 87.1% of superficial surgical site infections (SSIs) occurred within 30 days, 21.1%, 41.2% and 60% of the deep SSIs in spine, trauma and TJA respectively occurred beyond 30 days. The financial burden amounted to INR 1,01,55,770 and mean bed days lost was 7.6 per readmission. Age ≥70 years, indoor-stay ≥10 days, health insurance and co-morbid illnesses were associated with readmissions (p < 0.05).

CONCLUSIONS

Our study showed that limiting analysis to 30 day unplanned readmissions would lead to failure in identification of 34.85% of readmissions especially deep surgical site infections in TJA and trauma.

Frailty Index as a Predictor of Adverse Postoperative Outcomes in Patients Undergoing Cervical Spinal Fusion

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To investigate the applicability of the modified frailty index (mFI) as a predictor of adverse postoperative events in patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF).

SUMMARY OF BACKGROUND DATA

Prior studies have investigated the mFI and shown it as an independent predictor of adverse postoperative outcomes across multiple surgical specialties. However, this topic has not still been studied in patients undergoing cervical fusion or in spinal surgery.

METHODS

The National Surgical Quality Improvement Program is a multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent elective ACDF and PCF between 2005 and 2012. The mFI was calculated for each patient. Univariate analysis and multivariate logistic regression were used to analyze the mFI as a predictor for postoperative complications.

RESULTS

For ACDF group, Clavien-Dindo grade IV complications rate increased from 0.8% to 9.0% as mFI increased from 0 to ≥0.27, and mFI = 0.27 was found to be an independent predictor of Clavien-Dindo grade IV complications (odds ratio, OR, = 4.67, 95% confidence interval, CI, = 2.27-9.62, P < 0.001). For PCF groups, Clavien-Dindo grade IV complications rate increased from 0.7% to 20.0% as mFI increased from 0 to ≥0.36, and mFI ≥ 0.36 was identified as an independent predictor of Clavien-Dindo grade IV complications (OR = 41.26, 95% CI = 6.62-257.15, P < 0.001).

CONCLUSION

The mFI was shown to be an independent predictor of Clavien-Dindo grade IV complications in patients undergoing ACDF or PCF. The mFI itself may be used to stratify risks in patients undergoing cervical fusion, or, the mFI scheme could be used as a platform upon which more efficient risk stratification could be done with addition of other variables.

LEVEL OF EVIDENCE

4.

Home Discharge After Primary Elective Total Joint Arthroplasty: Postdischarge Complication Timing and Risk Factor Analysis

BACKGROUND

Bundled payment programs for primary total joint arthroplasty (TJA) have identified reducing nonhome discharge as a major area of cost savings. Health care providers must therefore identify, risk stratify, and appropriately care for home-discharged TJA patients. This study aimed to analyze risk factors and timing of postdischarge complications among home-discharged primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and risk stratify them to identify those who would benefit from higher level care.

METHODS

Patients discharged home after elective primary THA/TKA from 2011 to 2014 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were performed using perioperative variables.

RESULTS

A total of 50,376 and 71,293 home-discharged THA and TKA patients were included for analysis, of which, 1575 THA (3.1%) and 2490 TKA (3.5%) patients suffered postdischarge severe complications or unplanned readmissions. These patients were older, smokers, obese, and functionally dependent (P < .001 for all). In multivariate analysis, severe adverse event predischarge, age, male gender, functional status, and 10 other variables were all associated with ≥1.22 odds of postdischarge severe adverse event or readmission (P < .05). THA and TKA patients with 2, 3, or ≥4 risk factors had 1.43-5.06 times odds of complications within 14 days post discharge and 1.41-3.68 times odds of complications beyond 14 days compared to those with 0 risk factors (P < .001 for all).

CONCLUSION

Risk factors can be used to predict which home-discharged TJA patients are at greatest risk of postdischarge complications. Given that this is a growing population, we recommend the development of formal risk-stratification protocols for home-discharged TJA patients.

Simplified Frailty Index as a Predictor of Adverse Outcomes in Total Hip and Knee Arthroplasty

BACKGROUND

The modified frailty index (mFI) has been shown to predict adverse outcomes in multiple nonorthopedic surgical specialties. This study aimed to assess whether mFI is a predictor of adverse events in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients who underwent THA and TKA from 2005-2012 were identified in the National Surgical Quality Improvement Program database. mFI was calculated for each patient using 15 variables found in National Surgical Quality Improvement Program. Bivariate and multivariate analyses of postoperative adverse events, including Clavien-Dindo grade IV complications, were performed.

RESULTS

A total of 14,583 THA and 25,223 TKA patients were included for analysis. The mean (standard deviation, range) mFIs were 0.083 (0.080, 0-0.55) for THA and 0.097 (0.080, 0-0.64) for TKA cohorts. On bivariate analyses, incidence of Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), hospital-acquired conditions (surgical site infection, venous thromboembolism, and urinary tract infection), any complications, and mortality increased significantly with increase in mFI (P < .0001 for all). Adjusting for demographics, age ≥ 75, body mass index ≥40, American Society of Anesthesiologists class ≥4, and nonclean wound status, mFI ≥0.45 was shown to be the strongest independent predictor of Clavien-Dindo grade IV complications for both THA and TKA cohorts with odds ratios of 5.140 and 4.183, respectively.

CONCLUSION

mFI ≥0.45 is an independent predictor of Clavien-Dindo grade IV complications in TKA/THA patients with greater odds ratios than age >75, body mass index ≥40, American Society of Anesthesiologists class ≥4. mFI should be considered for risk stratifying joint arthroplasty patients preoperatively and perhaps determining immediate postoperative destination.

Reducing 30-day Readmission After Joint Replacement

Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.

Do shorter lengths of stay increase readmissions after total joint replacements?

Background

Enhanced recovery after surgery protocols for total joint replacements (TJRs) emphasize early discharge, yet the impact on readmissions is not well documented. We evaluate the impact of a one-day length of stay (LOS) discharge protocol on readmissions.

Methods

We conducted a retrospective review of all primary TJRs (hip and knee) from April 2014 to March 2015. Patients who had adequate support to be discharged home were categorized into 2 groups, 1-day (n = 174) vs 2-day (n = 285) LOS groups. Patients discharged to rehabilitation were excluded (n = 196).

Results

Patients in the 1 day group were more likely to be younger (61.7 vs 64.8 years, P < .001), be male (56.3% vs 40.4%, P = .001), and have a lower body mass index (30.0 vs 31.4 kg/m², P = .012). One-day LOS patients had shorter surgical times (79.7 vs 85.6 minutes, P = .001) and more likely had spinal anesthesia (46.0% vs 31.2%, P = .001). The overall 30-day all-cause (2.3% vs 2.5%, P = .591) and 90-day wound-related (1.1% vs 1.1%, P = .617) readmission rates were equivalent between groups.

Conclusions

Early discharge does not increase readmissions and may help attenuate costs associated with TJRs. Further refinement of protocols may allow for more patients to be safely discharged on postoperative day 1.

Joint arthroplasty Perioperative Surgical Home: Impact of patient characteristics on postoperative outcomes

AIM: To determine the impact of different characteristics on postoperative outcomes for patients in a joint arthroplasty Perioperative Surgical Home (PSH) program.

METHODS: A retrospective review was performed for patients enrolled in a joint arthroplasty PSH program who had undergone primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were preoperatively stratified based on specific procedure performed, age, gender, body mass index (BMI), American Society of Anesthesiologists Physical Classification System (ASA) score, and Charleston Comorbidity Index (CCI) score. The primary outcome criterion was hospital length of stay (LOS). Secondary criteria including operative room (OR) duration, transfusion rate, Post-Anesthesia Care Unit (PACU) stay, readmission rate, post-operative complications, and discharge disposition. For each outcome, the predictor variables were entered into a generalized linear model with appropriate response and assessed for predictive relationship to the dependent variable. Significance level was set to 0.05.

RESULTS: A total of 337 patients, 200 in the TKA cohort and 137 in the THA cohort, were eligible for the study. Nearly two-third of patients were female. Patient age averaged 64 years and preoperative BMI averaged 29 kg/m². The majority of patients were ASA score III and CCI score 0. After analysis, ASA score was the only variable predictive for LOS (P = 0.0011) and each increase in ASA score above 2 increased LOS by approximately 0.5 d. ASA score was also the only variable predictive for readmission rate (P = 0.0332). BMI was the only variable predictive for PACU duration (P = 0.0136). Specific procedure performed, age, gender, and CCI score were not predictive for any of the outcome criteria. OR duration, transfusion rate, post-operative complications or discharge disposition were not significantly associated with any of the predictor variables.

CONCLUSION: The joint arthroplasty PSH model reduces postoperative outcome variability for patients with different preoperative characteristics and medical comorbidities.

Shorter Hospital Stay and Lower 30-Day Readmission After Unicondylar Knee Arthroplasty Compared to Total Knee Arthroplasty

BACKGROUND

Reducing hospital stay and unplanned hospital readmission of arthroplasty patients has been a topic of recent interest. The aim of the present study was to query the National Surgical Quality Improvement Program database to compare the length of hospital stay (LOS) and the subsequent 30-day hospital readmission rates in patients undergoing primary unicondylar knee arthroplasty (UKA) and total knee arthroplasty (TKA).

METHODS

We identified 1340 UKAs and 36,274 TKAs over a 2-year period (2011-2012). Patient demographics, comorbidities, LOS, 30-day postoperative complications, and readmission rates were compared between the groups. Multivariate regression analysis was used to determine the effect of procedure type on LOS and readmission rates.

RESULTS

Unicondylar knee arthroplasty patients had a median LOS of 2 days compared to 3 days for TKAs (P < .001). The readmission rate in the TKA group was nearly double that of the UKA group (4.1% vs 2.2%) (P < .0001). Multivariate regression analysis identified that undergoing a UKA was predictive for a shorter LOS (coefficient -1 day) and was protective for 30-day readmission (odds ratio, 0.60; 95% confidence interval, 0.41-0.88).

CONCLUSION

Patients undergoing UKA had a shorter LOS and a lower 30-day readmission rate compared to TKA patients. After adjusting for selected cofounders, we demonstrated that undergoing a UKA is a protective factor for 30-day readmission.

Disparities in 30-Day Readmissions After Total Hip Arthroplasty

BACKGROUND

Policymakers have expanded readmissions penalties to include elective total hip arthroplasties (THA), but little is known whether disparities exist on the basis of race, socioeconomic status, or payer.

OBJECTIVE

To identify disparities in elective primary THA readmissions based on race, socioeconomic status, and type of insurance.

RESEARCH DESIGN

This analysis is a retrospective cohort study of patients discharged for an elective THA. The Healthcare Cost & Utilization Project's State Inpatient Database from California was used to identify index hospitalizations for elective primary THA and rehospitalizations within 30 days of discharge. We used multivariate logistic regression to examine differences in readmissions by race, socioeconomic status, and insurance.

SUBJECTS

Subjects included patients discharged from California hospitals from 2009 through 2011 after THA.

MEASURES

Risk-adjusted odds of all-cause 30-day readmission.

RESULTS

The overall rate of unplanned 30-day all-cause readmissions was 4.6%. African American [odds ratio (OR)=1.38; 95% confidence interval (CI), 1.16-1.64] and Hispanic (OR=1.16; 95% CI, 1.00-1.34) patients had a higher risk of readmission than white patients after THA, when accounting for comorbidities and hospital factors. The observed difference for Hispanic patients, however, was null after adjusting for socioeconomic status and payer. Lower socioeconomic status was associated with higher odds of readmission (OR=1.24; 95% CI, 1.10-1.39). Compared with private insurance, Medicare (OR=1.26; 95% CI, 1.13-1.43), Medicaid (OR=1.86; 95% CI, 1.49-2.32), and uninsured status (OR=1.31; 95% CI, 1.01-1.69) were also associated with increased readmission risk.

CONCLUSIONS

We found significant differences in the odds of 30-day readmissions on the basis of race, socioeconomic status, and payer. As readmissions penalties become widely adopted, payers need to be mindful of their effects on vulnerable populations.

The Impact of Risk Reduction Initiatives on Readmission: THA and TKA Readmission Rates

We assessed whether sequential incorporation of initiatives to decrease postoperative surgical complications were similarly effective in reducing 30-day readmission rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Readmission rates following TKA decreased substantially (5.6% vs. 3.0%, P<0.001), but readmissions following THA (4.0% vs. 3.4%, P=0.41) were not significantly reduced. The greatest impact of the multimodal treatment approach was a reduction of surgically related TKA complications. Advanced medical disease, facility discharge status, and Medicare or Medicaid coverage contributed to the highest risk for 30-day readmission after THA. Risk models defining expected readmission rates should account for these factors to avoid penalizing hospitals that provide higher proportional care to Centers for Medicaid and Medicare Services (CMS) beneficiaries.

Socioeconomically Disadvantaged CMS Beneficiaries Do Not Benefit From the Readmission Reduction Initiatives

We assessed the impact of minority and socioeconomic status on 30-day readmission rates after 3825 primary total hip arthroplasty (THA) and 3118 primary total knee arthroplasty (TKA) procedures. Minority patients had higher THA (7.4% vs 3.2%, P=0.001) and TKA (5.4% vs 3.7%, P<0.001) readmission rates. Low socioeconomic status was associated with higher THA (6.0% vs 3.1%, P<0.001) and TKA (6.3% vs 3.8%, P=0.02) readmission rates. Risk reduction initiatives were effective after TKA, but minority status and low socioeconomic status were still associated with higher 30-day readmission rates (4.6% vs 1.8%, P<0.01). Focused postoperative engagement for Centers for Medicare and Medicaid Services (CMS) beneficiaries less than 65 years of age may help reduce complications and 30-day readmissions.

Total hip arthroplasty in an outpatient setting in 27 selected patients

BACKGROUND AND PURPOSE

As a result of introduction of a fast-track program, length of hospital stay after total hip arthroplasty (THA) decreased in our hospital. We therefore wondered whether THA in an outpatient setting would be feasible. We report our experience with THA in an outpatient setting.

PATIENTS AND METHODS

In this prospective cohort study, we included 27 patients who were selected to receive primary THA in an outpatient setting between April and July 2014. Different patient-reported outcome measures (PROMs) were recorded preoperatively and at 6 weeks and 3 months postoperatively. Furthermore, anchor questions on how patients functioned in daily living were scored at 6 weeks and 3 months postoperatively.

RESULTS

3 of the 27 patients did not go home on the day of surgery because of nausea and/or dizziness. The remaining 24 patients all went home on the day of surgery. PROMs improved substantially in these patients. Moreover, anchor questions on how patients functioned in their daily living indicated that the patients were satisfied with the postoperative results. 1 re-admission occurred at 11 days after surgery because of seroma formation. There were no other complications or reoperations.

INTERPRETATION

At our hospital, with a fast-track protocol, outpatient THA was found to be feasible in selected patients with satisfying results up to 3 months postoperatively, without any outpatient procedure-specific complications or re-admissions.