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Chatad D, Monas A, Rodriguez AN, Roth E, Erez O, Razi AE. Trends and risk factors for readmissions following press-fit total knee arthroplasty for the treatment of end-stage osteoarthritis of the knee: a five-year analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3495-3499. [PMID: 37195308 DOI: 10.1007/s00590-023-03578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION The development of new prostheses with improved osseointegration, bone preservation, and reduced cost has renewed interest in uncemented total knee arthroplasty (UCTKA). In the current study, we aimed to: (1) assess demographic data of patients who were and were not readmitted and (2) identify patient-specific risk factors associated with readmission. METHODS A retrospective query from the PearlDiver database was performed from January 1, 2015, to October 31, 2020. International Classification of Disease, Ninth Revision (ICD-9), ICD-10, or Current Procedural Terminology (CPT) coding was used to distinguish cohorts of patients who had osteoarthritis of the knee and underwent UCTKA. Patients readmitted within 90 days were classified as the study population, while those who were not readmitted were classified as control. A linear regression model was utilized to analyze readmission risk factors. RESULTS The query yielded 14,575 patients, with 986 (6.8%) being readmitted. Patient demographics such as age (P < 0.0001), sex (P < 0.009), and comorbidity (P < 0.0001) were associated with annual 90-day readmission. Patient-specific risk factors associated with 90-day readmission following press-fit total knee arthroplasty were: arrhythmia (OR: 1.29, 95% CI: 1.11-1.49, P < 0.0005), coagulopathy (OR: 1.36, 95% CI: 1.13-1.63, P < 0.0007), fluid and electrolyte abnormalities (OR: 1.59, 95% CI: 1.38-1.84, P < 0.0001), iron deficiency anemia (OR: 1.49, 95% CI: 1.27-1.73, P < 0.0001), and obesity (OR: 1.37, 95% CI: 1.18-1.60, P < 0.0001). DISCUSSION This study demonstrates that patients with comorbidities, such as fluid and electrolyte problems, iron deficiency anemia, and obesity, were at an increased risk of readmission after having an uncemented total knee replacement. The risks of readmission following an uncemented total knee arthroplasty can be discussed with patients who have certain comorbidities by arthroplasty surgeons.
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Affiliation(s)
- Derrick Chatad
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York Downstate, Brooklyn, NY, USA
| | - Arie Monas
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, State University of New York Downstate, Brooklyn, NY, USA
| | - Ariel N Rodriguez
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA.
| | - Eric Roth
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Orry Erez
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Afshin E Razi
- Department of Orthopedic Surgery, Maimonides Medical Center, 927 49th Street, Brooklyn, NY, 11219, USA
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Summers S, Yakkanti R, Ocksrider J, Haziza S, Mannino A, Roche M, Hernandez VH. Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients. J Knee Surg 2023; 36:322-328. [PMID: 34464986 DOI: 10.1055/s-0041-1733901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.
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Affiliation(s)
- Spencer Summers
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Health System, Miami, Florida
| | - Ramakanth Yakkanti
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Health System, Miami, Florida
| | - Justin Ocksrider
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Health System, Miami, Florida
| | - Sagie Haziza
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Health System, Miami, Florida
| | - Angelo Mannino
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Martin Roche
- Department of Orthopedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida
| | - Victor H Hernandez
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Health System, Miami, Florida
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Suleiman LI, Tucker K, Ihekweazu U, Huddleston JI, Cohen-Rosenblum AR. Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration. J Arthroplasty 2022; 37:1421-1425. [PMID: 35158005 DOI: 10.1016/j.arth.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/16/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.
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Affiliation(s)
- Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL
| | | | | | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Anna R Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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Muchiri S, Pakdil F, Beazoglou H. The length of stay and readmissions of THA and TKA patients: A longitudinal analysis using a nationwide readmissions data. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Steve Muchiri
- Department of Economics and Finance, Eastern Connecticut State University, Willimantic, CT, USA
| | - Fatma Pakdil
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
| | - Hannah Beazoglou
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
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Yeung S, Perriman D, Chhabra M, Phillips C, Parkinson A, Glasgow N, Douglas KA, Cox D, Smith P, Desborough J. ACT Transition from Hospital to Home Orthopaedic Survey: a cross-sectional survey of unplanned 30-day readmissions for patients having total hip arthroplasty. BMJ Open 2022; 12:e055576. [PMID: 35636791 PMCID: PMC9152933 DOI: 10.1136/bmjopen-2021-055576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Sybil Yeung
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Diana Perriman
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- ACT Health, Canberra City, Australian Capital Territory, Australia
| | - Madhur Chhabra
- Department of Health Services Research and Policy, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Christine Phillips
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Anne Parkinson
- Australian Primary Health Care Research Institute, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas Glasgow
- Australian National University Research School of Population Health, Canberra, Australian Capital Territory, Australia
| | - Kirsty A Douglas
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Darlene Cox
- Health Care Consumer Association, Canberra, Australian Capital Territory, Australia
| | - Paul Smith
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- The Trauma and Orthopaedic Resarch Unit, ACT Health, Canberra City, Australian Capital Territory, Australia
| | - Jane Desborough
- Department of Health Services Research and Policy, Australian National University, Canberra, Australian Capital Territory, Australia
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Kulshrestha V, Sood M, Kumar S, Sood N, Kumar P, Padhi PP. Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study. Clin Orthop Surg 2022; 14:56-68. [PMID: 35251542 PMCID: PMC8858904 DOI: 10.4055/cios20234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022] Open
Abstract
Background With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. Methods This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. Results TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). Conclusions Screening and RM can reduce 90-day complications in patients undergoing TKA.
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Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Munish Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Santhosh Kumar
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
| | - Nikhil Sood
- Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Chandimandir, Chandigarh, India
| | - Pradeep Kumar
- Department of Orthopaedics and Major Rehabilitation Center, Air Force Hospital Kanpur, Kanpur, India
| | - Prashanth P Padhi
- Joint Replacement Center, Department of Orthopaedics and Major Rehabilitation Center, Command Hospital Air Force, Bangalore, India
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Borsinger TM, Simon AW, Culler SD, Jevsevar DS. Does Hospital Teaching Status Matter? Impact of Hospital Teaching Status on Pattern and Incidence of 90-day Readmissions After Primary Total Hip Arthroplasty. Arthroplast Today 2021; 12:45-50. [PMID: 34761093 PMCID: PMC8567323 DOI: 10.1016/j.artd.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022] Open
Abstract
Background Given financial and clinical implications of readmissions after total hip arthroplasty (THA) and the potential for varied expenditures related to a hospital’s teaching status, this study sought to characterize 90-day hospital readmission patterns and assess likelihood of readmission based on teaching designation of a Medicare beneficiaries’ (MB’s) index THA hospital. Methods Retrospective analysis of 2016-2018 Centers for Medicare and Medicaid Services-linked data identified primary THA hospitalizations and readmissions within 90 days. Hospitals were categorized as teaching or nonteaching (Council of Teaching Hospitals and Health Systems). Chi-squared analysis and Fisher exact test assessed differences between readmission hospitals and the index hospital teaching status. Multivariate logistic regression models estimated risk-adjusted probability of experiencing at least one 90-day readmission. Results Analysis identified 433,959 index THA admissions with an all-cause 90-day readmission rate of 9.12%. Most readmissions were to the same hospital regardless of index THA hospital teaching status (67.5% index teaching; 68.2% index nonteaching). Crossover in hospital teaching status from the index procedure to readmission location was more common for those with index THA at a teaching hospital (18.9%) than for MBs with index THA performed at a nonteaching hospital (6.2%). Controlling for patient characteristics, no significant relationship was found between 90-day readmission and index hospital teaching status (odds ratio 0.98, confidence interval 0.947–1.011). Conclusions Overall, while certain patterns of readmission after the index THA were observed, after controlling for patient characters and comorbidities, there was no significant association between 90-day all-cause readmission and index hospital teaching status.
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Affiliation(s)
- Tracy M Borsinger
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Gupta P, Golub IJ, Lam AA, Diamond KB, Vakharia RM, Kang KK. Causes, risk factors, and costs associated with ninety-day readmissions following primary total hip arthroplasty for femoral neck fractures. J Clin Orthop Trauma 2021; 21:101565. [PMID: 34476176 PMCID: PMC8387745 DOI: 10.1016/j.jcot.2021.101565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Risk factors associated with primary THA readmissions have not yet been thoroughly analyzed when stratified by underlying indication. Given that a majority of THAs are done electively in the context of osteoarthritis (OA), it remains to be explored whether or not THAs performed non-electively in the trauma setting have different readmission patterns. Therefore, the aims of this study were to identify: 1) causes of readmissions; 2) patient-related risk-factors for readmissions; and 3) costs associated with the reasons for readmissions. MATERIALS AND METHODS Patients who sustained a femoral neck fracture and underwent primary THA from 2005 to 2014 were identified. Those subsequently readmitted within 90-days following the procedure comprised the study cohort whereas those not readmitted served as the comparison cohort. Primary outcomes included identifying causes of readmissions, identifying patient-related risk-factors associated with readmissions and determining healthcare expenditures associated with the different readmission etiologies. A regression analysis was used to calculate the odds (OR) for readmissions. A p-value less than 0.01 was considered to be statistically significant. RESULTS The regression model demonstrated the greatest patient-related risk factors included: electrolyte and fluid disorders (OR: 1.80, p < 0.0001), morbid obesity (OR: 1.60, p < 0.0001), pathologic weight loss (OR: 1.58, p < 0.0001), congestive heart failure (OR: 1.41, p < 0.0001), were the leading risk factors for readmissions. Pulmonary-related causes ($42,357.71) of readmission were the leading driver of costs of care. CONCLUSION Orthopaedic surgeons should identify and optimize pre-operative management of patient-related risk factors that increase readmissions following primary THA for femoral neck fractures. Additionally, pulmonary-related causes of readmission lead to the highest costs of care. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Puneet Gupta
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA,George Washington University School of Medicine and Health Sciences, Department of Orthopaedic Surgery, Washington, D.C., USA,Corresponding author. Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA.
| | - Ivan J. Golub
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Aaron A. Lam
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Keith B. Diamond
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Rushabh M. Vakharia
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Kevin K. Kang
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
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Natural Language Processing of Patient-Experience Comments After Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:927-934. [PMID: 33127238 DOI: 10.1016/j.arth.2020.09.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/12/2020] [Accepted: 09/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is interest in improving patient experience after total knee arthroplasty (TKA) due to recent shifts toward value-based medicine. Patient narratives are a valuable but unexplored source of information. METHODS Records of 319 patients who had undergone primary TKA between August 2016 and August 2019 were linked with vendor-supplied patient satisfaction data, which included patient comments and the Press Ganey satisfaction survey. Using machine-learning-based natural language processing, 1048 patient comments were analyzed for sentiment and classified into themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not (positive, neutral, mixed grouped together). Multivariable regression was used to determine perioperative variables associated with providing a negative comment. RESULTS Of the 1048 patient comments, 25% were negative, 58% were positive, 8% were mixed, and 9% were neutral. Top 2 themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in most of the studied outcomes (eg, peak pain intensity, length of stay, or Knee Injury and Osteoarthritis Outcome Score Junior and pain scores at 6-week follow-up) between the 2 cohorts (P > .05). However, patients who made negative comments were less likely to highly recommend their hospital care to peers (P < .001). Finally, patients who had higher American Society of Anesthesiologists Score and those who received a scopolamine patch were more likely to provide negative comments (P < .05). CONCLUSION Although the current study showed that patient satisfaction might not be a proxy for traditional objective perioperative outcomes, efforts to improve the nontechnical aspects of medicine are still crucial in providing patient-centered care.
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Hong I, Westra JR, Goodwin JS, Karmarkar A, Kuo YF, Ottenbacher KJ. Association of Pain on Hospital Discharge with the Risk of 30-Day Readmission in Patients with Total Hip and Knee Replacement. J Arthroplasty 2020; 35:3528-3534.e2. [PMID: 32712118 PMCID: PMC7669554 DOI: 10.1016/j.arth.2020.06.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND It is not clear if there is a risk of 30-day readmissions following total hip and knee arthroplasty in patients reporting high levels of pain at hospital discharge. We examined the relationship between post-surgical pain on the day of discharge and 30-day readmission in patients who received total knee and hip arthroplasty. METHODS Retrospective cohort study was conducted of patients who received total knee (n = 155,284) or hip arthroplasty (n = 89,283) from 2011 to 2018 using electronic health records from the Optum database. Four categories of pain at discharge were created, from none to severe. Multivariate logistic regression models to predict 30-day all-cause readmission were adjusted for patient and clinical characteristics and built separately for knee and hip arthroplasty patients. RESULTS Mean ages for hip and knee patients were 64.4 (standard deviation 11.3) and 65.7 (standard deviation 9.7) years, respectively. The majority of patients were female (hip: 54.4%; knee: 61.5%). The unadjusted rate of 30-day readmission was 3.54% for hip replacement and 3.66% for knee replacement. In models adjusted for patient and clinical characteristics, for patients with total hip replacement, the odds of 30-day readmission for those with severe pain score at discharge vs those with no pain at discharge were 1.60 (95% confidence interval 1.33-1.92). Similarly, readmission likelihood increased as pain at discharge increased (severe pain vs no pain) for patients with total knee arthroplasty (odds ratio 1.38, 95% confidence interval 1.19-1.59). CONCLUSION Our findings demonstrated that the pain scores on the day of discharge are associated with 30-day hospital readmission.
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Affiliation(s)
- Ickpyo Hong
- Department of Occupational Therapy, Yonsei University, School of Health Sciences, Wonju, Republic of Korea
| | - Jordan R. Westra
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, School of Medicine, Galveston, TX
| | - James S. Goodwin
- Department of Internal Medicine, Sealy Center on Aging, University of Texas Medical Branch, School of Medicine, Galveston, TX
| | - Amol Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, School of Medicine, Richmond, VA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, Sealy Center on Aging, University of Texas Medical Branch, School of Medicine, Galveston, TX
| | - Kenneth J. Ottenbacher
- Division of Rehabilitation Sciences, Sealy Center on Aging, University of Texas Medical Branch, School of Health Professions, Galveston, TX
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Greiwe RM, Spanyer JM, Nolan JR, Rodgers RN, Hill MA, Harm RG. Improving Orthopedic Patient Outcomes: A Model to Predict 30-Day and 90-Day Readmission Rates Following Total Joint Arthroplasty. J Arthroplasty 2019; 34:2544-2548. [PMID: 31272826 DOI: 10.1016/j.arth.2019.05.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/20/2019] [Accepted: 05/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Over the next 10-15 years, there is expected to be an exponential increase in the number of total joint arthroplasties in the American population. This, combined with rising costs of total joint arthroplasty and more recent changes to the reimbursement payment models, increases the demand to perform quality, cost-effective total joint arthroplasties. The purpose of this study is to build models that could be used to estimate the 30-day and 90-day readmission rates for patients undergoing total joint arthroplasty. METHODS A retrospective review of patients admitted to a single hospital, over the course of 56 months, for total joint arthroplasty was performed. The goal is to identify patients with readmission in a 30-day or 90-day period following discharge from the hospital. Binary logistic regression was used to build predictive models that estimate the likelihood of readmission based on a patient's risk factors. RESULTS Of 5732 patients identified for this study, 237 were readmitted within 30 days, while 547 were readmitted within 90 days. Age, body mass index, gender, discharge disposition, occurrence of cardiac dysrhythmias and heart failure, emergency department visits, psychiatric diagnoses, and medication counts were all found to be associated with 30-day admission rates. Similar associations were found at 90 days, with the exclusion of age and psychiatric drug use, and the inclusion of intravenous drug abuse, narcotic medications, and total joint arthroplasty within 12 months. CONCLUSION There are patient variables, or risk factors, that serve to predict the likelihood of readmission following total joint arthroplasty.
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Affiliation(s)
| | | | - Joseph R Nolan
- Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, KY
| | | | - Misti A Hill
- St. Elizabeth Healthcare, Clinical Research Institute, Edgewood, KY
| | - Richard G Harm
- St. Elizabeth Healthcare, Clinical Research Institute, Edgewood, KY
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Weiser MC, Kim KY, Anoushiravani AA, Iorio R, Davidovitch RI. Outpatient Total Hip Arthroplasty Has Minimal Short-Term Complications With the Use of Institutional Protocols. J Arthroplasty 2018; 33:3502-3507. [PMID: 30107958 DOI: 10.1016/j.arth.2018.07.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/29/2018] [Accepted: 07/13/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Interest in outpatient/same-day discharge (SDD) total hip arthroplasty (THA) has been increasing over the last several years. There is considerable debate in the literature regarding the complication and readmission rates of these patients. To evaluate and validate the safety and efficacy of our institutional SDD THA care pathway, we compared the outcomes of patients undergoing SDD THA with patients who had a similar comorbidity profile and underwent inpatient THA. METHODS A retrospective review was conducted on 164 patients who underwent SDD THA from January 2015 to September 2016. The Risk of Readmission Tool, a validated risk stratification instrument, was applied to all inpatient THAs performed from June 2014 to December 2016. A cutoff Risk of Readmission Tool score < 3 was used to produce a cohort of 1858 inpatient THA patients, all of whom had a similar risk profile to patients who underwent SDD THA. Medicare patients were excluded from the inpatient THA cohort, which left a final inpatient sample of 1315 patients. Each cohort was evaluated for demographic variables, length of stay, 30-/90-day readmissions, and discharge disposition. RESULTS The SDD THA cohort had significantly lower body mass index (26.9 vs 28.2 kg/m2; P = .002), had fewer minorities (89.6% vs 66.3% Caucasians; P < .001), was exclusively commercial insurance (100% vs 36.3%), had a shorter length of stay (0.37 vs 2.3 days, P < .001), and was exclusively discharged home (100% vs 92.6%). There was no statistically significant difference in 30-day readmission rates between either cohort (SDD 0.6% vs inpatient 1.6%; P = .325). However, the SDD cohort had a significantly lower rate of 90-day readmissions than the inpatient cohort (0.6% vs 3.6%; P = .014). CONCLUSION The use of an institutional SDD THA care pathway can produce results with equivalent or better short-term outcomes than that of traditional inpatient THA.
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Affiliation(s)
- Mitchell C Weiser
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Kelvin Y Kim
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, New York
| | | | - Richard Iorio
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, New York
| | - Roy I Davidovitch
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, New York
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Lehtonen EJ, Hess MC, McGwin Jr. G, Shah A, Godoy-Santos AL, Naranje S. RISK FACTORS FOR EARLY HOSPITAL READMISSION FOLLOWING TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2018; 26:309-313. [PMID: 30464711 PMCID: PMC6220664 DOI: 10.1590/1413-785220182605190790] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Tucker A, Walls A, Leckey B, Hill JC, Phair G, Bennett DB, O'Brien S, Beverland DE. Postdischarge Unscheduled Care Burden After Lower Limb Arthroplasty. J Arthroplasty 2018; 33:2745-2751.e1. [PMID: 29805105 DOI: 10.1016/j.arth.2018.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Adam Tucker
- Department of Orthopaedics, Outcomes Unit, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
| | - Andrew Walls
- Department of Orthopaedics, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
| | - Beverley Leckey
- Department of Orthopaedics, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
| | - Janet C Hill
- Department of Orthopaedics, Outcomes Unit, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit (NICTU), Royal Victoria Hospital, Belfast, County Antrim, United Kingdom
| | | | - Seamus O'Brien
- Department of Orthopaedics, Outcomes Unit, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
| | - David E Beverland
- Department of Orthopaedics, Musgrave Park Hospital, Belfast, County Antrim, United Kingdom
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White RS, Sastow DL, Gaber-Baylis LK, Tangel V, Fisher AD, Turnbull ZA. Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status. J Racial Ethn Health Disparities 2018; 5:1202-1214. [DOI: 10.1007/s40615-018-0467-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 01/08/2023]
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Narula N, Kim BJ, Davis CH, Dewhurst WL, Samp LA, Aloia TA. A proactive outreach intervention that decreases readmission after hepatectomy. Surgery 2018; 163:703-708. [PMID: 29325786 DOI: 10.1016/j.surg.2017.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/30/2017] [Accepted: 08/30/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND After hepatectomy, 7%-19% of patients are readmitted within 30 days, accounting for substantial cost and poor patient experience. The purpose of this study was to analyze the impact of a proactive outreach intervention on readmissions. METHODS Consecutive patients undergoing hepatectomy by a single surgeon 2012-2016 were identified in a prospectively maintained database. In August 2013 a postoperative intervention was implemented; an advanced practice provider called each patient within 72 hours of discharge. Readmission rates were compared pre- and postintervention using standard statistics. RESULTS Two hundred thirty-one patients met the inclusion criteria and major hepatectomy was performed in 45.5% of patients. Although the complication rate was similar (25.0% preintervention and 19.4% postintervention, P = .324), readmissions within 30 days of operation decreased from 14.5% pre- to 6.5% postintervention (P = .046). Approximately 30% of outreach interactions required outpatient intervention. Factors associated with readmission on univariate analysis included increased operative time (P = .007), major hepatectomy (P = .012), hemi or extended hepatectomy (P = .032), second stage operation (P = .031), bile leak (P = 0.022), and any complication/modified Accordion complication ≥ 3 within 30 days (P <.0001). On multivariate analysis, lack of post-discharge intervention (P = .012) and bile leak (P = .031) were independently associated with readmission. CONCLUSION These data demonstrate the efficacy of a proactive communication intervention after discharge to decrease readmissions after hepatectomy. The additional work created by the intervention is likely offset by decreased inpatient care needs and costs. Identification of high-risk populations and application of technology are likely to lead to further improvements.
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Affiliation(s)
- Nisha Narula
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine H Davis
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Leigh A Samp
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Has Health Care Reform Legislation Reduced the Economic Burden of Hospital Readmissions Following Primary Total Joint Arthroplasty? J Arthroplasty 2017; 32:3274-3285. [PMID: 28669571 DOI: 10.1016/j.arth.2017.05.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/16/2017] [Accepted: 05/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine whether the cost of readmissions after primary total hip and knee arthroplasty (THA and TKA) has decreased since the introduction of health care reform legislation and what patient, clinical, and hospital factors drive such costs. METHODS The 100% Medicare inpatient dataset was used to identify 1,654,602 primary THA and TKA procedures between 2010 and 2014. The per-patient cost of readmissions was evaluated in general linear models in which the year of surgery and patient, clinical, and hospital factors were treated as covariates in separate models for THA and TKA. RESULTS The year-to-year risk of 90-day readmission was reduced by 2% and 4% (P < .001) for THA and TKA, respectively. By contrast, the cost of readmissions did not change significantly over time. The 5 most important variables associated with the cost of 90-day THA readmissions (in rank order) were the nature of the readmission (ie, due to medical or procedure-related reasons), the length of stay, hospital's teaching status, discharge disposition, and hospital's overall total joint arthroplasty volume. The top 5 factors associated with the cost of 90-day TKA readmissions were (in rank order) the length of stay, hospital's teaching status, discharge disposition, patient's gender, and age. CONCLUSION Although readmission rates declined slightly, the results of this study do not support the hypothesis that readmission costs have decreased since the introduction of health care reform legislation. Instead, we found that clinical and hospital factors were among the most important cost drivers.
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Affiliation(s)
- Steven M Kurtz
- Exponent Inc., Philadelphia, Pennsylvania; School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
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Xu HF, White RS, Sastow DL, Andreae MH, Gaber-Baylis LK, Turnbull ZA. Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York. J Clin Anesth 2017; 43:24-32. [PMID: 28972923 DOI: 10.1016/j.jclinane.2017.09.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/31/2017] [Accepted: 09/23/2017] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements. DESIGN Retrospective cohort study. SETTING Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. PATIENTS 295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51). INTERVENTIONS Patients underwent total hip replacement. MEASUREMENTS Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data. MAIN RESULTS Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS. CONCLUSIONS We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.
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Affiliation(s)
- Hannah F Xu
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
| | - Robert S White
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
| | - Dahniel L Sastow
- Weill Cornell Medicine Center for Perioperative Outcomes, 428 East 72nd St., Ste 800A, New York, NY 10021, USA.
| | - Michael H Andreae
- Penn State Milton S. Hershey Medical Center, 500 University Drive, H187, Hershey, PA 17033, USA.
| | - Licia K Gaber-Baylis
- Weill Cornell Medicine Center for Perioperative Outcomes, 428 East 72nd St., Ste 800A, New York, NY 10021, USA.
| | - Zachary A Turnbull
- New York Presbyterian Hospital- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, Box 124, New York, NY 10065, USA.
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McLawhorn AS, Buller LT. Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality. Curr Rev Musculoskelet Med 2017; 10:370-377. [PMID: 28741101 PMCID: PMC5577424 DOI: 10.1007/s12178-017-9423-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA). RECENT FINDINGS From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control. Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.
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Affiliation(s)
- Alexander S. McLawhorn
- Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Leonard T. Buller
- Department of Orthopedic Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL USA
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Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital. J Arthroplasty 2017; 32:1739-1746. [PMID: 28153458 DOI: 10.1016/j.arth.2016.12.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 02/01/2023] Open
Abstract
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.
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Weinberg DS, Kraay MJ, Fitzgerald SJ, Sidagam V, Wera GD. Are Readmissions After THA Preventable? Clin Orthop Relat Res 2017; 475:1414-1423. [PMID: 27837400 PMCID: PMC5384913 DOI: 10.1007/s11999-016-5156-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmissions after total joint arthroplasty have become a key quality measure in elective surgery in the United States. The Affordable Care Act includes the Hospital Readmission Reduction Program, which calls for reduced payments to hospitals with excessive readmissions. This policy uses a method to determine excess readmission ratios and calculate readmission payment adjustments to hospitals, however, it is unclear whether readmission rates are an effective quality metric. The reasons or conditions associated with readmission after elective THA have been well established but the extent to which readmissions can be prevented after THA remains unclear. QUESTIONS/PURPOSES (1) Are unplanned readmissions after THA associated with orthopaedic or medical causes? (2) Are these readmissions preventable? (3) When during the course of aftercare are orthopaedic versus medical readmissions more likely to occur? METHODS We retrospectively evaluated all 1096 elective THAs for osteoarthritis performed between January 1, 2011 and June 30, 2014 at a major academic medical center. Of those, 69 patients (6%) who met inclusion criteria were readmitted in our healthcare system within 90 days of discharge after the index procedure during the study period. Fifty patients were readmitted within 30 days of discharge after the index procedure (5%). We defined a readmission as any unplanned inpatient or observation status admission to the hospital spanning at least one midnight. A panel of physicians not involved in the care of these patients used available criteria and existing consensus guidelines to evaluate the medical records, radiographs, and operative reports to identify whether the underlying reason for readmission was orthopaedic versus medical. They subsequently were classified as either nonpreventable or potentially preventable readmissions, based on any care that may have occurred during the index hospitalization. To make such determinations, consensus specialty society guidelines were used whenever possible for each readmission diagnosis. RESULTS A total of 50 of 1096 patients (5% of those who underwent THA during the period in question) were readmitted within 30 days and 69 of 1096 (6%) were readmitted within 90 days of their index procedures. Thirty-one patients were readmitted for orthopaedic reasons (31/69; 45%) and 38 of 69 were readmitted for medical reasons (55%). Three readmissions (three of 69; 4%) were identified as potentially preventable. Of these potentially preventable readmissions, one was orthopaedic (hip dislocation) and two were medical. Thirty-day readmissions were more likely to be orthopaedic than 90-day readmissions (odds ratio, 4.06; 95% CI, 1.18-13.96; p = 0.026). CONCLUSIONS Using a panel of expert reviewers, available existing criteria, and consensus methodology, it appears only a small percentage of readmissions after THA are potentially preventable. Orthopaedic readmissions occur earlier during the postoperative course. Currently, existing policies and readmission penalties may not serve as valuable external quality metrics. The readmission rates in our study may represent the threshold for expected readmission rates after THA. Future studies should enroll larger numbers of patients and have independent review panels in efforts to refine criteria for what constitutes preventable readmissions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Douglas S. Weinberg
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Matthew J. Kraay
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Steven J. Fitzgerald
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Vasu Sidagam
- grid.67105.35Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Glenn D. Wera
- grid.411931.fMetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109 USA
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Late Complications Following Elective Primary Total Hip and Knee Arthroplasty: Who, When, and How? J Arthroplasty 2017; 32:719-723. [PMID: 27682005 DOI: 10.1016/j.arth.2016.08.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Improved pain management and early mobilization protocols have increased interest in the feasibility of short stay (<24 hours) or outpatient total hip (THA) and total knee (TKA) arthroplasty. However, concerns exist regarding patient safety and readmissions. The purposes of this study were to determine the incidence of in-hospital complications following THA/TKA, to create a model to identify comorbidities associated with the risk of developing major complications >24 hours postoperatively, and to validate this model against another consecutive series of patients. METHODS We prospectively evaluated a consecutive series of 802 patients who underwent elective primary THA and TKA over a 9-month period. The mean age was 62.3 years. Demographic, surgical, and postoperative readmission data were entered into an arthroplasty database. RESULTS Of the 802 patients, 382 experienced a complication postoperatively. Of these, 152 (19%) required active management. Multiple logistic regression analysis identified cirrhosis (odds ratio [OR], 5.89; 95% confidence interval [CI], 1.05-33.07; P = .044), congestive heart failure (OR, 3.12; 95% CI, 1.50-6.44; P = .002), and chronic kidney disease (OR, 3.85; 95% CI, 2.21-6.71; P < .001) as risk factors for late complications. One comorbidity was associated with a 77% probability of developing a major postoperative complication. This model was validated against an independent dataset of 1012 patients. CONCLUSION With improved pain management and mobilization protocols, there is increasing interest in short stay and outpatient THA and TKA. Patients with cirrhosis, congestive heart failure, or chronic kidney disease should be excluded from early discharge total joint arthroplasty protocols.
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Acetabular Abduction and Dislocations in Direct Anterior vs Posterior Total Hip Arthroplasty: A Retrospective, Matched Cohort Study. J Arthroplasty 2016; 31:2299-302. [PMID: 27067169 DOI: 10.1016/j.arth.2016.03.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/22/2016] [Accepted: 03/07/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is purported improvement in component positioning and hip stability with the use of direct anterior approach (DAA) total hip arthroplasty (THA). We sought to determine if there is a difference in acetabular component position or dislocation frequency between DAA and posterior THA. METHODS One arthroplasty fellowship-trained surgeon introduced DAA THA into his practice. From the initiation of DAA in 4/2012-8/2015, this comparative series resulted in 66 DAA THAs. A matched cohort (age, gender, body mass index [BMI], and comorbidities) was then created for posterior THA, 66 hips. DAA THA used fluoroscopy with anterior capsular excision; posterior group used no image guidance and had capsular repair. Posterior group BMI was 27.8 and DAA group BMI was 27.6 (P = .36). Minimum 3-month follow-up occurred in both groups. RESULTS Average acetabular abduction angle in the posterior group was 41.9° (range, 32°-60°; standard deviation [sdev], 6.24) and DAA group 43.8° (range, 30°-62°; sdev 6.9), P = .12. The percentage of outliers (outside Lewinnek safe zone, 30°-50°) was 9.1% (6 of 66) in posterior group and 13.6% (9 of 66) in DAA group. There were 2 anterior dislocations in the DAA THA group and 1 anterior dislocation in the posterior THA group, resulting in P = .56. The DAA dislocation frequency in this group was overall higher at 3.0% (2 of 66) compared with the matched posterior (1.5%, 1 of 66) and unmatched posterior larger series (.8%, 3 of 360). CONCLUSION We demonstrated no observable difference in hip stability or acetabular abduction. This study provides realistic outcomes for surgeons implementing DAA THA into their practice.
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Abstract
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.
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Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which Hospital and Clinical Factors Drive 30- and 90-Day Readmission After TKA? J Arthroplasty 2016; 31:2099-107. [PMID: 27133927 DOI: 10.1016/j.arth.2016.03.045] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/25/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to analyze the hospital, clinical, and patient factors associated with inpatient readmission after total knee arthroplasty (TKA) in the Medicare population and to understand the primary reasons for readmission. METHODS The Medicare 100% national hospital claims database was used to identify 952,593 older patients (65+) with a primary TKA in 3848 hospitals between 2010 and 2013. A multilevel logistic regression analysis with a clustered data structure was used to investigate the risk of all-cause 30- and 90-day readmission, incorporating hospital, clinical, and patient factors. RESULTS At 30 days, readmission ranged from 0% to 22% (median, 4.9%), whereas at 90 days, readmission ranged from 0% to 32% (median, 8.6%). Geographic census region, hospital procedure volume, rural hospital location, and nonprofit ownership were the only significant hospital factors among those we studied. Evaluation of clinical factors showed use of a perioperative transfusion was associated with 13% greater risk; patients discharged to home had 25% lower risk; and surgeon volume and length of stay were also significant. These effect sizes were at least comparable to patient factors, such as age, gender, comorbidities, and socioeconomic status. The top 5 most frequently reported primary reasons for 30- or 90-day readmission in TKA were surgery and medical related: wound infection, deep infection, atrial fibrillation, cellulitis and abscess of leg, or pulmonary embolism. CONCLUSION The results of this study support further optimization of anti-infection measures, both intraoperative and postoperative, to reduce the broad variation in hospital readmissions.
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Affiliation(s)
- Steven M Kurtz
- Exponent Inc., Philadelphia, Pennsylvania; School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
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Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Hospital, Patient, and Clinical Factors Influence 30- and 90-Day Readmission After Primary Total Hip Arthroplasty. J Arthroplasty 2016; 31:2130-8. [PMID: 27129760 DOI: 10.1016/j.arth.2016.03.041] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to analyze the hospital, clinical, and patient factors associated with inpatient readmission after total hip arthroplasty (THA) in the Medicare population and to understand the primary reasons for readmission. METHODS The Medicare 100% national hospital claims database was used to identify 442,333 older patients (65+) with a primary THA in 3730 hospitals between 2010 and 2013. A multilevel logistic regression analysis with a clustered data structure was used to investigate the risk of all-cause 30- and 90-day readmission, incorporating hospital, clinical, and patient factors. RESULTS At 30 days, 5.8% (median) of the patients were readmitted, whereas at 90 days, 10.5% (median) were readmitted. Geographic census region, hospital procedure volume, and nonprofit ownership were the only significant hospital factors among those we studied. Overall, clinical factors explained more of the variation in readmission rates than general hospital factors. Use of a perioperative transfusion was associated with 14% greater risk, patients discharged to home had 28% lower risk, and surgeon volume and length of stay were also significant risk factors. The top 5 most frequently reported primary reasons for 30-day readmission in THA were procedure related: dislocation (5.9%), deep infection (5.1%), wound infection (4.8%), periprosthetic fracture (4.4%), or hematoma (3.4%). CONCLUSION These findings support further optimization of the delivery of care-both intraoperative and postoperative-to reduce the broad variation in hospital readmissions.
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Affiliation(s)
- Steven M Kurtz
- Exponent Inc, Philadelphia, Pennsylvania; School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
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Complications of Primary Total Knee Arthroplasty Among Patients With Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Osteoarthritis. J Am Acad Orthop Surg 2016; 24:567-74. [PMID: 27355283 DOI: 10.5435/jaaos-d-15-00501] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although several studies have reported outcomes of primary total knee arthroplasty (TKA) in patients with rheumatoid arthritis, very little has been reported on the outcomes of this procedure in patients with other inflammatory arthritides. METHODS This study used a national database to evaluate 90-day postoperative complication rates, readmission rates, and revision rates after TKA in patients with inflammatory arthritis. Patients with rheumatoid arthritis (n = 153,531), psoriatic arthritis (n = 7,918), and ankylosing spondylitis (n = 4,575) were compared with patients with osteoarthritis (n = 1,751,938) who underwent TKA from 2005 to 2012. RESULTS The rates of systemic complications, infection, revision, and 90-day readmission after TKA in patients with different types of inflammatory arthritis were significantly higher than those in control patients with osteoarthritis (P < 0.0001). No differences were found in the rates of systemic or local complications, revision, or readmission among the types of inflammatory arthritis. CONCLUSION Inflammatory arthritis is associated with increased rates of perioperative complications, revision, and 90-day readmission after primary TKA. LEVEL OF EVIDENCE Level III.
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Noyes K, Baack‐Kukreja J, Messing EM, Schoeniger L, Galka E, Pan W, Xueya C, Fleming FJ, Monson JRT, Mohile SG, Francone T. Surgical readmissions: results of integrating pre-, peri- and postsurgical care. Nurs Open 2016; 3:168-178. [PMID: 27708827 PMCID: PMC5047346 DOI: 10.1002/nop2.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/29/2016] [Indexed: 12/20/2022] Open
Abstract
AIMS To explore the feasibility of recruiting surgical oncology patients and implementing a surgical integrated discharge (SID) programme led by advanced practice providers (APP). BACKGROUND Burden of illness and complexity of treatment regimen makes it challenging for surgical oncology patients to participate in research. Surgical oncology nurses may have the necessary expertise to overcome this problem. DESIGN Controlled longitudinal prospective observational study. METHODS The SID programme included multidisciplinary care coordination, regular communication among APPs and proactive postdischarge follow-up. Administrative databases were used to identify matching historical controls (n = 113) and evaluate programme outcomes. RESULTS Patient enrolment was 84%. The main challenges for the programme implementation included incompatible health information systems among care settings, variation in care processes among hospital units and need for provider behaviour change. CONCLUSIONS Most surgical oncology patients are willing to participate in outcomes programmes when contacted by familiar clinical personnel but programme implementation requires leadership support, communication among care teams and training and infrastructure.
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Affiliation(s)
- Katia Noyes
- Surgical Health Outcomes & Research Enterprise (SHORE)RochesterNew YorkUSA
- Department of SurgeryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Janet Baack‐Kukreja
- Department of UrologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Edward M. Messing
- Department of UrologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Luke Schoeniger
- Department of SurgeryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Eva Galka
- Department of SurgeryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Wei Pan
- Surgical Health Outcomes & Research Enterprise (SHORE)RochesterNew YorkUSA
| | - Cai Xueya
- Department of Biostatics and Computational BiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Fergal J. Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE)RochesterNew YorkUSA
- Department of SurgeryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - John RT Monson
- Surgical Health Outcomes & Research Enterprise (SHORE)RochesterNew YorkUSA
- Department of SurgeryUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Supriya G. Mohile
- Department of Medicine, Hematology/OncologyWilmot Cancer InstituteUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Todd Francone
- Lahey Hospital & Medical CenterBurlingtonMassachusettsUSA
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Graboyes EM, Kallogjeri D, Saeed MJ, Olsen MA, Nussenbaum B. 30-day hospital readmission following otolaryngology surgery: Analysis of a state inpatient database. Laryngoscope 2016; 127:337-345. [PMID: 27098654 DOI: 10.1002/lary.25997] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVES/HYPOTHESIS Determine patient and hospital-level risk factors associated with 30-day readmission for patients undergoing inpatient otolaryngologic surgery. STUDY DESIGN Retrospective cohort study. METHODS We analyzed the State Inpatient Database (SID) from California for patients who underwent otolaryngologic surgery between 2008 and 2010. Readmission rates, readmission diagnoses, and patient- and hospital-level risk factors for 30-day readmission were determined. Hierarchical logistic regression modeling was performed to identify procedure-, patient-, and hospital-level risk factors for 30-day readmission. RESULTS The 30-day readmission rate following an inpatient otolaryngology procedure was 8.1%. The most common readmission diagnoses were nutrition, metabolic, or electrolyte problems (44% of readmissions) and surgical complications (10% of readmissions). New complications after discharge were the major drivers of readmission. Variables associated with 30-day readmission in hierarchical logistic regression modeling were: type of otolaryngologic procedure, Medicare or Medicaid health insurance, chronic anemia, chronic lung disease, chronic renal failure, index admission via the emergency department, in-hospital complication during the index admission, and discharge destination other than home. CONCLUSION Approximately one out of 12 patients undergoing otolaryngologic surgery had a 30-day readmission. Readmissions occur across a variety of types of procedures and hospitals. Most of the variability was driven by patient-specific factors, not structural hospital characteristics. LEVEL OF EVIDENCE 4. Laryngoscope, 2016 127:337-345, 2017.
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Affiliation(s)
- Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Mohammed J Saeed
- Division of Infectious Disease, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Margaret A Olsen
- Division of Infectious Disease, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, U.S.A.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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