Emergency Department Visits Within Thirty Days of Discharge After Primary Total Hip Arthroplasty: A Hidden Quality Measure

Risk Factors for Return to the Emergency Department and Readmission After Same-Day Discharge Total Joint Arthroplasty

BACKGROUND

Same-day discharge (SDD) after total joint arthroplasty (TJA) is safe and cost effective. However, benefits may be offset by the potential cost of emergency department (ED) visits and readmissions. We identified risk factors for return to the ED and readmission in patients who underwent SDD and inpatient (IP) stays after TJA.

METHODS

We performed a retrospective review of patients who underwent primary TJA at an academic institution over the course of one year. There were 1,708 consecutive TJAs (721 THA [total hip arthroplasty] and 987 TKA [total knee arthroplasty]) included. A SDD occurred after 1,199 (70%) TJAs, 523 THAs, and 676 TKAs. We compared the demographics and comorbidities of patients who have SDD or IP who stayed following TJA. We documented rates of return to the ED or readmission within 90 days of surgery. Cohorts were compared using the Student's t-test or Chi-square test. Significant findings were those with P value < .05.

RESULTS

The SDD cohort had a significantly higher rate of young, non-White men who had a lower body mass index and fewer comorbidities than the IP cohort. Rates of return to ED and readmission were similar between SDD and IP cohorts after TJA and similar between THA and TKA. Factors that significantly influenced return to ED included a higher American Society of Anaesthesiologists score (SDD, IP), a higher Charlson Comorbidity Index score (SDD, IP), a lower body mass index (IP), and a psychological diagnosis (SDD, IP). Factors that significantly influenced readmission rates included a higher American Society of Anaesthesiologists score (SDD), older age (SDD), and psychological diagnosis (SDD, IP).

CONCLUSIONS

Patients who discharged the same day after primary TJA have similar rates of return to the ED and readmission as those admitted as an IP. Patients who had a psychological diagnosis, and particularly a diagnosis of depression, are at higher risk for return to the ED and readmission after primary TJA, regardless of discharge the same-day or IP admission. Improved measures that attempt to further treat and optimize this patient population could reduce unnecessary postoperative ED visits.

Advanced Multi-Layer Watertight Closure versus Conventional Closure in Total Hip and Knee Replacement Surgery

Background

In total joint replacement procedures, surgeons have increasingly adopted advanced multi-layer, watertight closure. The objective of the study was to compare the clinical and economic outcomes for advanced multi-layer, watertight closure patients to those with conventional closure with sutures and skin staples.

Methods

Patients aged ≥18 years were included in the study if they underwent total joint arthroplasty of the hip or knee as an elective, primary, inpatient procedure between January 2014 and March 2019. Cohorts having advanced multi-layer, watertight closure or conventional closure were compared using multivariable regression analysis of surgical site infections, length of stay, operating room time, procedure time, discharge status, readmissions, reoperations, and hospital emergency department visits.

Results

A total of 1828 patients received at least one total hip or knee replacement, of which 434 (23.7%) had advanced multi-layer, watertight closure and 1394 (76.3%) had conventional closure. Unadjusted time to readmission, when occurring, was considerably longer following advanced multi-layer, watertight closure (89.9 vs 51.1 days, p < 0.0001), and a lower proportion of the advanced multi-layer, watertight closure cohort required reoperation within 90 days (0.0% vs 2.6%, p < 0.0001). Adjusted mean hospital length of stay was approximately half of a day shorter for advanced multi-layer, watertight closure patients (1.10 vs 1.65 days; p < 0.001), and they were also more likely to be discharged to home (Odds Ratio: 4.61; p = 0.002).

Conclusion

Among patients undergoing total hip and knee arthroplasty in a highly optimized real-world clinical practice, advanced multi-layer, watertight closure was associated with significantly shorter inpatient length of stay and increased likelihood of being discharged to home compared with conventional closure. These findings suggest that advanced multi-layer, watertight closure is a valuable component of an optimal workflow for total hip or knee replacement, and may be especially valuable for high-risk patients.

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7] years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p < 0.05), 44% lower LOS (1.4 vs 2.5 days, p < 0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p < 0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90 days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9 days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Unplanned Emergency Department Visits Following Revision Total Joint Arthroplasty: Incidences, Risk Factors, and Mortalities

BACKGROUND

The incidence of unplanned emergency department (ED) visits following revision total joint arthroplasty is an indicator of the quality of postoperative care. The aim of this study was to investigate the incidences, timings, and characteristics of ED visits within 90 days after revision total joint arthroplasty.

METHODS

A retrospective review of 457 consecutive cases, including 254 revision total hip arthroplasty (rTHA) and 203 revision total knee arthroplasty (rTKA) cases, was conducted. Data regarding patient demographics, timings of the ED encounter, chief complaints, readmissions, and diagnoses indicating reoperation were analyzed.

RESULTS

The results showed that 41 patients who had rTHA (16.1%) and 14 patients who had rTKA (6.9%) returned to the ED within 90 days postoperatively. The incidence of ED visits was significantly higher in the rTHA group than in the rTKA group (P = .003). The most common surgery-related complications were dislocation among rTHA patients and wound conditions among rTKA patients. Apart from elevated calculated comorbidity scores, peptic ulcer in rTHA patients and cerebral vascular events and chronic obstructive pulmonary disease in rTKA patients might increase chances of unplanned ED visits. Patients who had ED visits showed significantly higher mortality rates than the others in both rTHA and rTKA cohorts (P = .050 and P = .008, respectively).

CONCLUSIONS

The ED visits within 90 days are more common after rTHA than after rTKA. Patients in both ED visit groups after rTHA and rTKA demonstrated worse survival. Efforts should be made to improve quality of care to prevent ED visits.

Utilization of Total Joint Arthroplasty by Rural-Urban Designation in Patients With Osteoarthritis in a Universal Coverage System

BACKGROUND

Utilization of total joint arthroplasty (TJA) is affected by differences linked to sex, race, and socioeconomic status; there is little information about how geographic variation contributes to these differences. We sought to determine whether discrepancies in TJA utilization exist in patients diagnosed with osteoarthritis (OA) based upon urban-rural designation in a universal coverage system.

METHODS

We conducted a cohort study using data from a US-integrated healthcare system (2015 to 2019). Patients aged ≥50 years who had a diagnosis of hip or knee OA were included. Total hip arthroplasty and total knee arthroplasty utilization (in respective OA cohorts) was evaluated by urban-rural designation (urban, mid, and rural). Incidence rate ratios (IRRs) for urban-rural regions were modeled using multivariable Poisson regressions.

RESULTS

The study cohort included 93,642 patients who have hip OA and 275,967 patients who had knee OA. In adjusted analysis, utilization of primary total hip arthroplasty was lower in patients living in urban areas (IRR = 0.87, 95% confidence interval = 0.81 to 0.94) compared to patients in rural regions. Similarly, total knee arthroplasty was used at a lower rate in urban areas (IRR = 0.88, 95% confidence interval = 0.82 to 0.95) compared with rural regions. We found no differences in the hip and knee groups within the mid-region.

CONCLUSIONS

In hip and knee OA patients enrolled in a universal coverage system, we found patients living in urban areas had lower TJA utilization compared to patients living in rural areas. Further research is needed to determine how patient location contributes to differences in elective TJA utilization.

LEVEL OF EVIDENCE

III.

Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population

BACKGROUND

Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations.

METHODS

Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression.

RESULTS

Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients.

CONCLUSION

Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA.

LEVEL OF EVIDENCE

III.

Bias in Care: Impact of Ethnicity on Time to Emergent Surgery Varies Between Subspecialties

INTRODUCTION

Disparity in access to emergency care among minority groups continues to exist despite growing awareness of the effect of implicit bias on public health. In this study, we evaluated ethnicity-based differences in time between admission and surgery for patients undergoing emergent procedures at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

METHODS

We conducted a retrospective review of 249,296 National Surgical Quality Improvement Program cases from 2006 to 2018 involving general, orthopaedic, and vascular surgeries. Analysis of variance was used to compare "time to operating room" (OR) between ethnic groups.

RESULTS

Notable differences in time to OR were noted among general and vascular surgeries but not orthopaedic surgery. Post hoc comparison identified notable variation in general surgery between White and Black/African Americans. In vascular surgery, notable variations were identified between White and Black/African Americans and White and Native Hawaiian/Pacific Islanders.

DISCUSSION

These findings suggest that certain surgical subspecialties continue to exhibit disparities in care that may manifest as surgical delay, most notably between White and Black/African Americans. Interestingly, variation in time to OR for patients treated by orthopaedic surgery was not notable. Overall, these results highlight the need for additional research into the role of implicit bias in emergent surgical care in the United States.

Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database

BACKGROUND

Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear.

QUESTIONS/PURPOSES

(1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA?

METHODS

Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race.

RESULTS

After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001).

CONCLUSION

These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research.

LEVEL OF EVIDENCE

Level III, therapeutic study.

What are the Causes, Costs and Risk-Factors for Emergency Department Visits Following Primary Total Hip Arthroplasty? An Analysis of 1,018,772 Patients

BACKGROUND

Well-powered studies analyzing the relationship and nature of emergency department (ED) visits following primary total hip arthroplasties (THAs) are limited. The aim of this study was to: 1) compare baseline demographics of patients with/without an ED visit; 2) determine leading causes of ED visits; 3) identify patient-related risk factors; and 4) quantify 90-day episode-of-care healthcare costs divided by final diagnosis.

METHODS

Patients undergoing primary THA between January 1, 2010 and October 1, 2020 who presented to the ED within 90-days postoperatively were identified using the Mariner dataset of PearlDiver, yielding 1,018,772 patients. This included 3.9% (n = 39,439) patients who did and 96.1% (n = 979,333) who did not have an ED visit. Baseline demographics between the control/study cohorts, ED visit causes, risk-factors, and subsequent costs-of-care were analyzed. Using Bonferroni-correction, a P-value less than 0.002 was considered statistically significant.

RESULTS

Patients who presented to the ED post-operatively were most often aged 65-74 years old (41.09%) or female sex (55.60%). Nonmusculoskeletal etiologies comprised 66.8% of all ED visits. Risk factors associated with increased ED visits included alcohol abuse, depressive disorders, congestive heart failure, coagulopathy, and electrolyte/fluid derangements (P < .001 for all). Pulmonary ($28,928.01) and cardiac ($28,574.69) visits attributed to the highest costs of care.

CONCLUSION

Nonmusculoskeletal causes constituted the majority of ED visits. The top five risk factors associated with increased odds of ED visits were alcohol abuse, electrolyte/fluid derangements, congestive heart failure, coagulopathy, and depression. This study highlights potential areas of pre-operative medical optimization that may reduce ED visits following primary THA.

Emergency department visits following total joint arthroplasty: do revisions present a higher burden?

Aims

Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits.

Methods

We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables.

Results

Overall, 28,033 patients were included, of whom 24,930 (89%) underwent primary and 3,103 (11%) underwent rTJA. The overall rate of 90-day ED visits was significantly lower for patients who underwent primary TJA in comparison to those who underwent rTJA (3.9% vs 7.0%; p < 0.001). Among those who presented to the ED, the readmission rate was statistically lower for patients who underwent primary TJA compared to rTJA (23.5% vs 32.1%; p < 0.001).

Conclusion

ED visits present a significant burden to the healthcare system. Patients who undergo rTJA are more likely to present to the ED within 90 days following surgery compared to primary TJA patients. However, among patients in both cohorts who visited the ED, three-quarters did not require readmission. Future efforts should aim to develop cost-effective and patient-centred interventions that can aid in reducing preventable ED visits following TJA.

Cite this article: Bone Jt Open 2022;3(7):543–548.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge

BACKGROUND

Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations.

METHODS

We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables.

RESULTS

Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131).

CONCLUSION

Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis

Background

Methods

Results

Conclusions

Characterizing 30-d Postoperative Acute Care Visits: A National Surgical Quality Improvement Program Collaborative Analysis

INTRODUCTION

Many postoperative acute care visits (PACVs) are likely more appropriately addressed in lower acuity settings; however, the frequency and nature of PACVs are not currently tracked by the National Surgical Quality Improvement Program (NSQIP), and the overall burden to emergency departments and urgent care centers is unknown.

METHODS

NSQIP collaborative data were augmented to prospectively capture 30-d PACVs for 1 y starting October 2018 across all NSQIP specialties, including visit reason and disposition. Data were analyzed using binomial logistic regression.

RESULTS

A total of 9933 patients were identified; 12.0% (n = 1193) presented to an acute care setting over 1413 visits, most commonly for surgical pain (15.4%) in the absence of an identified complication. Visits most commonly resulted in discharge (n = 817, 68.5%) or admission (n = 343, 24.3%). Variables independently associated with visits resulting in discharge included age (odds ratio [OR] 0.99 per year, P < 0.001), increasing comorbidities (1-2 [OR 1.55, P < 0.001]; 3-4 [OR 2.51, P < 0.001]; 5+ [OR 2.79 P < 0.001]), operative duration (OR 1.08 per hour, P = 0.001), and nonelective (OR 1.20, P = 0.01) or urologic (OR 1.46, P = 0.01) procedures.

CONCLUSIONS

PACVs are an overlooked burden on emergency medicine providers and healthcare systems; most do not require admission and could be potentially triaged outside of the acute care setting with improved perioperative care infrastructure. Younger patients, those with multiple comorbidities, and those undergoing nonelective procedures deserve special attention when designing initiatives to address postoperative acute care utilization. Data regarding PACVs can be routinely collected with minor modifications to current NSQIP workflows.

The Effects of Depression and Anxiety on 90-day Readmission Rates After Total Hip and Knee Arthroplasty

Background

Patients undergoing total joint arthroplasty have higher rates of anxiety, depression or anxiety and depression than the general population and higher costs of care, which lead to higher levels of postoperative dissatisfaction and readmission rates. We evaluated the readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression, or both.

Methods

Our hospital's prospectively collected data from Michigan's statewide total joint database were reviewed from 2013 to 2018. Rates of anxiety, depression or anxiety and depression were determined based on preoperative anxiolytic or antidepressant medications using National Drug Codes.

Results

A total of 4107 cases were included. Of which 4.28% had a readmission within the 90-day global period, and 12% had a history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (P = .017). When comparing total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients taking anxiolytic medication and undergoing TKA were 120% more likely to undergo readmission within 90 days (P = .021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (P = .991). For THA, neither diagnosis appeared a risk factor for readmission (P = .852).

Conclusions

Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90 days compared with patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. Patients undergoing THA on the other hand did not appear to share this risk profile.

Reasons and Risk Factors for Emergency Department Visits After Primary Total Knee Arthroplasty: An Analysis of 1.3 Million Patients

BACKGROUND

Well-powered studies investigating the relationship of emergency department (ED) visits and total knee arthroplasty (TKA) are limited. Therefore, the specific aims of this study were to: 1) compare patient demographics of patients who did and did not have an ED visit; and for the visits, identified: 2) leading reasons; and 3) risk factors for ED visits (prearthroplasty/postarthroplasty).

METHODS

Patients undergoing primary TKA who had an ED visit within 90 days after their index procedure were identified from a nationwide database. The query yielded 1,364,655 patients who did (n = 5689) and did not have (n = 1,358,966) an ED visit. Baseline demographics such as age, sex, and comorbidity prevalence between the two cohorts; reasons for ED visits; and prearthroplasty and postarthroplasty risk factors were analyzed. Odds ratios (ORs) of ED visits were assessed using multivariate binomial logistic regression analyses. A P-value less than 0.001 was considered statistically significant.

RESULTS

Patients who did and did not have ED visits differed with respect to age (P < .0001) and mean Elixhauser Comorbidity Index scores (9 vs 6, P < .0001). Musculoskeletal etiologies were the most common reason for ED visits. Hypertension was the greatest contributor to ED visits prearthroplasty and postarthroplasty. Comorbid conditions associated with ED visits postarthroplasty included peripheral vascular disease (OR: 1.61, P < .0001), coagulopathy (OR: 1.58, P < .0001), and rheumatoid arthritis (OR: 1.56, P < .0001).

CONCLUSION

By identifying demographic patterns of patients, reasons, and risk factors, the information found from this study can help identify targets for quality improvement to potentially reduce the incidence of ED visits after primary TKA.

The Efficacy of Orthopedic Telemedicine Encounters During the COVID-19 Crisis

Telemedicine technology was rapidly and widely adopted during the early phase of the coronavirus disease 2019 (COVID-19) response, and its efficacy in orthopedic surgery is still undetermined. The objective of this study was to determine the efficacy of new patient orthopedic surgery ambulatory encounters performed using telemedicine during the early phase of the COVID-19 crisis. Failure of the telemedicine encounter was assessed in this study by 2 separate criteria: (1) an unplanned visit to the emergency department (ED) within 6 weeks of the telemedicine encounter and (2) a planned subsequent in-person encounter for inability to formulate a complete diagnosis virtually. The authors retrospectively identified all new patient orthopedic surgery ambulatory encounters performed using telemedicine in the orthopedic surgery department of an academic tertiary care center during the first 6 weeks of the COVID-19 response, from March 16, 2020, to April 26, 2020. The study cohort included 298 new patients treated by 41 providers. The mean age of the 298 patients was 48 years, and 59% were women. Two hundred encounters were performed with video, and 98 were performed with telephone only. Three (1%) patients presented to the ED within 6 weeks of their new patient telemedicine encounter, and 8 (3%) patients presented for a planned in-person encounter. The authors concluded that new patient orthopedic surgery ambulatory encounters performed using telemedicine were able to effectively direct patients to a variety of treatments and dispositions, with a low rate of unplanned presentation to the ED or need for supplementary in-person assessment. [Orthopedics. 2021;44(2):e211-e214.].

What Goes Bump in the Night: An Evaluation of Emergency Department Visits Following Total Joint Arthroplasty

BACKGROUND

Interest in postoperative healthcare utilization has increased following the implementation of episode-of-care funding for elective orthopedic surgery. Most efforts have focused on readmission; however, little has been reported on emergency department (ED) presentation. We analyzed elective, primary total hip or knee arthroplasty (THA and TKA) cases to determine the rate, reasons, risk factors, timing, and hospital cost associated with 30-day ED presentations.

METHODS

An observational study of patients who underwent primary, elective TKA and THA between January 1, 2016, and December 31, 2017, was performed. The primary outcome was an ED visit within 30-days of the index operation. Secondary outcomes included reasons, risk factors, timing, and hospital cost of ED visits. A multivariable logistic regression was undertaken to determine patient factors associated with ED presentation.

RESULTS

Overall, 1690 patients were included, of which 9.2% presented to the ED within 30-days of surgery. Approximately two-thirds of the visits were after-hours, and most were discharged home without readmission (81.4%). The most commonly reported reasons were wound concerns (30.1%) and pain (20.5%). Older age (OR 1.1, P = .03) and preoperative dyspnea (OR 2.1, P < .001) increased the odds of ED visits. The mean cost of an ED visit was significantly greater after-hours (P = .015).

CONCLUSION

Overall, 1 in 10 patients undergoing TKA/THA presented to the ED within 30-days of surgery, of which over 80% were not readmitted, and most occurred after-hours where cost is greatest. Our observations suggest ED visits following TKA/THA are common, and most are likely preventable. Future efforts should focus on developing interventions to reduce these visits.

Same-Day vs One-Day Discharge: Rates and Reasons for Emergency Department Return After Hospital-Based Total Joint Arthroplasty

BACKGROUND

As short stay and outpatient total joint arthroplasties (TJAs) are more widely adopted, it is important to assess whether reducing length of stay leads to increased emergency department (ED) visits or readmissions.

METHODS

This is a retrospective review of 1743 primary TJA patients with same-day discharge (SDD) or 1-day length of stay between January and December 2019. Patients who returned to the ED or were readmitted within 30 days of TJA were identified, and chart review was performed to identify their primary reason for revisit.

RESULTS

Patients discharged on the day of surgery (n = 203, 11.6%) were more likely to be younger (P < .001) and have a lower body mass index (total hip arthroplasty, P = .018; total knee arthroplasty, P < .001) and American Society of Anesthesiologists score (P < .001). The overall rate of return was 6.3%, and 1.3% of patients were readmitted. Controlling for age, gender, body mass index, surgery type, and American Society of Anesthesiologists, patients selected for SDD were not found to be at higher risk of return to the ED compared to 1-day length of stay patients (4.9% vs 6.4%, odds ratio 0.980, 95% confidence interval 0.484-1.984, P = .956).

CONCLUSION

SDD of eligible patients does not increase the risk of 30-day return to the ED. Continued analysis of risk factors for return and readmission will improve prospective identification of patients who can safely be discharged on the day of surgery, and future quality improvement initiatives should target the most common reasons for ED return.

Outcomes of outpatient total hip arthroplasty: a systematic review

INTRODUCTION

Similar to other total joint arthroplasty procedures, total hip arthroplasty (THA) is shifting to an outpatient setting. The purpose of this study was to analyse outcomes following outpatient THA.

METHODS

A comprehensive literature search was performed in April 2019 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Embase, and Cochrane databases to identify articles that reported functional outcomes following outpatient total hip arthroplasty (THA).

RESULTS

9 articles, with 683 hips and a collective study period of 1988 to 2016, were included in this analysis. The mean age across all studies was 58.9 years and the follow-up period ranged from 4 weeks to 10 years. 4 studies reported Harris Hip Scores (HHSs) for their patient populations and in 3 studies, the average HHSs were excellent (>90) by 6 weeks postoperatively. The fourth study reported fair HHS scores for the outpatient and inpatient THA groups (75 ± 18, 75 ± 14, p = 0.77, respectively) at 4 weeks postoperatively. VAS scores improved significantly in two studies and NRS at rest and during activity improved significantly (p < 0.001) in a separate study. Overall, 88.1% of the enrolled patients were discharged the same day of surgery, as expected. Out of the 6 studies reporting on readmissions rate, there were two (0.34%) readmissions within 3 months of surgery.

CONCLUSION

In patients with no significant comorbidities, outpatient THA leads to favourable outcomes as well as low readmission rates in the short term.

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.

METHODS

PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.

RESULTS

Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.

CONCLUSION

ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.

The association between race/ethnicity and outcomes following primary shoulder arthroplasty

BACKGROUND

Although prior studies have reported health disparities in total knee and hip arthroplasty, few have evaluated the effect of race/ethnicity on total shoulder arthroplasty, particularly in a setting in which patients have uniform access to care. Because the procedural volume of shoulder arthroplasty has increased dramatically over the past decade, evaluating the association between race/ethnicity and postoperative outcomes is warranted. We sought to evaluate racial/ethnic disparities in adverse postoperative events within a universally insured shoulder arthroplasty cohort in an integrated health care system.

METHODS

An integrated health care system's registry was used to identify patients who underwent elective primary (total or reverse) shoulder arthroplasty from 2005 to 2016. Four mutually exclusive race/ethnicity groups were investigated: white, Asian, black, and Hispanic. Racial differences were evaluated using Cox proportional hazards regression for all-cause revision and conditional logistic regression for 90-day unplanned readmissions and 90-day emergency department (ED) visits while adjusting for confounders.

RESULTS

Of the 8360 shoulder procedures, 2% were performed in Asian patients; 5%, black patients; 9%, Hispanic patients; and 84%, white patients. Compared with white patients, Hispanic patients had a 44% lower revision risk (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97). Black patients had a 45% higher likelihood of a 90-day ED visit (odds ratio, 1.45; 95% confidence interval, 1.12-1.89).

CONCLUSION

We found minority groups to have revision and unplanned readmission risks that were similar to or lower than those of white patients. However, black patients had a higher likelihood of ED visits. Further investigation is needed to determine the reasons for this disparity and identify interventions to mitigate unnecessary ED visits.

How Accurate Are the Surgical Risk Preoperative Assessment System (SURPAS) Universal Calculators in Total Joint Arthroplasty?

BACKGROUND

Surgical outcome prediction models are useful for many purposes, including informed consent, shared decision making, preoperative mitigation of modifiable risk, and risk-adjusted quality measures. The recently reported Surgical Risk Preoperative Assessment System (SURPAS) universal risk calculators were developed using 2005-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), and they demonstrated excellent overall and specialty-specific performance. However, surgeons must assess whether universal calculators are accurate for the small subset of procedures they perform. To our knowledge, SURPAS has not been tested in a subset of patients undergoing lower-extremity total joint arthroplasty (TJA).

QUESTIONS/PURPOSES

How accurate are SURPAS models' predictions for patients undergoing TJA?

METHODS

We identified an internal subset of patients undergoing non-emergency THA or TKA from the 2012 ACS-NSQIP, the most recent year of the SURPAS development dataset. To assess the accuracy of SURPAS prediction models, 30-day postoperative outcomes were defined as in the original SURPAS study: mortality, overall morbidity, and six complication clusters-pulmonary, infectious, cardiac or transfusion, renal, venous thromboembolic, and neurologic. We calculated predicted outcome probabilities by applying coefficients from the published SURPAS logistic regression models to the TJA cohort. Discrimination was assessed with C-indexes, and calibration was assessed with Hosmer-Lemeshow 10-group chi-square tests and decile plots.

RESULTS

The 30-day postoperative mortality rate for TJA was 0.1%, substantially lower than the 1% mortality rate in the SURPAS development dataset. The most common postoperative complications for TJA were intraoperative or postoperative transfusion (16%), urinary tract infection (5%), and vein thrombosis (3%). The C-indexes for joint arthroplasty ranged from 0.56 for venous thromboembolism (95% CI 0.53 to 0.59 versus SURPAS C-index 0.78) to 0.82 for mortality (95% CI 0.76 to 0.88 versus SURPAS C-index 0.94). All joint arthroplasty C-index estimates, including CIs, were lower than those reported in the original SURPAS development study. Decile plots and Hosmer-Lemeshow tests indicated poor calibration. Observed mortality rates were lower than expected for patients in all risk deciles (lowest decile: no observed deaths, 0.0% versus expected 0.1%; highest decile: observed mortality 0.7% versus expected 2%; p < 0.001). Conversely, observed morbidity rates were higher than expected across all risk deciles (lowest decile: observed 12% versus expected 8%; highest decile: observed morbidity 32% versus expected 25%; p < 0.001) CONCLUSIONS: The universal SURPAS risk models have lower accuracy for TJA procedures than they do for the wider range of procedures in which the SURPAS models were originally developed.

CLINICAL RELEVANCE

These results suggest that SURPAS model estimates must be evaluated for individual surgical procedures or within restricted groups of related procedures such as joint arthroplasty. Given substantial variation in patient populations and outcomes across numerous surgical procedures, universal perioperative risk calculators may not produce accurate and reliable results for specific procedures. Surgeons and healthcare administrators should use risk calculators developed and validated for specific procedures most relevant to each decision. Continued work is needed to assess the accuracy of universal risk calculators in more narrow procedural categories based on similarity of outcome event rates and prevalence of predictive variables across procedures.

Association of Type and Frequency of Postsurgery Care with Revision Surgery after Total Joint Replacement

CONTEXT

Postmarket surveillance is limited in the ability to detect medical device problems. Electronic health records can provide real-time information that might help with device surveillance. Specifically, the frequency of postsurgery care might indicate early problems and determine high-risk patients requiring more active surveillance.

OBJECTIVE

To evaluate whether intensity of postsurgery care is associated with revision risk after total joint arthroplasty (TJA).

DESIGN

Using an integrated health care system's TJA registry, we identified primary TJA performed between April 2001 and July 2013 (22,953 knees and 9904 hips). Survival analyses evaluated the frequency of specific types of outpatient and inpatient utilization 0 to 90 and 91 to 180 days postoperatively and revision risk.

MAIN OUTCOME MEASURES

Revision surgery occurring at least 6 months after primary TJA.

RESULTS

Knee arthroplasty recipients with 3 or more outpatient orthopedic allied health/nurse visits within 90 days had a 2.2 times (95% confidence interval [CI] = 1.6-2.9) higher risk of revision within the first 2 years postoperatively and 10.1 times higher risk (95% CI = 7.6-13.3) after 2 years. Compared with hip arthroplasty recipients who had 0 to 3 visits, patients with 6 or more outpatient orthopedic office visits within 90 days had a 15.7 times (95% CI = 5.7-42.9) higher risk of revision. Similar results were observed for 91-day to 180-day visits.

CONCLUSION

Future studies are needed to determine if more specific data on reasons for the higher frequency of outpatient visits can refine these findings and elicit more specific recommendations for TJA devices.

Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study

BACKGROUND

Unplanned visits to the emergency department after total joint arthroplasty are far more common than unplanned readmissions. Our objectives were to characterize the prevalence of presentation to an emergency department for any reason after total joint arthroplasty and to identify risk factors for such visits.

METHODS

Using health administrative databases, we conducted a population-based retrospective cohort study of adults (19-89 yr of age) who received their first primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure for arthritis between April 2011 and March 2016 in Ontario. We made univariate comparisons between patients who presented to the emergency department within 30 days of surgery and those who did not in. We determined differences in use of health care services between groups by comparing the change in use in the year before and after surgery between patients who presented to the emergency department and those who did not. We developed logistic regression models for the occurrence of an emergency department visit using backward variable elimination.

RESULTS

We identified 42 273 total hip recipients and 70 725 total knee recipients, of whom 5640 (13.3%) and 11 224 (15.9%), respectively, presented to the emergency department within 30 days of surgery. Fewer than 1% of these patients required admission, and nearly half (45%) went to a different institution from where they had their surgery. Among both THA and TKA recipients, patients who presented to the emergency department had a net increase in their median annual health care costs (THA: $501, TKA: $682), compared to a net decrease for the cohort as a whole. Factors associated with increased risk of an emergency visit included increased patient age, male sex, rural residence and various comorbidities. Predictive regression models showed poor discriminative ability for both THA (C-statistic 0.57) and TKA (C-statistic 0.58) recipients.

INTERPRETATION

One in 7 patients presented to the emergency department within 30 days of THA or TKA. Some may conceivably have been managed remotely, and very few required readmission. There is a crucial need for strategies to minimize these events.

Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls

Background and purpose - Outpatient arthroplasty has gained popularity in recent years; however, safety concerns still remain regarding complications and readmissions. In a prospective 2-center study we investigated early readmissions with overnight stay and complications following outpatient total hip (THA) and total knee arthroplasty (TKA) compared with a matched patient cohort with at least 1 postoperative night in hospital. Patients and methods - All consecutive and unselected patients scheduled for THA or TKA at 2 participating hospitals were screened for potential day of surgery (DOS) discharge. Patients who fulfilled the DOS discharge criteria were discharged home. Patients discharged on DOS were matched on preoperative characteristics using propensity scores to patients operated at the same 2 departments prior to the beginning of this study with at least 1 overnight stay. All readmissions within 90 days were identified. Results - It was possible to match 116 of 138 outpatients with 339 inpatient controls. Median LOS in the control cohort was 2 days (1-9). 7 (6%) outpatients and 13 (4%) inpatient controls were readmitted within 90 days. Readmissions occurred between postoperative day 2-48 and day 4-58 in the outpatient and control cohorts, respectively. Importantly, we found no readmissions within the first 48 hours and no readmissions were related to the DOS discharge. Interpretation - Readmission rates in patients discharged on DOS may be similar to matched patients with at least 1 overnight stay. With the selection criteria used, there may be no safety signal associated with same-day discharge.