When Do Readmissions for Infection Occur After Spine and Total Joint Procedures?

Background

The episode-of-care concept promulgated by the federal government requires hospitals to assume the cost burden for all care rendered up to 30 days after discharge, including all readmissions occurring in that time. Although surgical site infections (SSIs) are a leading cause of readmission after total joint arthroplasties (TJA) and spine surgery, it is unclear whether these readmissions occur relative to the 30-day period.

Questions/Purposes

We determined whether (1) most readmissions for SSIs occurred in 30 days, (2) the type of procedure performed affected the timing of readmission, and (3) the type of infecting organism influenced the timing of readmission.

Methods

From our hospital database we identified 91 patients treated with elective TJAs and spine surgery from 2007 through 2010 who were readmitted with SSIs. Of the 91 patients, 46 had undergone spine surgery and 45 had TJAs. For each of these readmissions, we determined the type of surgery, the length of time from initial discharge to readmission, and the type of infecting organism.

Results

Readmissions after spine surgery were more likely to occur within 30 days of discharge (80.4% for spine, 58.3% for TJAs). In the TJA cohort, there was a trend toward readmissions occurring within 30 days of discharge more often in the THA subset. We identified no correlation between type of infecting organism and timing of readmission.

Conclusions

With the episode-of-care model, SSIs pose a substantial cost burden for hospitals since the majority would be included in the 30-day period included in the bundled reimbursement.     

The Impact of Discharge Disposition on Episode-of-Care Reimbursement After Primary Total Hip Arthroplasty

Background

Total joint arthroplasty (TJA) accounts for more Medicare expenditure than any other inpatient procedure. The Comprehensive Care for Joint Replacement model was introduced to decrease cost and improve quality in TJA. The largest portion of episode-of-care costs occurs after discharge. This study sought to quantify the cost variation of primary total hip arthroplasty (THA) according to discharge disposition.

How Much Does a Readmission Cost the Bundle Following Primary Hip and Knee Arthroplasty?

Background

As alternative payment models increase in popularity for total joint arthroplasty (TJA), providers and hospitals now share the financial risk associated with unexpected readmissions. While studies have identified postacute care as a driver for costs in a bundle, the fiscal burden associated with specific causes of readmission is unclear. The purpose of this study is to quantify the additional costs associated with each of the causes of readmission following primary TJA.

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

Background

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

Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System

Background

Previous studies evaluating reasons for 30-day readmissions following total joint arthroplasty (TJA) may underestimate hospital-based utilization of healthcare resources during a patient's episode-of-care. We sought to identify common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary elective unilateral TJA.

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Background

Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited.

Questions/purposes

We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained?

Methods

We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors.

Results

There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor.

Conclusions

There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care.

Level of Evidence

Level II, economic analysis.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4445-0) contains supplementary material, which is available to authorized users.     

Factors That Influence Provider Selection for Elective Total Joint Arthroplasty

Background

The growth of consumer-directed health plans has sparked increased demand for information regarding the cost and quality of healthcare services, including total joint arthroplasty (TJA). However, the factors that influence patients’ choice of provider when pursuing elective orthopaedic care, such as TJA, are poorly understood.

Questions/purposes

We evaluated the factors patients consider when selecting an orthopaedic surgeon and hospital for TJA.

Methods

Two hundred fifty-one patients who sought treatment from either an academic or community-based orthopaedic practice for primary TJA completed a 37-item survey using a 5-point Likert scale rating (“unimportant” to “very important”) regarding seven established clinical and nonclinical dimensions of care patients considered when selecting a provider and hospital.

Result

Patients rated physician manner (average Likert, 4.7) and physician quality (eg, outcomes) (average Likert, 4.6) as most important in their selection of surgeon and hospital for TJA. Despite the expressed importance of surgeon and hospital quality, only 46% of patients were able to find useful information to compare outcomes among surgeons, and 47% for hospitals that perform TJA.

Conclusions

Our findings suggest physician manner and surgical outcomes are the most important considerations for patients when choosing a provider for elective TJA. Cost sharing is the least important criterion patients considered. Patients expressed high motivation to seek out provider quality information but indicated accessible and actionable sources of information are lacking. Future efforts should be directed at developing clinically relevant, easily interpretable, objective, risk-adjusted measures of physician and hospital quality.     

Incidence,Risk Factors,and Costs for Hospital Returns After Total Joint Arthroplasties

Background

Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA.

Which Clinical and Patient Factors Influence the National Economic Burden of Hospital Readmissions After Total Joint Arthroplasty?

Background

The Affordable Care Act of 2010 advanced the economic model of bundled payments for total joint arthroplasty (TJA), in which hospitals will be financially responsible for readmissions, typically at 90 days after surgery. However, little is known about the financial burden of readmissions and what patient, clinical, and hospital factors drive readmission costs.

Questions/purposes

(1) What is the incidence, payer mix, and demographics of THA and TKA readmissions in the United States? (2) What patient, clinical, and hospital factors are associated with the cost of 30- and 90-day readmissions after primary THA and TKA? (3) Are there any differences in the economic burden of THA and TKA readmissions between payers? (4) What types of THA and TKA readmissions are most costly to the US hospital system?

Methods

The recently developed Nationwide Readmissions Database from the Healthcare Cost and Utilization Project (2006 hospitals from 21 states) was used to identify 719,394 primary TJAs and 62,493 90-day readmissions in the first 9 months of 2013 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. We classified the reasons for readmissions as either procedure- or medical-related. Cost-to-charge ratios supplied with the Nationwide Readmissions Database were used to compute the individual per-patient cost of 90-day readmissions as a continuous variable in separate general linear models for THA and TKA. Payer, patient, clinical, and hospital factors were treated as covariates. We estimated the national burden of readmissions by payer and by the reason for readmission.

Results

The national rates of 30- and 90-day readmissions after THA were 4% (95% confidence interval [CI], 4.2%–4.5%) and 8% (95% CI, 7.5%–8.1%), respectively. The national rates of 30- and 90-day readmissions after primary TKA were 4% (95% CI, 3.8%–4.0%) and 7% (95% CI, 6.8%–7.2%), respectively. The five most important variables responsible for the cost of 90-day THA readmissions (in rank order, based on the Type III F-statistic, p < 0.001) were length of stay (LOS), all patient-refined diagnosis-related group (APR DRG) severity, type of readmission (that is, medical- versus procedure-related), hospital ownership, and age. Likewise, the five most important variables responsible for the cost of 90-day TKA readmissions were LOS, APR DRG severity, gender, hospital procedure volume, and hospital ownership. After adjusting for covariates, mean 90-day readmission costs reimbursed by private insurance were, on average, USD 1324 and USD 1372 greater than Medicare (p < 0.001) for THA and TKA, respectively. In the 90 days after TJA, two-thirds of the total annual readmission costs were covered by Medicare. In 90 days after THA, more readmissions were still associated with procedure-related complications, including infections, dislocations, and periprosthetic fractures, which in aggregate account for 59% (95% CI, 59.1%–59.6%) of the total readmission costs to the US healthcare system. For TKA, 49% of the total readmission cost (95% CI, 48.8%–49.6%) in 90 days for the United States was associated with procedure issues, most notably including infections.

Conclusions

Hospital readmissions up to 90 days after TJA represent a massive economic burden on the US healthcare system. Approximately half of the total annual economic burden for readmissions in the United States is medical and unrelated to the joint replacement procedure and half is related to procedural complications.

Clinical Relevance

This national study underscores LOS during readmission as a primary cost driver, suggesting that hospitals and doctors further optimize, to the extent possible, the clinical pathways for the hospitalization of readmitted patients. Because patients readmitted as a result of infection, dislocation, and periprosthetic fractures are the most costly types of readmissions, efforts to reduce the LOS for these types of readmissions will have the greatest impact on their economic burden. Additional clinical research is needed to determine the extent to which, if any, the LOS during readmissions can be reduced without sacrificing quality or access of care.

     

Identification of Process Measures to Reduce Postoperative Readmission

Background

Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates.

Study Design

Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology.

Results

Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient’s comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient’s referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication.

Conclusions

An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.     

No Difference in Total Episode-of-Care Cost Between Staged and Simultaneous Bilateral Total Joint Arthroplasty

Background

Due to concerns about higher complication rates, surgeons debate whether to perform simultaneous bilateral total joint arthroplasty (BTJA), particularly in the higher-risk Medicare population. Advances in pain management and rehabilitation protocols have called into question older studies that found an overall cost benefit for simultaneous procedures. The purpose of this study was to compare 90-day episode-of-care costs between staged and simultaneous BTJA among Medicare beneficiaries.

Questionnaire Versus Telephone Follow-up to Detect Postdischarge Complications in Surgical Patients: Randomized Clinical Trial

Background

Postdischarge complications in surgical patients are usually recorded only when readmission is required, a method that likely underestimates the overall complication rate. Our aim was to determine which method—telephone interview or questionnaire by mail—collects the most postdischarge complications.

Methods

We performed a randomized clinical equivalence trial. From December 2008 until August 2009, all adult surgical patients admitted to a university hospital were randomized to be approached by mail or by phone 30?days after discharge to collect information about postdischarge complications. Primary outcome was the total number of reported complications after discharge. Secondary outcome was the severity of the complications.

Results

In all, 1595 patients were reached: 890 by means of a telephone interview and 705 through a questionnaire. Response rate was higher in the telephone group than in the questionnaire group (63.8 % vs. 51.3 %). The percentage of patients reporting one or more complications did not differ significantly between the groups: 43.3 % in the telephone group versus 39.6 % in the questionnaire group. Length of stay, American Society of Anesthesiologist class, and type of surgery—but not the survey techniques compared here—significantly influenced the number of complications reported. The percentage of patient-reported complications requiring treatment did not differ significantly between the groups.

Conclusions

The two survey methods did not differ in their ability to appreciate postdischarge complications as reported by the patients. The decision to use either method may be determined by the institution, costs involved, and labor requirement.     

Calculating the Cost and Risk of Comorbidities in Total Joint Arthroplasty in the United States

Background

With increased scrutiny regarding the cost and safety of health care delivery, there is increasing interest in judicious patient selection for total joint arthroplasty (TJA) procedures. It is unknown which comorbidities incur the greatest increase in risk to the patient and cost to the system after TJA. Therefore, this study sought to characterize the association of common preoperative comorbidities with both the risk for postoperative in-hospital complications and the total hospital cost in patients undergoing TJA.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur

Background

The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible.

Inpatient Consults and Complications During Primary Total Joint Arthroplasty in a Bundled Care Model

Background

The Centers for Medicare and Medicaid Services (CMS) are implementing changes in hospital reimbursement models for total joint arthroplasty (TJA), moving to value-based bundled payments from the fee-for-service model. The purpose of this study is to identify consults and complications during the perioperative period that increase financial burden.