More Patients Are Being Discharged Home After Total Knee Arthroplasty,However Rates Vary Between Large Databases

BackgroundThere have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications.MethodsPatients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed.ResultsIn total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001).ConclusionPatients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.     

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.

Trial registration: ClinicalTrials.gov identifier: NCT01515670.     

An Analysis of Centers for Medicare & Medicaid Service Payment in Maryland: Can a Global Budget Revenue Model Save Money in Lower Extremity Arthroplasty?

Background

Maryland is the only state utilizing the Global Budget Revenue (GBR) model to reduce costs. The purpose of this study is to evaluate whether the GBR payment model effectively reduced the following: (1) costs of inpatient hospital stays; (2) post-acute care costs; (3) lengths of stay (LOS); (4) readmission rates; and (5) discharge disposition in patients who underwent primary total hip and knee arthroplasty (THA and TKA).

Recent Increases in Outpatient Total Hip Arthroplasty Have Not Increased Early Complications

BackgroundOutpatient total hip arthroplasty (THA) has increased in recent years. Recent regulatory changes may allow and incentivize outpatient THA in more patients; however, there are concerns regarding safety. The purpose of this study is to assess early complications in outpatient THA compared to longer hospitalization.MethodsWe identified patients undergoing primary THA in the National Surgical Quality Improvement Program database between 2015 and 2018. Patients were stratified by length of stay (LOS): 0 days (LOS 0), 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Multivariate analysis was performed.ResultsIn total, 4813 (4%) patients underwent outpatient THA, 84,627 (64%) had LOS of 1-2 days, and 42,293 (32%) had LOS ≥3 days. LOS 0 patients were younger, had lower body mass index, and less medical comorbidities compared to those with postsurgical hospitalization. Any complication was experienced in 3.2% of the LOS 0 group, 5.3% of the LOS 1-2 group, and 15.6% for the LOS ≥3 group (P < .0001). Readmission rates were 1.6%, 2.6%, and 4.7% for the 3 groups, respectively (P < .0001). After controlling for confounding variables, patients with LOS 1-2 days had higher odds for any complication (odds ratio 1.56 [1.32-1.83) and readmission (odds ratio 1.41 [1.12-1.78]) compared to LOS 0 days. Patients with LOS ≥3 days had higher odds for complications compared to LOS 0 or 1-2 days.ConclusionOutpatient THA had lower odds for readmission or complications compared to LOS 1-2 days. Despite increased outpatient surgery, many patients had postsurgical hospitalization and, due to patient factors, this remains an integral patient of post-THA care.     

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons

BackgroundWe sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT).MethodsA single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019.ResultsIn total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001).ConclusionFor both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training.Level III EvidenceRetrospective Cohort Study.     

Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis

BackgroundPigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs.MethodsPatients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch’s t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant.ResultsPVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001).ConclusionWithout controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.     

Psychological Distress Independently Predicts Prolonged Hospitalization After Primary Total Hip and Knee Arthroplasty

BackgroundThe purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA).MethodsA retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed.ResultsThe prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P < .0001) and more likely to have depression (P < .0001), lower educational attainment (P < .0001), smoke tobacco (P = .003), be Hispanic/Latino (P = .001), live alone (P = .001), and have higher rates of nonprimary osteoarthritis (P < .0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P = .049 and .006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P = .913 and .782 for THA and TKA, respectively), emergency room visits (P = .467 and .355 for THA and TKA respectively), or readmissions (P = .118 and .334 for THA and TKA, respectively).ConclusionPsychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted.     

Accelerated Discharge After Aseptic Revision Total Hip Arthroplasty Does Not Predict Inferior 30-Day Outcomes

BackgroundPerioperative advancements have made outpatient primary total hip arthroplasty (THA) a viable option for patients. This study evaluated the feasibility of expedited discharge after revision THA and compared 30-day outcomes to patients who had prolonged inpatient hospitalizations. The authors hypothesized that expedited discharge would not result in inferior 30-day outcomes.MethodsAseptic revision THAs in a national database were reviewed from 2013 to 2020. THAs were stratified by hospital length of stay (LOS) more or less than 24 hours. Demographics, comorbidities, preoperative laboratory values, American Society of Anesthesiology (ASA) scores, operative times, components revised, 30-day readmissions, and reoperations were compared. Multivariable analyses evaluated predictors of discharge prior to 24 hours, 30-day readmissions, and reoperations. Of 17,044 aseptic revision THAs, 211 were discharged within 24 hours.ResultsAccelerated discharge patients were younger, mean age 63 years (range, 20-92) versus 66 years (range, 18-94) (P < .01) had lower body mass index, mean 28.7 (range, 18.3-46.4) versus 29.9 (range, 17.3-52.5) (P = .01), and ASA scores (ASA, 1-2; 40.4-57.8%) (P < .01). Components revised had no association with LOS (P = .39); however, operative times were shorter and mean 100 minutes (range, 35-369) versus 139 minutes (range, 24-962) (P < .01) in accelerated discharge patients. Accelerated discharge patients had lower readmission rates (P < .01) but no difference in reoperation rates (P = .06).ConclusionDischarge less than 24 hours after revision THA is a feasible option for the correct patient and further efforts to decrease LOS should be evaluated.     

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

BackgroundUnplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.MethodsWe performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.ResultsAmong THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).ConclusionReadmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.     

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BackgroundAdvances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.MethodsAdult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.ResultsOf the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35–3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86–8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0–3.1% per year) with no evidence of an increasing trend over time (P = .21).ConclusionAmbulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.     

The Need for an Interpreter Increases Length of Stay and Influences Postoperative Disposition Following Primary Total Joint Arthroplasty

BackgroundMany US patients who undergo total joint arthroplasty have low English proficiency, yet no study has investigated how the need for a translator impacts postoperative outcomes for these patients. We hypothesized that need for an interpreter after total joint arthroplasty would impact discharge disposition and length of stay.MethodsWe performed a retrospective chart review of patients at a single large urban academic institution undergoing single primary total joint replacement from July 2016 to November 2019. Patients were classified as primarily English speaking (E), non-English primary language and did not require an interpreter (NE-N), or non-English primary language and did require an interpreter (NE-I). Data on patient characteristics, length of stay, and discharge disposition were collected.ResultsTotal hip arthroplasty (THA) patients in the NE-I group had significantly longer length of stay than both the NE-N group (2.85 vs 2.28 days, P = .015) and the E group (2.85 s vs 1.87 days, P < .0001). THA patients who required a translator were also significantly less likely to be discharged to home than those who were primarily English speaking (71.4% vs 88.8%, P < .0001). Total knee arthroplasty (TKA) patients in the NE-I group had significantly longer length of stay than the E group (2.66 vs 2.50 days, P = .009). The TKA patients in the NE-I group were significantly less likely to be discharged home than in the E group (74.5% vs 82.4%, P < .0001).ConclusionAlthough interpreter services are provided by the hospital for NE-I patients, the communication barrier that exists affects both length of stay and discharge disposition for both THA and TKA.     

No Changes in Patient Selection and Value-Based Metrics for Total Hip Arthroplasty After Comprehensive Care for Joint Replacement Bundle Implementation at a Single Center

BackgroundAlternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services to decrease overall healthcare cost. The associated shift of financial risk to participating institutions may negatively influence patient selection to avoid high cost of care (“cherry picking,” “lemon dropping”). This study evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery, and hospital costs at a single care center.MethodsPatients undergoing a primary THA from 2015-2017 were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before (pre-CJR) or after (post-CJR) CJR bundle implementation. Patient age, gender, and body mass index, Elixhauser comorbidities and American Society of Anesthesiologists scores, were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared pre- and post-CJR.ResultsA total of 751 THA patients (273 Medicare and 478 commercial Insurance) were evaluated pre-CJR (29%) and post-CJR (71%). Patient demographics were similar (age, gender, BMI); however, commercially insured patients had less comorbidities pre-CJR (P = .033). Medicare patient post-CJR length of stay (P = .010) was reduced with a trend toward discharge to home (P = .019). Surgical time, operating room service time, 90-day readmissions and direct hospital costs were similar pre- and post-CJR.ConclusionThere was no differential patient selection after CJR bundle implementation and value-based metrics (surgical time, operating room service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals.     

Length of Stay After Joint Arthroplasty is Less Than Predicted Using Two Risk Calculators

BackgroundPredicting the length of stay (LOS) after total joint arthroplasty (TJA) has become more important with their recent removal from inpatient-only designation. The American College of Surgeons (ACS) National Surgical Quality Improvement Program surgical risk calculator and the CMS’ diagnosis-related group (DRG) calculator are two common LOS predictors. The aim of our study was to determine how our actual LOS compared with those predicted by both the ACS and DRG.Methods99 consecutive TJA (49 hips and 50 knee procedures) were reviewed in Medicare-eligible patients from four fellowship-trained arthroplasty surgeons. Predicted LOS was calculated using the DRG and ACS risk calculators for each patient using demographics, medical histories, and comorbidities. LOS was compared between the predicted and the actual LOS for both total hip arthroplasty (THA) and total knee arthroplasty (TKA) using paired t-tests.ResultsActual LOS was shorter in the THA group vs the TKA group (1.29 days vs 1.46 days, P < .05). The actual LOS of patients at our institution was significantly shorter than both DRG and ACS predictions for both THA and TKA (P < .05). In both the THA and TKA patients, the actual LOS (1.29 and 1.46 day) was significantly shorter than the DRG-predicted LOS (2.15 and 2.15 days) which was significantly shorter than the ACS-predicted LOS (2.9 and 3.14 days).ConclusionWe found the actual LOS was significantly shorter than that predicted by both the DRG and ACS risk calculators. Current risk calculators may not be accurate for contemporary fast-track protocols and newer tools should be developed.     

Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes

Background

Medicare has enacted a mandatory bundled payment program for primary total joint arthroplasty that includes nonelective primary total hip arthroplasty (THA). Efficient postacute care management has been identified as an opportunity to improve value for patients. We aimed to identify risk factors for and compare rates of complications by discharge destination and then use those factors to risk-stratify non-elective THA patients.

Rates and Causes of 90-day Complications and Readmissions Following Outpatient Hip and Knee Arthroplasty: A Retrospective Analysis of 525 Patients in a Single Institution

BackgroundOutpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist.Patients and MethodsThis retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs ≥1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis.ResultsThe complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS ≥1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS ≥1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m2 (vs BMI <25 kg/m2).ConclusionSDD following OJA did not result in more complications and hospital readmissions compared to a prolonged hospital stay. The majority of complications and readmissions were due to noninfected wound discharge.     

Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination

BackgroundThe average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be.MethodsWe analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS.Results1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery.ConclusionWe have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.     

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

BackgroundWith the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA.MethodsAt our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites.ResultsBetween 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient.ConclusionQuality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.     

Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty

BackgroundTo determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient.MethodsRetrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed.ResultsThe cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2).ConclusionThe LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient’s first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge.Level of EvidenceLevel 3-retrospective cohort study.     

Surgeon Reimbursement Unchanged as Hospital Charges and Reimbursements Increase for Total Joint Arthroplasty

BackgroundDespite increasing demands on physicians and hospitals to increase value and reduce unnecessary costs, reimbursement for healthcare services has been under downward pressure for several years. This study aimed to analyze the trend in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for total hip (THA) and knee arthroplasty (TKA).MethodsThe 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 56,228 patients who underwent primary THA and 117,698 patients who underwent primary TKA between 2005 and 2014. Two values were calculated: (1) the charge multiplier (CM), the ratio of hospital to surgeon charges and (2) the payment multiplier (PM), the ratio of hospital to surgeon payments. Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.ResultsHospital charges were significantly higher than surgeon charges and increased substantially for both THA (CM increased from 8.7 to 11.5, P < .0001) and TKA (CM increased from 7.9 to 11.4, P < .0001). PM followed a similar trend, increasing for both THA and TKA (P < .0001). LOS decreased significantly for both THA and TKA (P < .0001), while Charlson Comorbidity Index remained stable. Both CM (r² = 0.84 THA, 0.90 TKA) and PM (r² = 0.75 THA, 0.84 TKA) were strongly negatively associated with LOS.ConclusionHospital charges and payments relative to surgeon charges and payments have increased substantially for THA and TKA despite stable patient complexity and decreasing LOS.     

Factors implicated in discharge disposition following elective bariatric surgery

BackgroundCurrent bariatric surgery studies have focused on traditional outcomes such as mortality and morbidity and have thus far have neglected an important marker of surgical care- discharge destination.ObjectivesThe aim of this study was to 1) characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery with respect to discharge disposition and to 2) evaluate factors which predict alternate care facility (ACF) discharge.SettingParticipating Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centers.MethodsData was extracted from the MBSAQIP data registry from 2015 to 2018. All primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included while prior revisional surgeries and emergency surgeries were excluded. Our primary objective was to characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery and are discharged to an alternate care facility (ACF). Our secondary outcome was to identify predictors of discharge to an ACF using multivariable logistic regression modeling.ResultsMost patients (n = 588,256; 99.6%) were discharged home while only a small proportion were discharged to an ACF (n = 1502; .4%). Patients discharged to an ACF were older (51.5 ± 13.5 yr versus 44.4 ± 12.0 yr; P < .0001), of increased body mass index (49.7 ± 11.9 kg/m² versus 45.3 ± 7.8 kg/m²; P < .0001), and more likely to be of male sex (26.8% versus 20.4%; P < .0001). Patients with hypertension (65.2% versus 47.9%; P < .0001), dyslipidemia (40.1% versus 23.7%; P < .0001), sleep apnea (52.7% versus 38.1%; P < .0001), and medication-dependent diabetes (39.5% versus 26.3%; P < .0001) were more likely to be discharged to an ACF. Multivariable logistic regression revealed that partially dependent and dependent functional status were the single greatest preoperative predictors of ACF discharge with an 8- and 7-fold respective increase in odds of ACF versus patients of independent functional status.ConclusionImpaired functional status was the single greatest independent preoperative predictor of ACF discharge, providing evidence against the current use of a strict age cut-off criteria and support for implementation of a more patient-centered functional approach in selection of surgical candidates.