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1.
R. Carter Clement Caitlin M. Gray Michael M. Kheir Peter B. Derman Rebecca M. Speck L. Scott Levin Lee A. Fleisher 《The Journal of arthroplasty》2017,32(3):709-713
Background
The Centers for Medicare & Medicaid Services (CMS) recently imposed penalties against hospitals with above-average 30-day readmission rates following total joint arthroplasty (TJA). Hospitals must decide whether investments in readmission prevention are worthwhile. This study examines the financial incentives associated with unplanned readmissions before and after invocation of these penalties.Methods
Financial data were reviewed for 2028 consecutive primary TJAs performed on Medicare beneficiaries over a 2-year period at an urban academic health system. Readmission penalties were estimated in accordance with CMS policies.Results
Unplanned readmissions generated a $4416 median contribution margin. The initial hospitalizations (when the TJA was performed) were financially unfavorable for patients subsequently readmitted relative to those not readmitted due to increased costs of care (P = .002), but these costs were more than outweighed by the increased reimbursement earned during the readmission (P < .001), ultimately making readmitted patients financially preferable (P < .001). Going forward, penalties will be levied for risk-adjusted readmission rates above the national rate of 4.8%. For the institution under review, the penalty per readmission outweighs the financial gains earned through readmission by $12,184, resulting in a net loss from readmissions if the rate exceeds 6.5%. It will be financially optimal to maintain a readmission rate (after risk adjustment) equal to the national average but exceeding that rate will be $7768 more expensive per readmission than undershooting that target.Conclusion
If our results are generalizable, unplanned Medicare readmissions have traditionally been financially beneficial, but CMS penalties outweigh this benefit. Thus, penalties should incentivize institutions to maintain below-average arthroplasty readmissions rates. 相似文献2.
Bheeshma Ravi Zhang Nan Adam J. Schwartz Henry D. Clarke 《The Journal of arthroplasty》2017,32(7):2077-2081
Background
Readmission among Medicare recipients is a leading driver of healthcare expenditure. To date, most predictive tools are too coarse for direct clinical application. Our objective in this study is to determine if a pre-existing tool to identify patients at increased risk for inpatient falls, the Hendrich Fall Risk Score, could be used to accurately identify Medicare patients at increased risk for readmission following arthroplasty, regardless of whether the readmission was due to a fall.Methods
This study is a retrospective cohort study. We identified 2437 Medicare patients who underwent a primary elective total joint arthroplasty (TJA) of the hip or knee for osteoarthritis between 2011 and 2014. The Hendrich Fall Risk score was recorded for each patient preoperatively and postoperatively. Our main outcome measure was hospital readmission within 30 days of discharge.Results
Of 2437 eligible TJA recipients, there were 226 (9.3%) patients who had a score ≥6. These patients were more likely to have an unplanned readmission (unadjusted odds ratio 2.84, 95% confidence interval 1.70-4.76, P < .0001), were more likely to have a length of stay >3 days (49.6% vs 36.6%, P = .0001), and were less likely to be sent home after discharge (20.8% vs 35.8%, P < .0001). The effect of a score ≥6 on readmission remained significant (adjusted odds ratio 2.44, 95% confidence interval 1.44-4.13, P = .0009) after controlling for age, paralysis, and the presence of a major psychiatric disorder.Conclusion
Increased Hendrich fall risk score after TJA is strongly associated with unplanned readmission. Application of this tool will allow hospitals to identify these patients and plan their discharge. 相似文献3.
P. Maxwell Courtney Anthony J. Boniello Richard A. Berger 《The Journal of arthroplasty》2017,32(5):1426-1430
Background
As outpatient total hip (THA) and knee arthroplasties (TKA) increase in popularity, concerns exist about the safety of discharging patients home the same day. The purpose of this study is to determine the complications associated with outpatient total joint arthroplasty (TJA) and to identify high-risk patients who should be excluded from these protocols.Methods
We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary TKA or THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between outpatient and traditional inpatient procedures. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes.Results
Of the total 169,406 patients who underwent TJA, 1220 were outpatient (0.7%). The outpatient and inpatient groups had an overall complication rate of 8% and 16%, respectively. Patients aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications after THA and TKA (all P < .05). Surprisingly, outpatient TJA alone did not increase the risk of readmission (OR 0.652, 95% CI 0.243-1.746, P = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651, P = .789), and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567, P < .001).Conclusion
With the resources available in a hospital setting, outpatient TJA may be a safe option, but only in select, healthier patients. Care should be taken to extrapolate these results to an outpatient facility, where complications may be more difficult to manage. 相似文献4.
Dong-han Yao Aakash Keswani Chirag K. Shah Alex Sher Karl M. Koenig Calin S. Moucha 《The Journal of arthroplasty》2017,32(2):375-380
Background
Bundled payment programs for primary total joint arthroplasty (TJA) have identified reducing nonhome discharge as a major area of cost savings. Health care providers must therefore identify, risk stratify, and appropriately care for home-discharged TJA patients. This study aimed to analyze risk factors and timing of postdischarge complications among home-discharged primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and risk stratify them to identify those who would benefit from higher level care.Methods
Patients discharged home after elective primary THA/TKA from 2011 to 2014 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were performed using perioperative variables.Results
A total of 50,376 and 71,293 home-discharged THA and TKA patients were included for analysis, of which, 1575 THA (3.1%) and 2490 TKA (3.5%) patients suffered postdischarge severe complications or unplanned readmissions. These patients were older, smokers, obese, and functionally dependent (P < .001 for all). In multivariate analysis, severe adverse event predischarge, age, male gender, functional status, and 10 other variables were all associated with ≥1.22 odds of postdischarge severe adverse event or readmission (P < .05). THA and TKA patients with 2, 3, or ≥4 risk factors had 1.43-5.06 times odds of complications within 14 days post discharge and 1.41-3.68 times odds of complications beyond 14 days compared to those with 0 risk factors (P < .001 for all).Conclusion
Risk factors can be used to predict which home-discharged TJA patients are at greatest risk of postdischarge complications. Given that this is a growing population, we recommend the development of formal risk-stratification protocols for home-discharged TJA patients. 相似文献5.
Jarrett Williams Benjamin S. Kester Joseph A. Bosco James D. Slover Richard Iorio Ran Schwarzkopf 《The Journal of arthroplasty》2017,32(3):714-718
Background
To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.Methods
We analyzed the medical records of 1329 consecutive lower extremity total joint patients enrolled in Centers for Medicare and Medicaid Services' Bundled Program for Care Improvement treated over a 21-month period. The goal of this study was to ascertain if hospital LOS is associated with unplanned readmissions within 90 days of admission for a total hip or knee arthroplasty.Results
After controlling for multiple demographic variables including sex, age, comorbidities and discharge location, we found that hospital LOS greater than 4 days is a significant risk factor for unplanned readmission within 90 days (odd ratio = 1.928, P = .010). Total knee arthroplasty (TKA) and discharge to a location other than home are also independent risk factors for 90-day readmission.Conclusion
Our results demonstrate that increased LOS is a significant risk factor for readmission within 90 days of admission for a hip or knee arthroplasty in the Medicare population. 相似文献6.
Gregory G. Klingenstein Scott D. Schoifet Rajesh K. Jain Jeremy J. Reid Manny D. Porat Mojisola K. Otegbeye 《The Journal of arthroplasty》2017,32(11):3308-3313
Background
This study was aimed at assessing the risk of readmission for Medicare patients discharged home within a day of total knee arthroplasty (TKA) compared to those discharged on day 2 or beyond in a community medical center.Methods
A hospital inpatient database was queried for all unilateral, primary TKAs performed on patients 65 years or older from January 1, 2013, to December 31, 2015. A total of 2287 patients met the study criteria, of which 1502 were discharged within a day (short stay), and 785 were discharged on day 2 or beyond (traditional stay). The main outcome measures were all-cause 30-day and unplanned 90-day readmissions.Results
Short-stay patients did not experience a higher 30-day readmission rate (1.1%) compared to the traditional-stay patients (2.7%), nor did they experience a higher rate of unplanned 90-day readmissions (1.7% vs 3.6%). The short-stay group had more favorable demographics compared to the traditional-stay group. Logistic regression results revealed that none of the demographic factors considered had a statistically significant impact on 30-day readmission odds for either group. For unplanned 90-day readmissions, the results showed that for the short-stay patients, with the exception of age, none of the other demographic factors had significant impact on readmission odds and none were significant for the traditional-stay group.Conclusion
Our results suggest that the Medicare patients meeting discharge criteria and discharged home within a day of TKA do not have an increased risk of 30-day and 90-day readmission. 相似文献7.
Caitlin W. Hicks Michael Bronsert Karl E. Hammermeister William G. Henderson Douglas R. Gibula James H. Black Natalia O. Glebova 《Journal of vascular surgery》2017,65(4):1130-1141.e9
Objective
Although postoperative readmissions are frequent in vascular surgery patients, the reasons for these readmissions are not well characterized, and effective approaches to their reduction are unknown. Our aim was to analyze the reasons for vascular surgery readmissions and to report potential areas for focused efforts aimed at readmission reduction.Methods
The 2012 to 2013 American College of Surgeons National Quality Improvement Program (ACS NSQIP) data set was queried for vascular surgery patients. Multivariable models were developed to analyze risk factors for postdischarge infections, the major drivers of unplanned 30-day readmissions.Results
We identified 86,403 vascular surgery patients for analysis. Thirty-day readmission occurred in 8827 (10%), of which 8054 (91%) were unplanned. Of the unplanned readmissions, 61% (n = 4951) were related to the index vascular surgery procedure. Infectious complications were the most common reason for a surgery-related readmission (1940 [39%]), with surgical site infection being the most common type of infection related to unplanned readmission. Multivariable analysis showed the top five preoperative risk factors for postdischarge infections were the presence of a preoperative open wound, inpatient operation, obesity, work relative value unit, and insulin-dependent diabetes (but not diabetes managed with oral medications). Cigarette smoking was a weak predictor and came in tenth in the mode (overall C index, 0.657). When operative and postoperative factors were included in the model, total operative time was the strongest predictor of postdischarge infectious complications (odds ratio [OR] 1.2 for each 1-hour increase in operative time), followed by presence of a preoperative open wound (OR, 1.5), inpatient operation (OR, 2), obesity (OR, 1.8), and discharge to rehabilitation facility (OR, 1.7; P < .001 for all). Insulin-dependent diabetes, cigarette smoking, dialysis dependence, and female gender were also predictive, albeit with smaller effects (OR, 1.1-1.3 for all; P < .001). The overall fit of the multivariable model was fair (C statistic, 0.686).Conclusions
Infectious complications dominate the reasons for unplanned 30-day readmissions in vascular surgery patients. We have identified preoperative, operative, and postoperative risk factors for these infections with the goal of reducing these complications and thus readmissions. Expected patient risk factors, such as diabetes, obesity, renal insufficiency, and cigarette smoking, were less important in predicting infectious complications compared with operative time, presence of a preoperative open wound, and inpatient operation. Our findings suggest that careful operative planning and expeditious operations may be the most effective approaches to reducing infections and thus readmissions in vascular surgery patients. 相似文献8.
9.
Background
Epilepsies is a spectrum of brain disorders ranging from severe, life threatening, and disabling to more benign, but little is known about its impact in the perioperative arthroplasty setting. We sought to determine whether epileptic patients undergoing elective total joint arthroplasty (TJA) would be at increased risk for in-hospital complications and death, prolonged stay, and nonroutine discharge.Methods
Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 6,054,344 patients undergoing elective primary TJA, of whom 31,865 (0.5%) were identified as having epilepsy. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling.Results
Patients with epilepsy were associated with increased in-hospital mortality (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.57-2.62) and morbidity, including (in decreasing order of magnitude of effect estimate): mechanical ventilation (OR 1.74, 95% CI 1.56-1.94), induced mental disorder (OR 1.70, 95% CI 1.56-1.85), stroke (OR 1.63, 95% CI 1.23-2.15), pneumonia (OR 1.34, 95% CI 1.21-1.49), and ileus or gastrointestinal events (OR 1.26, 95% CI 1.12-1.42). Epilepsy was associated with higher risk for blood transfusion (OR 1.30, 95% CI 1.27-1.33), prolonged hospital stay (OR 1.14, 95% CI 1.11-1.17), and nonroutine discharge (OR 1.54, 95% CI 1.50-1.58). We found no association with inpatient thromboembolic events, acute renal failure, and myocardial infarction.Conclusion
Patients with epilepsy are at increased risk for early postoperative complications (especially mechanical ventilation, induced mental disorder, and stroke) and resource utilization after elective joint arthroplasty. Greater awareness of epilepsy and its health consequences may contribute to improvements in the perioperative management of TJA patients. 相似文献10.
Objective
Hospital readmissions after surgical operations are preventable and are now counted as a quality metric. Patients with peripheral arterial disease often have several serious medical comorbidities. With advancements in endovascular technology and increasing comfort level of vascular surgeons, more and more patients with peripheral arterial disease are being treated with endovascular therapy. Most of these interventions are done as same-day operations. This study retrospectively reviewed the factors associated with hospital readmission after lower extremity endovascular interventions.Methods
This study used the 2013 endovascular repair-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery Program User Files. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity endovascular surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for hospital readmission ≤30 days after surgery.Results
During 2013, 1096 patients (61% men, 39% women) underwent lower extremity endovascular interventions. Indications for operations included claudication (40%), critical limb ischemia with rest pain (19%), critical limb ischemia with tissue loss (35%), and others (6%) Among these patients, 147 (13.4%) were readmitted to the hospital ≤30 days after surgery, and ～46% of all readmissions were ≤2 weeks after the discharge The following factors had significant associations with readmission: smoking (odds ratio [OR], 0.52, 95% confidence interval [CI], 0.3-0.9), noninsulin-dependent diabetes mellitus (OR, 1.65; 95% CI, 0.9-3.2), dyspnea (OR, 1.9; 95% CI, 1-3.7), insulin-dependent diabetes mellitus (OR, 2.1; 95% CI, 1.2-3.6), body mass index >30 kg/m2 (OR, 2.5; 95% CI, 1.3-5.1), dependent functional status (OR, 2.6; 95% CI, 1.4-4.8), emergent surgery (OR, 4.3; 95% CI, 1.9-9.6), and unplanned return to the operating room (OR, 8.3; 95% CI, 4.7-14.7).Conclusions
Readmission after lower extremity endovascular intervention is a serious complication. Various factors place a patient at a high risk for readmission. High body mass index, unplanned return to the operating room, insulin-dependent diabetes mellitus, noninsulin-dependent diabetes mellitus, nonsmoking status, dyspnea, dependent functional status, and emergency operation are independent risk factors for hospital readmission. Return to operating room is associated with an 8.3-fold increase in hospital readmission. 相似文献11.
Adam I. Edelstein Francis Lovecchio Dimitri E. Delagrammaticas David W. Fitz Kevin D. Hardt David W. Manning 《The Journal of arthroplasty》2017,32(2):362-366
Background
The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty.Methods
We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed.Results
Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups.Conclusion
MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases. 相似文献12.
Jeremiah D. Johnson Joseph M. Nessler Ryan D. Horazdovsky Sandy Vang Avis J. Thomas Scott B. Marston 《The Journal of arthroplasty》2017,32(3):924-928
Background
Periprosthetic joint infection is the most common cause of readmissions after total joint arthroplasty (TJA). Intrawound vancomycin powder (VP) has reduced infection rates in spine surgery; however, there are no data regarding VP in primary TJA.Methods
Thirty-four TJA patients received 2 g of VP intraoperatively to investigate VP's pharmacokinetics. Serum and wound concentrations were measured at multiple intervals over 24 hours after closure.Results
All serum concentrations were subtherapeutic (<15μg/mL) and peaked 12 hours after closure (4.7μg/mL; standard deviation [SD], 3.2). Wound concentrations were 922 μg/mL (SD, 523) 3 hours after closure and 207 μg/mL (SD, 317) at 24 hours. VP had a half-life of 7.2 hours (95% confidence interval, 7.0-9.3) in TJA wounds.Conclusions
VP produced highly therapeutic intrawound concentrations while yielding low systemic levels in TJA. VP may serve as a safe adjunct in the prevention of periprosthetic joint infection. 相似文献13.
Jaime L. Bellamy Robert P. Runner CatPhuong Cathy L. Vu Mara L. Schenker Thomas L. Bradbury James R. Roberson 《The Journal of arthroplasty》2017,32(10):2963-2968
Background
Frailty is described as decreased physiological reserve and typically increasing with age. Hospitals are being penalized for reoperations and readmissions, which can affect reimbursement. The purpose of this study was to determine if the modified frailty index (MFI) could be used as a risk assessment tool for preoperative counseling and to make an objective decision on whether to perform total hip arthroplasty (THA) on a frail patient.Methods
The American College of Surgeons National Surgical Quality Improvement Program database was queried by Current Procedural Terminology code for primary THA (27130) from 2005 to 2014. MFI was calculated using 11 variables extracted from the medical record. Bivariate analysis was performed for outcomes and complications, and the multiple logistic regression model was used to compare MFI with other predictors of readmission, any complication, and reoperation.Results
A total of 51,582 patients underwent primary THA during the study period. MFI was a significant and stronger predictor than the American Society of Anesthesiologists class and age for readmission (odds ratio [OR], 14.72; 95% confidence interval [CI], 6.95-31.18; P < .001), any complication (OR, 3.63; 95% CI, 1.64-8.05; P = .002), and reoperation (OR, 8.78; 95% CI, 3.67-20.98; P < .001). As MFI increased, adverse discharge, any complication, readmission, reoperation, and mortality significantly increased (P < .001). Rates of systemic complications and length of stay significantly increased with increasing MFI.Conclusion
MFI is a simple and effective risk assessment tool to preoperatively counsel and make an objective decision on whether to perform THA on a frail patient. 相似文献14.
Matthew A. Varacallo Leah Herzog Nader Toossi Norman A. Johanson 《The Journal of arthroplasty》2017,32(6):1739-1746
Background
Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.Methods
Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013.Results
In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period.Conclusion
Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission. 相似文献15.
Brian P. Chen Johanna Dobransky Stephane Poitras Alan Forster Paul E. Beaulé 《The Journal of arthroplasty》2017,32(12):3563-3567
Background
Readmission rate has emerged as an important metric to measure quality, but varying definitions and timeframes are used. We aimed to evaluate the impact of different readmission definitions (postoperative vs postdischarge) and timeframes (30 vs 90-day) on capturing surgery-related readmissions after primary total joint arthroplasty.Methods
Patients who underwent primary total hip or knee arthroplasty between January 1, 2013 and December 31, 2015 were included. The electronic medical records of readmitted patients were reviewed to determine whether a surgery-related event was most responsible for readmission. The performances of 4 definition-timeframe combinations in capturing surgery-related readmissions were evaluated.Results
A total of 2586 patients were included. Using both postoperative and postdischarge definitions, there were no differences in the proportion of readmissions that were surgery-related when comparing 30 and 90-day timeframes (postoperative: 71% vs 60%, P = .118; postdischarge: 68% vs 60%, P = .219). Greater proportion of readmissions between days 0 and 30 were for surgery-related reasons compared with readmissions between days 31 and 90 using both postoperative and postdischarge definitions (postoperative: 71% vs 47%, P = .005; postdischarge: 68% vs 49%, P = .022). Among 104 patients readmitted for surgery-related reasons within 1 year of discharge, 52% were readmitted within 30 days of surgery compared with 79% within 90 days (P < .001). Similarly, 53% and 81% of readmissions were captured by the 30 and 90-day postdischarge definitions, respectively (P < .001).Conclusion
A 90-day timeframe is superior in capturing surgery-related readmissions after total joint arthroplasty. Important Total hip and knee arthroplasty adverse events may be missed using a 30-day timeframe. 相似文献16.
Joshua C. Rozell P. Maxwell Courtney Jonathan R. Dattilo Chia H. Wu Gwo Chin Lee 《The Journal of arthroplasty》2017,32(3):719-723
Background
Improved pain management and early mobilization protocols have increased interest in the feasibility of short stay (<24 hours) or outpatient total hip (THA) and total knee (TKA) arthroplasty. However, concerns exist regarding patient safety and readmissions. The purposes of this study were to determine the incidence of in-hospital complications following THA/TKA, to create a model to identify comorbidities associated with the risk of developing major complications >24 hours postoperatively, and to validate this model against another consecutive series of patients.Methods
We prospectively evaluated a consecutive series of 802 patients who underwent elective primary THA and TKA over a 9-month period. The mean age was 62.3 years. Demographic, surgical, and postoperative readmission data were entered into an arthroplasty database.Results
Of the 802 patients, 382 experienced a complication postoperatively. Of these, 152 (19%) required active management. Multiple logistic regression analysis identified cirrhosis (odds ratio [OR], 5.89; 95% confidence interval [CI], 1.05-33.07; P = .044), congestive heart failure (OR, 3.12; 95% CI, 1.50-6.44; P = .002), and chronic kidney disease (OR, 3.85; 95% CI, 2.21-6.71; P < .001) as risk factors for late complications. One comorbidity was associated with a 77% probability of developing a major postoperative complication. This model was validated against an independent dataset of 1012 patients.Conclusion
With improved pain management and mobilization protocols, there is increasing interest in short stay and outpatient THA and TKA. Patients with cirrhosis, congestive heart failure, or chronic kidney disease should be excluded from early discharge total joint arthroplasty protocols. 相似文献17.
Matthew P. Kelly Heather A. Prentice Wei Wang Brian H. Fasig Dhiren S. Sheth Elizabeth W. Paxton 《The Journal of arthroplasty》2018,33(7):2075-2081
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.Methods
Patients from July 1, 2012 through June 30, 2015 having primary elective TJA and at least one 90-day postoperative ED-only visit and/or readmission for any reason were identified using the Kaiser Permanente Total Joint Replacement Registry. Chart reviews for ED visits/readmissions included 13 surgical and 11 medical reasons. The 2344 total hips and 5520 total knees were analyzed separately.Results
Incidence of at least one ED visit following total hip arthroplasty (THA) was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%) and pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%). The incidence of at least one ED visit following total knee arthroplasty (TKA) was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%) and swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anesthesia (9.4%).Conclusion
Swelling and pain related to the procedure were the most frequent reasons for 90-day ED visits after both THA and TKA. Readmissions were most commonly due to infection or unrelated procedures for THA and gastrointestinal or manipulation under anesthesia for TKA. Modifications to discharge protocols may help prevent or alleviate these issues, avoiding unnecessary hospital returns. 相似文献18.
Steven M. Kurtz Edmund C. Lau Kevin L. Ong Edward M. Adler Frank R. Kolisek Michael T. Manley 《The Journal of arthroplasty》2017,32(11):3274-3285
Background
The purpose of this study was to determine whether the cost of readmissions after primary total hip and knee arthroplasty (THA and TKA) has decreased since the introduction of health care reform legislation and what patient, clinical, and hospital factors drive such costs.Methods
The 100% Medicare inpatient dataset was used to identify 1,654,602 primary THA and TKA procedures between 2010 and 2014. The per-patient cost of readmissions was evaluated in general linear models in which the year of surgery and patient, clinical, and hospital factors were treated as covariates in separate models for THA and TKA.Results
The year-to-year risk of 90-day readmission was reduced by 2% and 4% (P < .001) for THA and TKA, respectively. By contrast, the cost of readmissions did not change significantly over time. The 5 most important variables associated with the cost of 90-day THA readmissions (in rank order) were the nature of the readmission (ie, due to medical or procedure-related reasons), the length of stay, hospital's teaching status, discharge disposition, and hospital's overall total joint arthroplasty volume. The top 5 factors associated with the cost of 90-day TKA readmissions were (in rank order) the length of stay, hospital's teaching status, discharge disposition, patient's gender, and age.Conclusion
Although readmission rates declined slightly, the results of this study do not support the hypothesis that readmission costs have decreased since the introduction of health care reform legislation. Instead, we found that clinical and hospital factors were among the most important cost drivers. 相似文献19.
Background
There has been increasing interest in outpatient total joint arthroplasty (TJA) in the orthopedic community, but how patients feel about outpatient TJA is unknown. The purpose of this study was to understand patient perspectives on hip and knee replacements performed in an outpatient setting.Methods
We surveyed 110 consecutive patients scheduled for primary TJA in an academic suburban arthroplasty practice regarding their knowledge and perceptions of outpatient TJA. Questionnaires were administered during preoperative clinic visits before discussion of surgery location, length of stay, and before preoperative joint replacement education.Results
Fifty-seven percent of respondents were female, and 42.7% were aged 65 years or older. Very few patients expected same-day discharge (n = 3) or a one night stay in the hospital (n = 17). Fifty-four percent of patients were expected to stay in the hospital two or more nights. Only 54.5% of patients were aware that outpatient TJA is an option, with 55.3% of men and 31.7% of women reporting that they were comfortable with outpatient TJA (P = .030). In contrast, 61% and 72.8% believed that faster recovery and decreased likelihood of infection are likely advantages of outpatient TJA. Interestingly, 51.9% felt ambulatory surgery centers are as safe as hospitals, and 62.6% believed that home is the best place to recovery from TJA.Conclusion
These observations suggest that there is need for patient education regarding outpatient TJA. As outpatient procedures become more common, it is essential that patients understand the ambulatory surgery process, the benefits and risks of same day discharge, and their role in a successful outpatient experience. 相似文献20.
Paul K. Edwards Cale A. Jacobs Kristie B. Hadden C. Lowry Barnes 《The Journal of arthroplasty》2017,32(4):1100-1102