Does Patient Experience After a Total Knee Arthroplasty Predict Readmission?

BackgroundTo our knowledge, the relationship between patient Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and patient outcomes in total knee arthroplasty (TKA) has not yet been analyzed. Therefore, the purpose of this study is to determine whether readmissions within the 30 or 90 days postoperative window after TKA were predicted by patient satisfaction scores, as measured by the HCAHPS survey.MethodsWe analyzed HCAHPS survey scores from all patients who underwent primary or revision TKA at our institution between January 1, 2016 and September 1, 2016. Demographic readmission information, preoperative baseline health status measures, validated patient-reported pain and joint function measures, and HCAHPS survey scores were collected. To determine whether 30-day or 90-day readmissions were independently associated with HCAHPS scores, statistical analyses were conducted using chi-squared and Student’s t-tests for categorical and continuous variables. Multivariable regression analysis adjusted for patient-level risk factors.ResultsPatients readmitted within 30 days were significantly less likely to choose the highest rating on survey questions in several dimensions of patient satisfaction when compared to patients who were not readmitted. These dimensions included physician communication (P = .045), discharge information (P = .016), and transition of care (P = .044). Similarly, patients who were readmitted within 90 days were less likely to choose the highest rating in survey questions that pertained to physician communication (P = .046), medication information (P = .040), and quietness of the hospital environment (P = .048).ConclusionOur results show that readmission is predicted by lower patient satisfaction scores in several dimensions of patient care including physician communication, hospital environment, medication information, discharge information, and transition of care.     

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy—a Predictable Event?

Background

Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG).

Methods

We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission.

Results

Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI?=?[1.19, 5.40]), intraoperative drain placement (OR 3.11, CI?=?[1.58, 6.13]), postoperative complications (OR 8.21, CI?=?[2.33, 28.97]), and pain at discharge (OR?8.49, CI?=?[2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR?72.4, CI?=?[15.8, 330.5]).

Conclusions

The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

     

Will Medicare Readmission Penalties Motivate Hospitals to Reduce Arthroplasty Readmissions?

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.

Does Discharge Disposition After Primary Total Joint Arthroplasty Affect Readmission Rates?

We reviewed 90-day readmission rates for 9150 patients with a primary total hip or knee arthroplasty performed between April 2001 and December 2004. Patients with an American Society of Anesthesiologists score of 3 or greater or with perioperative complications were excluded. We correlated the readmission rate with discharge disposition to either skilled nursing facilities (SNFs) or Home. Of the 9150 patients identified, 1447 were discharged to an SNF. After statistically adjusting for sex, age and American Society of Anesthesiologists scores, total hip arthroplasty and total knee arthroplasty patients discharged to SNFs had higher odds of hospital readmission within 90 days of surgery than those discharged home (total hip arthroplasty: odds ratio = 1.9; 95% confidence interval, 1.2-3.2; P = .008; total knee arthroplasty: odds ratio = 1.6; 95% confidence interval, 1.1-2.4; P = .01). Healthy patients discharged to SNFs after primary total joint arthroplasty need to be followed closely for complications.     

Readmission Rates in the State of Florida: A Reflection of Quality?

Background

High readmission rates are viewed by the Centers for Medicare & Medicaid Services as a quality of care determinant but it is unclear whether readmission rates per se reflect quality and the drivers of readmissions after hip arthroplasty remain unclear.

Question/purposes

We therefore describe the effects of (1) insurance, discharge disposition, and mental health status as they relate to rates; (2) rehospitalization charges; and (3) reasons for readmissions.

Methods

We studied a cohort of all 27,019 patients who initially underwent hip arthroplasty in Florida (April 2009 to March 2010). Participants were identified using the All Patient-Refined Diagnosis-Related Group 301. Data were provided by the Agency for Health Care Administration and the Florida Hospital Association who with the Florida Orthopedic Society studied readmissions within 15 days. We extracted readmission rates and their reasons; original payers, discharge disposition, mental health status; and readmission charges.

Results

The readmission rate in the first 15 days was 5%. Rates varied by type of insurance: self-pay/underinsured, Medicaid, and Medicare patients (6%) had higher rates than individuals with commercial insurance, HMO, or PPO (3%). Patients discharged to skilled nursing facilities (SNFs) had higher rates (7%) than patients discharged home with/without health care (both 3%). Patients with a mental health issue (10%) were readmitted more frequently than patients without it (5%). Medicare readmissions comprised 81% (USD 59,222,829) of the total readmission charges in this cohort. The most common reasons were infections (all 27%), hip arthroplasty (11%), and cardiovascular problems (9%).

Conclusions

Patients were more frequently readmitted if their payer was the government, they were discharged to a SNF, or they had a mental health disorder. Infections were the most common reasons for readmission. Our data suggest readmission rates alone do not necessarily reflect quality of care.     

Readmission After Abdominal Surgery for Crohn’s Disease: Identification of High-Risk Patients

Background

Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn’s disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery.

Methods

All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn’s indications were not included.

Results

Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005–1.04; p?<?0.006), a history of previous proctectomy (OR 3, 95%CI 1.2–9, p?<?0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1–1.002, p?<?0.05).

Conclusion

Readmission occurred in 8–9% of abdominal procedures for CD within 1–3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.

     

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

HSS Journal ® - Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that...     

Hospital Readmission for Fluid and Electrolyte Abnormalities Following Ileostomy Construction: Preventable or Unpredictable?

Background

Ileostomy creation has complications, including rehospitalization for fluid and electrolyte abnormalities. Although studies have identified predictors of this morbidity, readmission rates remain high.

Methods

The researchers conducted a retrospective chart review of all patients with ileostomy creation at a tertiary institution from January 2008 to June 2011.

Results

One hundred fifty-four patients (154) were included in this study; 71 (46.1 %) were female. Mean age was 49?±?17.64 (range 16–91), and mean BMI was 26.9?±?6.44 (range 13–52). The readmission rate for fluid and electrolyte abnormalities was 20.1 % for the study population; of those readmitted for all diagnoses, dehydration accounted for 40.7 % of all readmissions. Cancer was associated with readmission (χ ²?=?4.73, p?=?0.03) as was neoadjuvant therapy (χ ²?=?9.20, p?=?0.01). After multivariate analysis, only the use of anti-diarrheals and neoadjuvant therapy remained significant. High stoma output, adjuvant treatment, and postoperative complications were not significant.

Conclusions

Our study found that the use of anti-diarrheals and neoadjuvant therapy for rectal cancer were associated with readmission. Our findings imply that the use of anti-diarrheals may be a marker for patients at risk for fluid and electrolyte abnormalities; these patients should be strictly monitored at home. Our study also suggests consideration of avoidance of ileostomy creation or different discharge criteria for at-risk patients. Prospective studies focused on stoma monitoring after discharge may help reduce rehospitalizations for fluid and electrolyte abnormalities after ileostomy creation.     

Understanding Readmission After Primary Total Hip and Knee Arthroplasty: Who’s at Risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.     

Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster?

BackgroundAs the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department.MethodsA retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution’s average payment for Medicare readmissions and observations, actual and potential savings were calculated.ResultsSixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status.ConclusionAt our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.     

Are There Modifiable Risk Factors for Hospital Readmission After Total Hip Arthroplasty in a US Healthcare System?

Background

Although total hip arthroplasty (THA) is a successful procedure, 4% to 11% of patients who undergo THA are readmitted to the hospital. Prior studies have reported rates and risk factors of THA readmission but have been limited to single-center samples, administrative claims data, or Medicare patients. As a result, hospital readmission risk factors for a large proportion of patients undergoing THA are not fully understood.

Questions/purposes

(1) What is the incidence of hospital readmissions after primary THA and the reasons for readmission? (2) What are the risk factors for hospital readmissions in a large, integrated healthcare system using current perioperative care protocols?

Methods

The Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) was used to identify all patients with primary unilateral THAs registered between January 1, 2009, and December 31, 2011. The KPTJRR’s voluntary participation is 95%. A logistic regression model was used to study the relationship of risk factors (including patient, clinical, and system-related) and the likelihood of 30-day readmission. Readmissions were identified using electronic health and claims records to capture readmissions within and outside the system. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Of the 12,030 patients undergoing primary THAs included in the study, 59% (n = 7093) were women and average patient age was 66.5 years (± 10.7).

Results

There were 436 (3.6%) patients with hospital readmissions within 30 days of the index procedure. The most common reasons for readmission were infection and inflammatory reaction resulting from internal joint prosthetic (International Classification of Diseases, 9^th Revision, Clinical Modification [ICD-9-CM] 996.66, 7.0%); other postoperative infection (ICD-9-CM 998:59, 5.5%); unspecified septicemia (ICD-9-CM 038.9, 4.9%); and dislocation of a prosthetic joint (ICD-9-CM 996.42, 4.7%). In adjusted models, the following factors were associated with an increased likelihood of 30-day readmission: medical complications (OR, 2.80; 95% CI, 1.59-4.93); discharge to facilities other than home (OR, 1.89; 95% CI, 1.39–2.58); length of stay of 5 or more days (OR, 1.80; 95% CI, 1.22–2.65) versus 3 days; morbid obesity (OR, 1.74; 95% CI, 1.25–2.43); surgeries performed by high-volume surgeons compared with medium volume (OR, 1.53; 95% CI, 1.14–2.08); procedures at lower-volume (OR, 1.41; 95% CI, 1.07–1.85) and medium-volume hospitals (OR, 1.81; 95% CI, 1.20–2.72) compared with high-volume ones; sex (men: OR, 1.51; 95% CI, 1.18–1.92); obesity (OR, 1.32; 95% CI, 1.02–1.72); race (black: OR, 1.26; 95% CI, 1.02–1.57); increasing age (OR, 1.03; 95% CI, 1.01–1.04); and certain comorbidities (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, and psychoses).

Conclusions

The 30-day hospital readmission rate after primary THA was 3.6%. Modifiable factors, including obesity, comorbidities, medical complications, and system-related factors (hospital), have the potential to be addressed by improving the health of patients before this elective procedure, patient and family education and planning, and with the development of high-volume centers of excellence. Nonmodifiable factors such as age, sex, and race can be used to establish patient and family expectations regarding risk of readmission after THA. Contrary to other studies and the finding of increased hospital volume associated with lower risk of readmission, higher volume surgeons had a higher risk of patient readmission, which may be attributable to the referral patterns in our organization.

Level of Evidence

Level III, therapeutic study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-015-4278-x) contains supplementary material, which is available to authorized users.