1201 C OPYRIGHT 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Factors Affecting Readmission Rates Following Primary Total Hip Arthroplasty Rachel E. Mednick, MD, Hasham M. Alvi, MD, Varun Krishnan, BA, Francis Lovecchio, BA, and David W. Manning, MD Investigation performed at the Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois
Background: Readmissions following total hip arthroplasty are a focus given the forthcoming financial penalties that hospitals in the United States may incur starting in 2015. The purpose of this study was to identify both preoperative comorbidities and postoperative conditions that increase the risk of readmission following total hip arthroplasty. Methods: Using the American College of Surgeons–National Surgical Quality Improvement Program data for 2011, a study population was identified using the Current Procedural Terminology code for primary total hip arthroplasty (27130). The sample was stratified into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, laboratory values, operative characteristics, and surgical outcomes were compared between the groups using univariate and multivariate logistic regression models. Results: Of the 9441 patients, there were 345 readmissions (3.65%) within the first thirty days following surgery. Comorbidities that increased the risk for readmission were diabetes (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), bleeding disorders (p < 0.001), preoperative blood transfusion (p = 0.035), corticosteroid use (p < 0.001), dyspnea (p = 0.001), previous cardiac surgery (p = 0.002), and hypertension (p < 0.001). A multivariate regression model was used to control for potential confounders. Having a body mass index of ‡40 kg/m2 (odds ratio, 1.941 [95% confidence interval, 1.019 to 3.696]; p = 0.044) and using corticosteroids preoperatively (odds ratio, 2.928 [95% confidence interval, 1.731 to 4.953]; p < 0.001) were independently associated with a higher likelihood of readmission, and a high preoperative serum albumin (odds ratio, 0.688 [95% confidence interval, 0.477 to 0.992]; p = 0.045) was independently associated with a lower risk for readmission. Postoperative surgical site infection, pulmonary embolism, deep venous thrombosis, and sepsis (p < 0.001) were also independent risk factors for readmission. Conclusions: The risk of readmission following total hip arthroplasty increases with growing preoperative comorbidity burden, and is specifically increased in patients with a body mass index of ‡40 kg/m2, a history of corticosteroid use, and low preoperative serum albumin and in patients with postoperative surgical site infection, a thromboembolic event, and sepsis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
S
urgical outcomes for total hip arthroplasties, specifically complication rates and readmission rates, will be under more scrutiny as the second phase of the Patient Protection and Affordable Care Act of 2010 takes effect in 2015 in the United States. Hip arthroplasty was listed as a second-tier diagnosis to be included in a readmission policy that imposes
financial penalties to hospitals for any excess readmission occurring within thirty days of discharge starting in 20151. Preoperative comorbidities such as cardiac disease, diabetes mellitus, and obesity increase a patient’s risk for postoperative complications that could feasibly require readmission following orthopaedic surgery2-9. Patient demographic factors
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:1201-9
d
http://dx.doi.org/10.2106/JBJS.M.00556
1202 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 14 J U LY 16, 2 014 d
d
d
F A C T O R S A F F E C T I N G R E A D M I S S I O N R AT E S F O L L O W I N G P R I M A RY T O TA L H I P A R T H R O P L A S T Y
TABLE I Preoperative Characteristics Not Readmitted* (N = 9096) Demographic characteristics Age‡ (yr) Sex§ Male Female Race§ White Black Asian Other BMI category§ Underweight (
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Factors Affecting Readmission Rates Following Primary Total Hip Arthroplasty Rachel E. Mednick, MD, Hasham M. Alvi, MD, Varun Krishnan, BA, Francis Lovecchio, BA, and David W. Manning, MD Investigation performed at the Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois
Background: Readmissions following total hip arthroplasty are a focus given the forthcoming financial penalties that hospitals in the United States may incur starting in 2015. The purpose of this study was to identify both preoperative comorbidities and postoperative conditions that increase the risk of readmission following total hip arthroplasty. Methods: Using the American College of Surgeons–National Surgical Quality Improvement Program data for 2011, a study population was identified using the Current Procedural Terminology code for primary total hip arthroplasty (27130). The sample was stratified into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, laboratory values, operative characteristics, and surgical outcomes were compared between the groups using univariate and multivariate logistic regression models. Results: Of the 9441 patients, there were 345 readmissions (3.65%) within the first thirty days following surgery. Comorbidities that increased the risk for readmission were diabetes (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), bleeding disorders (p < 0.001), preoperative blood transfusion (p = 0.035), corticosteroid use (p < 0.001), dyspnea (p = 0.001), previous cardiac surgery (p = 0.002), and hypertension (p < 0.001). A multivariate regression model was used to control for potential confounders. Having a body mass index of ‡40 kg/m2 (odds ratio, 1.941 [95% confidence interval, 1.019 to 3.696]; p = 0.044) and using corticosteroids preoperatively (odds ratio, 2.928 [95% confidence interval, 1.731 to 4.953]; p < 0.001) were independently associated with a higher likelihood of readmission, and a high preoperative serum albumin (odds ratio, 0.688 [95% confidence interval, 0.477 to 0.992]; p = 0.045) was independently associated with a lower risk for readmission. Postoperative surgical site infection, pulmonary embolism, deep venous thrombosis, and sepsis (p < 0.001) were also independent risk factors for readmission. Conclusions: The risk of readmission following total hip arthroplasty increases with growing preoperative comorbidity burden, and is specifically increased in patients with a body mass index of ‡40 kg/m2, a history of corticosteroid use, and low preoperative serum albumin and in patients with postoperative surgical site infection, a thromboembolic event, and sepsis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
S
urgical outcomes for total hip arthroplasties, specifically complication rates and readmission rates, will be under more scrutiny as the second phase of the Patient Protection and Affordable Care Act of 2010 takes effect in 2015 in the United States. Hip arthroplasty was listed as a second-tier diagnosis to be included in a readmission policy that imposes
financial penalties to hospitals for any excess readmission occurring within thirty days of discharge starting in 20151. Preoperative comorbidities such as cardiac disease, diabetes mellitus, and obesity increase a patient’s risk for postoperative complications that could feasibly require readmission following orthopaedic surgery2-9. Patient demographic factors
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:1201-9
d
http://dx.doi.org/10.2106/JBJS.M.00556
1202 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 14 J U LY 16, 2 014 d
d
d
F A C T O R S A F F E C T I N G R E A D M I S S I O N R AT E S F O L L O W I N G P R I M A RY T O TA L H I P A R T H R O P L A S T Y
TABLE I Preoperative Characteristics Not Readmitted* (N = 9096) Demographic characteristics Age‡ (yr) Sex§ Male Female Race§ White Black Asian Other BMI category§ Underweight (
