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Hospital-acquired conditions seen as strong indicator for early readmission after TJA
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Hospital-acquired conditions were the strongest predictor of 30-day hospital readmission following primary knee and hip arthroplasty, and accounted for 42% of complications found during a 5-year period.
Researchers retrospectively analyzed data from the Surgical Care Improvement Project and the Veteran’s Affairs Surgical Quality Improvement Program (VASQIP) to identify16,808 partial and total knee and 9,902 partial and total hip arthroplasties performed from 2005 to 2009. Hospital-acquired conditions (HACs), such as venous thromboembolism, pneumonia, surgical site infections and urinary tract infections, were the independent variables of interest, with the dependent variable being hospital readmission within 30 days of discharge.
Predictors for early readmission collected from VASQIP data included: patient demographics, lifestyle variables, and pulmonary, cardiovascular, hepatobiliary, renal, immune and nutritional comorbidities. In addition, researchers analyzed arthroplasty type, the indication for surgery, wound classification, American Society of Anesthesiologist status and duration of surgery. Multivariate regression analysis was used to determine predictors of 30-day readmission.
Findings showed 12.4% of patients were more likely to be readmitted after having developed at least one postoperative complication compared with patients without complications. Of the 3,371 total complications observed in 1,405 patients, 41.7% were HACs. Overall, 1,901 patients had 2,082 non-HAC complications.
Investigators found 53% of HACs were observed prior to discharge, and 47% of HACs developed after patients were discharged. Most patients were discharged home then either discharged to a skilled nursing facility, immediate care or rehabilitation facility. Patients were frequently readmitted when they left the hospital against medical advice. Overall, 5.7% of patients were readmitted after they were discharged home. ‒ by Monica Jaramillo
Disclosures: Raines reports no relevant financial disclosures. Please see the full study for a full list of all other authors’ relevant financial disclosures.
Perspective
Back to TopJohn M. Cuckler, MD
The study by Raines and colleagues on the likelihood of readmission following hip or knee arthroplasty is an important notice for surgeons and hospitals, particularly in view of the proposed CMS penalties for readmissions (and potentially, surgeons if bundled reimbursement is instituted). While there are probably differences between the Veterans Affairs (VA) patient base and the patient base at large, and the criteria for readmission may be different between the VA health care system and conventional for-profit and non-profit hospitals, the lessons from this study should be, in broad terms, applicable to all providing hip and knee arthroplasty services.
The important conclusions of this study are that an HAC that is diagnosed prior to discharge has a four-times less likelihood of requiring readmission. Hospital staff need to pay particular attention to the “preventable” complications, such as urinary tract infection, venous thromboembolism, surgical site infection and pneumonia. Discharge to an extended care facility as opposed to discharge to home is associated with higher risk of readmission, so oversight of care in these institutions may need improvement.
On the other hand, more than half of readmissions following total joint replacement did not involve HACs. Given the modifiable factors associated with HACs (diabetes, steroid use, chronic obstructive pulmonary disease, congestive heart failure, etc.), careful preoperative optimization may also reduce the risk of readmission.
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