Emergency department visit data may provide information on post-discharge care

Despite accounting for differences in case mix, the frequency of emergency department visits after TJA varied widely.

Issue: August 2016

Hospital-based acute care required shortly after total joint arthroplasty is not limited to hospital readmissions, and data on emergency department visits may provide additional information on post-discharge hospital-based acute care, according to study results.

“Although hospital readmission has received more attention, emergency department visits are more common and are often for diagnoses related to the initial surgery,” Roman Trimba, MD, a resident of the Wright State University Boonshoft School of Medicine Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation in Dayton, Ohio, told Orthopedics Today.

Emergency department visits

Trimba and his colleagues studied 272,853 discharges from 517 hospitals between July 2009 and September 2010. Primary outcomes included hospital readmission, emergency department visits and a composite measure termed hospital-based acute care within 30 days of discharge following total joint arthroplasty (TJA).

Results showed compared with hospital readmissions, emergency department visits were slightly more common and the incidences of both were highest immediately after discharge. Patients with postoperative infections and dislocations were more commonly readmitted to the hospital, while patients with symptoms of pain and edema or swelling were common for emergency department visits.

“We were surprised to learn frequency of emergency department visits varied as much as three-fold despite accounting for differences in case mix,” Trimba said. “Hospital readmission rates also did not correlate with emergency department usage, suggesting simply measuring one outcome may not be sufficient.”

He noted a substantial impact on performance evaluations when emergency department visits were included in a broader, hospital-based acute care measure, with 62.5% of hospitals changing rankings compared with peer hospitals.

“Most dramatically, 13.3% of hospitals — which would have been considered very high performers in a readmission measure — would drop to low or very low performing in the broader context and 8.8% of very low performers would be reclassified as very high performers,” Trimba said. “If this current measure is linked to financial reimbursement, these 8.8% would face financial penalty despite performing well when a broader evaluation of the post-discharge period is considered.”

Changing focus

According to Trimba, although there are many ways to improve post-discharge care, the full spectrum of patient experience after discharge is not captured when the focus is solely on hospital readmissions. He suggested making preoperative education and personalized postoperative contacts may reduce readmission rates, and should be focused on in future research.

“The expansion of such programs to include greater preoperative teaching, prompt orthopedic follow-up and a nurse or physician assistant available to take phone calls during off-hours could potentially reduce episodes of acute hospital-based care even further,” Trimba said. “This has previously been found to be successful with reducing readmissions for heart failure and chronic lung disease patients. Specific studies evaluating such interventions in the [TJA] population could provide further insight into their applicability.” – by Casey Tingle

Reference:
Trimba R, et al. J Arthroplasty. 2016;doi:10.1016/j.arth.205.10.019.

For more information:
Roman Trimba, MD, can be reached at the Wright State University Boonshoft School of Medicine Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, 30 East Apple St., Suite 2200, Dayton, OH 45409: email: roman.trimba@wright.edu.

Disclosure: Ross reports research support through Yale University from Medtronic Inc., Johnson and Johnson, CMS, FDA and Blue Cross-Blue Shield Associated to better understand medical technology evidence generation.