Study: Discharge to SNF after TJR associated with complications

Hospitals and physicians should determine which skilled nursing facilities are safe for discharged patients.

Jesse E. Otero

Discharge to a skilled nursing facility after total joint replacement was a strong predictor of 30-day complications and unplanned readmissions among Medicare and skilled nursing facility eligible patients, according to results published in The Journal of Arthroplasty.

“It should not be a reflex to send a patient to a skilled nursing facility [SNF] after a total joint replacement because skilled nursing discharge is associated with increased complications,” Jesse E. Otero, MD, PhD, of the department of orthopedics and rehabilitation at University of Iowa Hospital and Clinics, told Orthopedics Today. “There are individuals who require skilled nursing or extra care that cannot be provided at home and we acknowledge that. For certain patients, a skilled facility is the safest place, but physicians and hospitals and nursing discharge systems should make every effort to make homes safe for patients.”

Risks with discharge to SNFs

Using the National Surgical Quality Improvement Program database, Otero and his colleagues divided 34,610 patients aged 65 years and older who had been hospitalized for at least 3 nights after TJR between 2012 and 2013 into a home discharge group or a SNF disposition group. Researchers used univariate analysis to compare demographics, comorbidities and complications between the groups and used a multivariate logistic regression model to determine independent risk factors for complications or readmission after discharge.

Overall, results showed 54.8% of patients were discharged home vs. 45.2% discharged to a SNF. Univariate analysis showed patients discharged to a SNF tended to be older and have higher rates of obesity, diabetes, coronary artery disease, chronic obstructive pulmonary disease and were more frequently American Society of Anesthesiologists class 3 or 4 compared with patients discharged home.

Patients discharged to a SNF had a complication and hospital readmission rate that was about 40% higher than for patients discharged home. The multivariate regression model showed being discharged to a SNF was the strongest predictor for any complication and a strong predictor for unplanned readmission, which Otero said was a surprising finding.

“You assume patients going to skilled facilities are older or they have more comorbidities. They have less help at home. They are going to be more likely to have complications just by nature of the types of patients that go there,” Otero said. “We thought we would test the hypothesis by putting the skilled nursing discharge in a multivariate analysis and thought maybe it will wash out and with these other comorbidities and other risk factors it will not be significant. Not only was it significant, it was the strongest predictor.”

In search of safe SNFs

Despite careful selection and optimization of patients, some patients may still need to be discharged to a SNF postoperatively. In those cases, physicians should make sure the SNF chosen uses best practices for TJR patients, Otero said.

“It is unfair to say in a blanket statement that all SNFs are risky,” Otero said. “I think there are some [skilled nursing facilities] that are actually good, but it is up to the hospital and physicians who work with hospitals to determine which ones are safe.” – by Casey Tingle

Reference:

Owens JM, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.01.002.

For more information:

Jesse E. Otero, MD, PhD, can be reached at 200 Hawkins Dr., Iowa City, IA 52242; email: jesse-otero@uiowa.edu.

Disclosure: Otero reports no relevant financial disclosures.