Health Policy & Economics
Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends

https://doi.org/10.1016/j.arth.2015.11.044Get rights and content

Abstract

Background

This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination.

Methods

Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables.

Results

A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001).

Conclusion

SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.

Section snippets

Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) from 2011 to 2013. The TKA cohort was identified using the common procedural terminology code corresponding to primary TKA (27447). The THA cohort was similarly identified using the common procedural terminology code (27130). Patients with incomplete data or who underwent nonelective TJA were

Results

A total of 64,763 TKA and 41,597 THA patients were included for analysis. The most common discharge destinations were home (70%), SNF (19%), and IRF (11%). Bivariate analysis revealed that nonhome discharge destination (IRF or SNF) patients tended to be older, female, functionally dependent, and morbidly obese (body mass index [BMI], >40) as compared to patients discharged home (all P < .001; Table 1). Nonhome TJA patients had increased rates of diabetes, pulmonary disease, cardiac disease,

Discussion

Many recent policy initiatives have focused on TJA because of the high cost, prevalence, and relative clinical homogeneity of this procedure. Understanding variability in care processes, costs, and outcomes is a critical step in optimizing the value of care for TJA patients [8]. Post–acute care accounts for almost half of the total TJA costs, largely due to the use of IRF and SNF. In this context, understanding the value post–acute care facilities provide will be required to optimize discharge

Conclusion

SNF and IRF discharge destinations are independent risk factors for 30-day readmission and postdischarge severe adverse events. Across patient risk levels, TJA patients discharged home tend to have the lowest rates of 30-day readmission and postdischarge severe adverse events. Modifiable patient risk factors such as morbid obesity, smoking, diabetes, pulmonary disease, and hypertension should be optimized during the preoperative period to reduce risk of nonhome discharge and adverse events.

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    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.11.044.

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