Health Policy and Economics
The Association Between Hospital Length of Stay and 90-Day Readmission Risk Within a Total Joint Arthroplasty Bundled Payment Initiative

https://doi.org/10.1016/j.arth.2016.09.005Get rights and content

Abstract

Background

To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.

Methods

We analyzed the medical records of 1329 consecutive lower extremity total joint patients enrolled in Centers for Medicare and Medicaid Services' Bundled Program for Care Improvement treated over a 21-month period. The goal of this study was to ascertain if hospital LOS is associated with unplanned readmissions within 90 days of admission for a total hip or knee arthroplasty.

Results

After controlling for multiple demographic variables including sex, age, comorbidities and discharge location, we found that hospital LOS greater than 4 days is a significant risk factor for unplanned readmission within 90 days (odd ratio = 1.928, P = .010). Total knee arthroplasty (TKA) and discharge to a location other than home are also independent risk factors for 90-day readmission.

Conclusion

Our results demonstrate that increased LOS is a significant risk factor for readmission within 90 days of admission for a hip or knee arthroplasty in the Medicare population.

Section snippets

Methods

This study was conducted as part of an existing quality control initiative to evaluate our performance in the type 2 lower extremity joint arthroplasty Bundled Program for Care Improvement (BPCI). We analyzed the prospectively collected data of all patients treated with primary THA or TKA at our institution that had insurance coverage consisting of Medicare part A + B or Railroad Medicare and followed them through their 90 days episodes of care. We used data from only a single high-volume

Results

Our analysis included 1329 patients. Eighty-one (6.1%) of 1248 patients were readmitted within 90 days of the index procedure. Patients were mostly female, older, white, non-Hispanic, and nonsmokers (Table 1). Univariate analysis demonstrated that readmitted patient had longer average LOS (3.81 ± 2.0 vs 2.10 ± 1.3 days, P < .001). Readmitted patients on average were older (73.7 ± 8.0 vs 71.7 ± 8.1 years, P = .024), had higher ASA scores (P = .009), underwent TKA (P = .043), and were more likely

Discussion

We found that a longer LOS is associated with a greater chance of 90-day post-discharge readmission for patients undergoing lower extremity total joint arthroplasty (LETJA) in our BPCI program. As of April 1, 2016, CMS requires mandatory participation in its CJR program for 33% of all hospitals performing LETJAs. These hospitals are selected at random [7]. The CJR is nearly identical to type 2 BPCI for LETJA. Because these reimbursement models include target 90-day prices (monetary amounts

Conclusion

Unplanned readmissions decrease health care value. With changing reimbursement models, health care providers are given more responsibility to decrease readmission rates for patients following TJA of the lower extremity. Our results indicate that increased LOS is a risk factor for readmission and care pathways that recognize and intervene in these patients should be developed and evaluated in order to try to reduce readmissions in this patient group.

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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.2016.09.005.

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