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Factors Associated With 30-Day Readmission After Primary Total Hip ArthroplastyAnalysis of 514 455 Procedures in the UK National Health Service

Educational Objective
To understand which patient factors are most strongly associated with 30-day readmission after primary total hip arthroplasty
1 Credit CME
Key Points

Question  Which patient factors are most strongly associated with 30-day readmission after primary total hip arthroplasty, and is there a difference between predictors of all-cause, surgical, and return-to-theater readmissions?

Findings  In this study of 514 455 patients from the UK National Health Service, we found that key predictors of each type of total hip arthroplasty readmission were different.

Meaning  All-cause readmission is the only metric in widespread use but overlooks important information that enables readmission risk to be understood; focus on surgical and return-to-theater readmission may facilitate risk reduction and cost savings.

Abstract

Importance  Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood.

Objective  To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant.

Design, Setting, and Participants  Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA.

Main Outcomes and Measures  Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT.

Results  Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population attributable fractions of the comorbidities (3.4%). Return to theater in the index episode was associated with a significantly increased risk of RTT readmission (OR, 5.35; 95% CI, 4.45-6.43; P < .001). Emergency readmission to the hospital in the preceding 12 months increased the risk of readmission significantly, with the association being most pronounced for all-cause readmission (for >2 emergency readmissions, OR, 2.33; 95% CI, 2.11-2.57; P < .001). Hip resurfacing was associated with a lower risk of RTT when compared with cemented implants (OR, 0.69; 95% CI, 0.54-0.88; P = .002) but for other types of readmission, implant type had no significant association with readmission risk. Increasing age and length of stay were strongly associated with all-cause readmission.

Conclusions and Relevance  Many patient-related risk factors for surgical and RTT readmission differ from those for all-cause readmission despite the latter being the only measure in widespread use. Clinicians and policy makers should consider these alternative readmission metrics in strategies for risk reduction and cost savings.

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Article Information

Corresponding Author: Adam M. Ali, BMBCh, MA(Cantab), MRCS(Eng); St Mary’s Hospital, Praed St, London W2 1NY, United Kingdom (adamali@post.harvard.edu).

Accepted for Publication: July 22, 2017.

Correction: This article was corrected on November 15, 2017, to correct errors in the Introduction, Methods, and Discussion sections.

Published Online: October 4, 2017. doi:10.1001/jamasurg.2017.3949

Author Contributions: Dr Bottle had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ali, Loeffler, Bottle.

Acquisition, analysis, or interpretation of data: Ali, Aylin, Bottle.

Drafting of the manuscript: Ali, Aylin, Bottle.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ali, Bottle.

Obtained funding: Aylin, Bottle.

Administrative, technical, or material support: Aylin.

Supervision: Bottle.

Conflict of Interest Disclosures: None reported.

Funding/Support: The Dr Foster Unit at Imperial College London is partially funded by a grant from Dr Foster Intelligence, an independent healthcare information company. Drs Aylin and and Bottle declare that they are partially funded by this grant. The Dr Foster Unit at Imperial is affiliated with the National Institute of Health Research Imperial Patient Safety Translational Research Centre. The National Institute of Health Research Imperial Patient Safety Translational Centre is a partnership between the Imperial College Healthcare National Health Services Trust and Imperial College London.

Role of the Funder/Sponsor: The funding organizations were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The views expressed in this publication are those of the authors and not necessarily those of the UK National Health Service, the National Institute of Health Research, or the Department of Health.

Additional Contributions: We thank Rukhsana Kamal, MBBS, Chelsea and Westminster Hospital NHS Foundation Trust Clinical Coding Manager, for her assistance with clinical coding. No financial compensation was associated with this.

References
1.
Centers for Medicare and Medicaid Services. Readmissions reduction program. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed January 4, 2017.
2.
Kurtz  S, Ong  K, Lau  E, Mowat  F, Halpern  M.  Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.  J Bone Joint Surg Am. 2007;89(4):780-785.PubMedGoogle Scholar
3.
Jencks  SF, Williams  MV, Coleman  EA.  Rehospitalizations among patients in the Medicare fee-for-service program.  N Engl J Med. 2009;360(14):1418-1428.PubMedGoogle ScholarCrossref
4.
Bosco  JA  III, Karkenny  AJ, Hutzler  LH, Slover  JD, Iorio  R.  Cost burden of 30-day readmissions following Medicare total hip and knee arthroplasty.  J Arthroplasty. 2014;29(5):903-905.PubMedGoogle ScholarCrossref
5.
Sibia  US, Mandelblatt  AE, Callanan  MA, MacDonald  JH, King  PJ.  Incidence, risk factors, and costs for hospital returns after total joint arthroplasties.  J Arthroplasty. 2017;32(2):381-385.PubMedGoogle ScholarCrossref
6.
Zuckerman  RB, Sheingold  SH, Orav  EJ, Ruhter  J, Epstein  AM.  Readmissions, observation, and the hospital readmissions reduction program.  N Engl J Med. 2016;374(16):1543-1551.PubMedGoogle ScholarCrossref
7.
Desai  NR, Ross  JS, Kwon  JY,  et al.  Association between hospital penalty status under the hospital readmission reduction program and readmission rates for target and nontarget conditions.  JAMA. 2016;316(24):2647-2656.PubMedGoogle ScholarCrossref
8.
Lu  N, Huang  KC, Johnson  JA.  Reducing excess readmissions: promising effect of hospital readmissions reduction program in US hospitals.  Int J Qual Health Care. 2016;28(1):53-58.PubMedGoogle ScholarCrossref
9.
Thompson  MP, Kaplan  CM, Cao  Y, Bazzoli  GJ, Waters  TM.  Reliability of 30-day readmission measures used in the hospital readmission reduction program.  Health Serv Res. 2016;51(6):2095-2114.PubMedGoogle ScholarCrossref
10.
Chen  Q, Mull  HJ, Rosen  AK, Borzecki  AM, Pilver  C, Itani  KM.  Measuring readmissions after surgery: do different methods tell the same story?  Am J Surg. 2016;212(1):24-33.PubMedGoogle ScholarCrossref
11.
Blunt  I, Bardsley  M, Grove  A, Clarke  A.  Classifying emergency 30-day readmissions in England using routine hospital data 2004-2010: what is the scope for reduction?  Emerg Med J. 2015;32(1):44-50.PubMedGoogle ScholarCrossref
12.
Schairer  WW, Sing  DC, Vail  TP, Bozic  KJ.  Causes and frequency of unplanned hospital readmission after total hip arthroplasty.  Clin Orthop Relat Res. 2014;472(2):464-470.PubMedGoogle ScholarCrossref
13.
Ricciardi  BF, Oi  KK, Daines  SB, Lee  YY, Joseph  AD, Westrich  GH.  Patient and perioperative variables affecting 30-day readmission for surgical complications after hip and knee arthroplasties: a matched cohort study.  J Arthroplasty. 2017;32(4):1074-1079PubMedGoogle ScholarCrossref
14.
Paxton  EW, Inacio  MC, Singh  JA, Love  R, Bini  SA, Namba  RS.  Are there modifiable risk factors for hospital readmission after total hip arthroplasty in a US healthcare system?  Clin Orthop Relat Res. 2015;473(11):3446-3455.PubMedGoogle ScholarCrossref
15.
Bottle  A, Aylin  P, Loeffler  M.  Return to theatre for elective hip and knee replacements: what is the relative importance of patient factors, surgeon and hospital?  Bone Joint J. 2014;96-B(12):1663-1668.PubMedGoogle ScholarCrossref
16.
Bernatz  JT, Tueting  JL, Anderson  PA.  Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis.  PLoS One. 2015;10(4):e0123593.PubMedGoogle ScholarCrossref
17.
Ramkumar  PN, Chu  CT, Harris  JD,  et al.  Causes and rates of unplanned readmissions after elective primary total joint arthroplasty: a systematic review and meta-analysis.  Am J Orthop (Belle Mead NJ). 2015;44(9):397-405.PubMedGoogle Scholar
18.
Siracuse  BL, Chamberlain  RS.  A preoperative scale for determining surgical readmission risk after total hip replacement.  JAMA Surg. 2016;151(8):701-709.PubMedGoogle ScholarCrossref
19.
National Health Services. Hospital episode statistics. http://content.digital.nhs.uk/hes. Accessed January 4, 2017.
20.
Pujol  N, Merrer  J, Lemaire  B,  et al.  Unplanned return to theater: a quality of care and risk management index?  Orthop Traumatol Surg Res. 2015;101(4):399-403.PubMedGoogle ScholarCrossref
21.
Ghoneim  MM, O’Hara  MW.  Depression and postoperative complications: an overview.  BMC Surg. 2016;16:5.PubMedGoogle ScholarCrossref
22.
Browne  JA, Sandberg  BF, D’Apuzzo  MR, Novicoff  WM.  Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study.  J Arthroplasty. 2014;29(3):481-483.PubMedGoogle ScholarCrossref
23.
Jameson  SS, Mason  JM, Baker  PN, Elson  DW, Deehan  DJ, Reed  MR.  The impact of body mass index on patient reported outcome measures (PROMs) and complications following primary hip arthroplasty.  J Arthroplasty. 2014;29(10):1889-1898.PubMedGoogle ScholarCrossref
24.
Saucedo  JM, Marecek  GS, Wanke  TR, Lee  J, Stulberg  SD, Puri  L.  Understanding readmission after primary total hip and knee arthroplasty: who’s at risk?  J Arthroplasty. 2014;29(2):256-260.PubMedGoogle ScholarCrossref
25.
Rajgopal  R, Martin  R, Howard  JL, Somerville  L, MacDonald  SJ, Bourne  R.  Outcomes and complications of total hip replacement in super-obese patients.  Bone Joint J. 2013;95-B(6):758-763.PubMedGoogle ScholarCrossref
26.
Meller  MM, Toossi  N, Gonzalez  MH, Son  MS, Lau  EC, Johanson  N.  Surgical risks and costs of care are greater in patients who are super obese and undergoing THA.  Clin Orthop Relat Res. 2016;474(11):2472-2481.PubMedGoogle ScholarCrossref
27.
Werner  BC, Higgins  MD, Pehlivan  HC, Carothers  JT, Browne  JA.  Super obesity is an independent risk factor for complications after primary total hip arthroplasty.  J Arthroplasty. 2017;32(2):402-406.PubMedGoogle ScholarCrossref
28.
Maradit Kremers  H, Visscher  SL, Kremers  WK, Naessens  JM, Lewallen  DG.  Obesity increases length of stay and direct medical costs in total hip arthroplasty.  Clin Orthop Relat Res. 2014;472(4):1232-1239.PubMedGoogle ScholarCrossref
29.
Pugely  AJ, Callaghan  JJ, Martin  CT, Cram  P, Gao  Y.  Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP.  J Arthroplasty. 2013;28(9):1499-1504.PubMedGoogle ScholarCrossref
30.
Mesko  NW, Bachmann  KR, Kovacevic  D, LoGrasso  ME, O’Rourke  C, Froimson  MI.  Thirty-day readmission following total hip and knee arthroplasty: a preliminary single institution predictive model.  J Arthroplasty. 2014;29(8):1532-1538.PubMedGoogle ScholarCrossref
31.
Liao  KM, Lu  HY.  A national analysis of complications following total hip replacement in patients with chronic obstructive pulmonary disease.  Medicine (Baltimore). 2016;95(12):e3182.PubMedGoogle ScholarCrossref
32.
Marshall  DA, Pykerman  K, Werle  J,  et al.  Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes.  Clin Orthop Relat Res. 2014;472(7):2217-2230.PubMedGoogle ScholarCrossref
33.
Kurtz  SM, Lau  EC, Ong  KL, Adler  EM, Kolisek  FR, Manley  MT.  Hospital, patient, and clinical factors influence 30- and 90-day readmission after primary total hip arthroplasty.  J Arthroplasty. 2016;31(10):2130-2138.PubMedGoogle ScholarCrossref
34.
Saucedo  J, Marecek  GS, Lee  J, Huminiak  L, Stulberg  SD, Puri  L.  How accurately are we coding readmission diagnoses after total joint arthroplasty?  J Arthroplasty. 2013;28(7):1076-1079.PubMedGoogle ScholarCrossref
35.
Burns  EM, Rigby  E, Mamidanna  R,  et al.  Systematic review of discharge coding accuracy.  J Public Health (Oxf). 2012;34(1):138-148.PubMedGoogle ScholarCrossref
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