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Comparison of Hospital Readmission After Total Hip and Total Knee Arthroplasty vs Spinal Surgery After Implementation of the Hospital Readmissions Reduction Program

Educational Objective
To review the findings on readmission after total hip and total knee arthroplasty vs spinal surgery
1 Credit CME
Key Points

Question  Is the US Hospital Readmissions Reduction Program associated with a greater decrease in unplanned readmissions after targeted surgical procedures when compared with similar nontargeted procedures?

Findings  In this nationwide, all-payer cohort study of 6 687 007 weighted index surgical admissions, implementation of the Hospital Readmissions Reduction Program was associated with a decrease of 0.018% per month in the risk-adjusted readmission rate after targeted procedures, while the readmission rate after nontargeted procedures remained constant, a difference that was statistically significant.

Meaning  Readmission trends appear to be consistent with hospitals’ response to the possibility of Hospital Readmissions Reduction Program penalties after total hip arthroplasty and total knee arthroplasty.


Importance  The Hospital Readmissions Reduction Program (HRRP) was recently expanded to penalize excessive readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). These are the first surgical procedures to be included in the HRRP.

Objective  To determine whether the HRRP was associated with a greater decrease in readmissions after targeted procedures (THA and TKA) compared with similar nontargeted procedures (lumbar spine fusion and laminectomy).

Design, Setting, and Participants  A retrospective cohort study was conducted of patients 50 years or older among all payers in the Nationwide Readmissions Database who underwent THA, TKA, lumbar spine fusion, or laminectomy between January 1, 2010, and September 30, 2015. Multivariable logistic regression and interrupted time-series models were used to calculate and compare 30-day readmission trends in 3 periods associated with the HRRP: preimplementation (January 2010-September 2012), implementation (October 2012-September 2014), and penalty (October 2014-September 2015). Statistical analysis was performed from January 1, 2010, to September 30, 2015.

Exposures  Announcement and implementation of the HRRP.

Main Outcomes and Measures  Readmission within 30 days after hospitalization for THA, TKA, lumbar spine fusion, or laminectomy surgery.

Results  The study included 6 687 077 (58.3% women and 41.7% men; mean age, 66.7 years; 95% CI, 66.7-66.8 years) weighted hospitalizations for THA, TKA, lumbar spine fusion, and laminectomy surgery: 4 765 466 hospitalizations for targeted conditions and 1 921 611 for nontargeted conditions. After passage of the Patient Protection and Affordable Care Act, the risk-adjusted rates of readmission after all procedures decreased in a similar fashion. Implementation of the HRRP was associated with a 0.018% per month decrease in the rate of readmission (95% CI, −0.025% to −0.010%) after targeted procedures, which was not observed after nontargeted procedures (slope per month, −0.003%; 95% CI, −0.016% to 0.010%). Penalties were not associated with a greater decrease in readmission for either targeted or nontargeted procedures.

Conclusions and Relevance  These results appear to be consistent with hospitals responding to the future possibility of penalties by reducing readmissions after surgical procedures targeted by the HRRP.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: April 7, 2019.

Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.4634

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Ramaswamy A et al. JAMA Network Open.

Corresponding Author: Quoc-Dien Trinh, MD, Division of Urological Surgery, Brigham and Women’s Hospital, 45 Francis St, Ambulatory Service Bldg II-3, Boston, MA 02115 (qtrinh@bwh.harvard.edu).

Author Contributions: Dr Trinh 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: Ramaswamy, Cole, Harmouch, Weissman, Haider, Kibel, Trinh.

Acquisition, analysis, or interpretation of data: Ramaswamy, Marchese, Harmouch, Friedlander, Weissman, Lipsitz, Schoenfeld, Trinh.

Drafting of the manuscript: Ramaswamy, Cole, Friedlander, Lipsitz, Schoenfeld, Trinh.

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

Statistical analysis: Ramaswamy, Marchese, Cole, Harmouch, Lipsitz.

Obtained funding: Ramaswamy, Kibel.

Administrative, technical, or material support: Ramaswamy, Friedlander, Weissman, Haider, Kibel, Schoenfeld, Trinh.

Supervision: Ramaswamy, Weissman, Lipsitz, Haider, Kibel, Trinh.

Conflict of Interest Disclosures: Dr Kibel reported receiving consulting fees from Profound, Janssen, and ConfirmMDX unrelated to this work. Dr Trinh reported receiving consulting fees from Astellas, Bayer, Insightec, Intuitive Surgical, and Janssen unrelated to this work. No other disclosures were reported.

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