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Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program

Educational Objective
To review if Inaugural Readmission Penalties are associated with surgical volume and with hospital and patient characteristics
1 Credit CME
Key Points

Question  How are the inaugural penalties for surgical readmissions under the Hospital Readmissions Reduction Program of the Centers for Medicare and Medicaid Services associated with surgical volume and with hospital and patient characteristics?

Findings  In this case-control study of 143 Florida hospitals, with 2991 readmitted Medicare patients, hospitals with a high volume of elective total hip and total knee arthroplasty procedures had lower, but not significantly different, readmission penalties than those with low volumes of these procedures. No other systematic differences were detected across hospitals or readmitted patients.

Meaning  It seems that penalties for surgical readmissions under the Hospital Readmissions Reduction Program may be inversely associated with surgical volume, but this requires validation in a larger, nationwide cohort.

Abstract

Importance  The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice.

Objective  To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures—elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)—in the context of hospital and patient characteristics.

Design, Setting, and Participants  Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017.

Exposures  Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment.

Main Outcomes and Measures  The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined.

Results  Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = −0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = −0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity.

Conclusions and Relevance  This study’s findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.

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Article Information

Accepted for Publication: October 1, 2019.

Published: November 22, 2019. doi:10.1001/jamanetworkopen.2019.16008

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

Corresponding Author: Ted A. Skolarus, MD, MPH, Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (tskolar@med.umich.edu).

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

Concept and design: Li, Urish, Jacobs, Borza, Ellimoottil, Lavieri, Helm, Skolarus.

Acquisition, analysis, or interpretation of data: Li, Urish, Jacobs, He, Borza, Qin, Min, Dupree, Hollenbeck, Lavieri, Skolarus.

Drafting of the manuscript: Li, Urish, Min, Helm, Skolarus.

Critical revision of the manuscript for important intellectual content: Li, Urish, Jacobs, He, Borza, Qin, Dupree, Ellimoottil, Hollenbeck, Lavieri, Skolarus.

Statistical analysis: He, Qin, Min, Lavieri.

Obtained funding: Urish.

Administrative, technical, or material support: Urish, Dupree, Lavieri, Skolarus.

Supervision: Urish, Jacobs, Borza, Dupree, Lavieri, Helm, Skolarus.

Conflict of Interest Disclosures: Dr Urish reported receiving grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases during the conduct of the study, being a paid consultant with Smith and Nephew, and being a board member of the American Academy of Orthopedic Surgeons and ASTM International (formerly known as American Society for Testing and Materials). Dr Dupree reported receiving grants from Blue Cross Blue Shield of Michigan and owning personal, common stock in Lipocine outside the submitted work. Dr Hollenbeck reported receiving grants from the National Institute on Aging during the conduct of the study and being an Associate Editor of Urology. Dr Lavieri reported receiving grants from the National Science Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Urish is supported in part by the Institutional Career Development Award KL2TR0001856 from the National Institutes of Health and by a New Investigator Award from the Orthopaedic Research and Education Foundation. Dr Jacobs is supported in part by the Institutional Career Development Award KL2TR000146-08, a GEMSSTAR award (R03AG048091), and the Jahnigen Career Development Award, all from the National Institutes of Health. Dr Borza is supported by a Training Grant (T32-CA180984) from the National Cancer Institute. Dr Hollenbeck is supported by the Research Project Grant R01-AG-048071 from the National Institute on Aging. Dr Lavieri is supported by a Civil, Mechanical and Manufacturing Innovation Career Award (CMMI-1552545) from the National Science Foundation. Dr Skolarus is supported by a Health Services Research and Development Career Development Award (CDA 12-171) from the US Department of Veterans Affairs.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The research content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

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