Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.
Key points
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Hospital readmission rate contributes a practically avoidable source of waste and financial burden; the topic is a focus in the surgical literature and a target for quality improvement.
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Unplanned readmissions bring about severe ramifications for the patient, patient families, the institution, and the health care system.
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The implications of readmission within 30 days of discharge should drive providers, administrators, and policymakers to turn more attention to system-based procedures.
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These system-based procedures can help to decrease readmission, and ultimately improve quality of care while decreasing health care–associated costs.
Introduction
Total joint arthroplasty (TJA) is one of the most effective and efficient interventional procedures in medicine, because it offers a successful option to address chronic pain and functional disability of the associated joint. Although it was developed initially to address degenerative changes seen in the elderly population, TJA indications have continued to expand to include conditions that affect younger, more active patients.
It is projected that there will be as many as 610,582 primary and 99,898 revision total hip arthroplasty (THA) procedures annually by 2020. For total knee arthroplasty (TKA), as many as 1.5 million primary TKA procedures and 161,405 revision TKAs are anticipated in the same year. Based on current trends, 5.6% of those THAs and 3.3% of TKAs are followed by a readmission within 30 days of discharge. Hospital readmission has become a focus of quality measures used by the Centers for Medicare and Medicaid (CMS) to evaluate quality of care. Recent policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions, with the hopes of improving the quality of health care delivery.
In 2013, the CMS rolled out the implementation of the Readmission Penalty Program. Hospitals are no longer reimbursed for necessary care of patients that are readmitted within 30 days of discharge, with few exceptions to the primary diagnosis for readmission. As more provisions within the Patient Protection and Affordable Care Act are developed, readmission rates, as part of a bigger set of quality metrics, are being used to determine reimbursement rates for physicians. Further, the need for readmission is deemed as an indication for inadequate quality of care, and is therefore subjected to financial penalties. However, readmissions may often be a result of an independent incident, unrelated to the surgical arthroplasty procedure. As such, surgeons and administrators are pressed with the challenge to accommodate the growing number of patients who qualify for arthroplasty procedures, while also improving quality of care and decreasing the costs to the system. With this daunting task before total joint surgeons, the purpose of this review is to identify risk factors that have been significantly associated with higher readmission rates, address approaches to minimize 30-day readmission, and discuss the potential future direction within this area as new government regulations arise.
Introduction
Total joint arthroplasty (TJA) is one of the most effective and efficient interventional procedures in medicine, because it offers a successful option to address chronic pain and functional disability of the associated joint. Although it was developed initially to address degenerative changes seen in the elderly population, TJA indications have continued to expand to include conditions that affect younger, more active patients.
It is projected that there will be as many as 610,582 primary and 99,898 revision total hip arthroplasty (THA) procedures annually by 2020. For total knee arthroplasty (TKA), as many as 1.5 million primary TKA procedures and 161,405 revision TKAs are anticipated in the same year. Based on current trends, 5.6% of those THAs and 3.3% of TKAs are followed by a readmission within 30 days of discharge. Hospital readmission has become a focus of quality measures used by the Centers for Medicare and Medicaid (CMS) to evaluate quality of care. Recent policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions, with the hopes of improving the quality of health care delivery.
In 2013, the CMS rolled out the implementation of the Readmission Penalty Program. Hospitals are no longer reimbursed for necessary care of patients that are readmitted within 30 days of discharge, with few exceptions to the primary diagnosis for readmission. As more provisions within the Patient Protection and Affordable Care Act are developed, readmission rates, as part of a bigger set of quality metrics, are being used to determine reimbursement rates for physicians. Further, the need for readmission is deemed as an indication for inadequate quality of care, and is therefore subjected to financial penalties. However, readmissions may often be a result of an independent incident, unrelated to the surgical arthroplasty procedure. As such, surgeons and administrators are pressed with the challenge to accommodate the growing number of patients who qualify for arthroplasty procedures, while also improving quality of care and decreasing the costs to the system. With this daunting task before total joint surgeons, the purpose of this review is to identify risk factors that have been significantly associated with higher readmission rates, address approaches to minimize 30-day readmission, and discuss the potential future direction within this area as new government regulations arise.
Understanding the economic scope of 30-day readmissions
The rate of THA being performed in the United States is 4 times higher than it was in 2005, with associated economic burden of $13.43 billion. Following a similar trend, TKAs have increased by up to 5 times with a total cost of $40.8 billion, further straining financial resources and expenditures. Unplanned readmissions carry a cost burden of $17.5 billion for Medicare patients alone. However, the etiology and the cost associated with the event of readmission after arthroplasty vary greatly. As such, understanding the various factors and variables that lead to readmission after TJA is a principal goal for both policymakers and hospital administrators.
The high efficiency and impact of TJA has led to further resource allocation, as TJA expenditure constitutes the greatest share of Medicare funds. Because the hospital readmission rate contributes a practically avoidable source of waste and financial burden, the topic became a central focus in the surgical literature and a target for multiple quality improvement approaches. The average cost of readmissions for THA is $17,103 and readmissions after TKA are $13,008. The financial costs for revision operations are even greater, with the average revision owing to a surgical complication being $29,893. Considering the substantial costs of an additional hospital admission, the goal of reducing 30-day readmission rates has become a primary focus of the CMS.
Risk and gain sharing strategies will continue to evolve as more provisions within the Patient Protection and Affordable Care Act are implemented. It is important that such changes do not negatively impact quality of care or the sustainability of hospitals and providers to ensure access to high-quality care. Shared responsibility for the gains and risks associated with care delivery will be bundled into a single payment for an entire episode of care. As such, physicians should be equipped with the tools to negotiate bundle payments, taking into account the costly reality of a possible readmission. More emphasis should be placed on quality improvement, and as such, understanding factors that increase the risk of readmissions is vital to adequately mitigate poor patient outcomes and financial waste.
Risk factors associated with increased 30-day readmission rates
Orthopedic readmissions are owing to a number of variables, both nonmodifiable and modifiable. A multitude of factors have been analyzed in the literature. These range from hospital-related factors, such as hospital and surgeon volume; to patient-associated elements, including demographics, age, and comorbidities; to orthopedic/surgical-specific facets like surgical time. Determining patients at risk for readmission requires identification of a number of variables beyond merely the patients’ background and comorbidities. In fact, establishing a predictive model for readmissions requires thorough consideration of a broad category of variables such as social history, family support, economic status, and the interplay between these factors.
Patient-Specific Factors
Patient demographics, such as age, race, and gender have been shown to be associated significantly with an increased risk in readmission rates. Patients over the age of 40 have a steady increase in hospital readmission risk until over the age of 75, and then there is a decreased risk of unrelated readmission. African American race and male gender have also been identified as independent predictors of readmission, with an odds ratio of 1.5 for males compared with females. The higher readmission risk noted in these populations might be partly explained by the association of these variables with an increased risk for other medical comorbidities. Although patient demographics are nonmodifiable factors, they can be used to establish patient expectations and to better guide preoperative optimization for TJA candidates.
Additional patient-specific variables, such as comorbid conditions independent of the index surgery, have also been studied to determine their impact on 30-day readmission. Among the most common comorbidities in the aging US population is obesity. Obesity has been associated with an increased risk of surgical complications, compounded comorbid illness, and increased readmission after TJA. The rest of the identified comorbidities represent serious medical conditions and poor health status before the index procedure. Among those, the strongest correlation with higher readmission rates is reported in pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, bleeding disorder, history of cancer, and psychoses. Several studies also assessed the burden of comorbidity with standardized scoring systems such as the Charlson comorbidity index and have shown that worse preoperative scores are predictive of worse outcomes, higher postoperative complications, and higher rates of readmission.
Care Delivery Factors
Other modifiable factors associated with an increased likelihood of 30-day readmission are related to the care delivery process. Studies demonstrate that the level of expertise has an impact on the postoperative course and readmission. THA patients who were operated on in a high-volume surgical center have lower readmission rates, although greater surgeon volume was associated with greater readmission rates. However, in patients who underwent TKA, there is a lower rate of complications and readmission with higher provider volume. This finding is consistent when accounting for all TJA patients. Patients undergoing surgical intervention in public hospitals had higher readmission rates compared with those receiving the procedure at private or teaching institutions.
Identifying and addressing these factors will allow institutions to develop guidelines around perioperative surgical management of TJA patients. Also, all arthroplasty procedures do not carry equal risk for hospital readmission. TKA procedures tend to result in greater readmission rates than unilateral knee arthroplasty procedures, which is likely related to the longer surgical time, older patient population, and complication rate. In total elbow arthroplasty, osteoarthritis and infectious arthritis posed a greater risk for reoperation and readmission than posttraumatic arthroplasty. Additionally, the type of anesthesia might impact complication rates. Patients who had epidural anesthesia were 56% more likely to have a minor systemic complication and 2.6 times more likely to have a major systemic complication than patients who had spinal anesthesia, which can lead to readmission in the geriatric patient population undergoing joint arthroplasty. The use of a multidisciplinary care team in the management of operative patients as well as process standardization in the care of TJA patients reduced readmission, revision operation, and mortality.
Health system factors related to care, such as insurance type and discharge destination, are reported consistently to be associated with readmission risk. When the cost of the index admission is greater, there is an increased risk of readmission. Rather than this being identified as an independent factor, it may suggest a longer index admission that was the result of complications, putting the patient at greater risk for subsequent readmissions. Interestingly, payer status has been suggested as a factor that can be incorporated in a predictive model for 30-day readmission. Medicare and Medicaid patients are more likely to return to the hospital within the 30-day readmission observation period. Also, TJA patients discharged to skilled nursing facilities or homes with home health care are also at a greater risk for readmission. Although poorer health status upon discharge might be assumed as a confounding variable in this population, more recent studies have adjusted for preoperative comorbidities and postoperative complications that suggest place of discharge may independently have an impact on readmission outcomes.
Complications
Several studies have identified postoperative complications as the leading cause for all-cause surgical readmission. Complications associated with higher readmission include wound infections, sepsis, thromboembolic and cardiac events, and respiratory issues. Within arthroplasty, deep or superficial surgical site infection is the leading cause of 30-day readmission after TKA and accounts for 12.1% of unplanned readmissions. Other complications are broken down into broad categories that may be joint specific, such as dislocation, prosthetic misalignment, ligamentous laxity, periprosthetic fracture, a septic joint, or systemic complications including cardiac, pulmonary, and circulatory issues. The postoperative course, including inadequate pain control, inability to mobilize, falling episodes, anemia, or hematoma, account for the second leading cause for 30-day readmission rates particularly among THA patients. Thromboembolic disease (deep vein thrombosis or pulmonary embolism) accounts for the third most common reason for hospital readmission after both THA and TKA procedures. All of these factors have an impact on the length of in-hospital stay after the index admission. Although still accounting for the various factors that determine hospital length of stay, patients should be discharged as soon as possible. This is primarily pertinent in the elderly population, where increased duration of primary hospitalization has been associated with increased readmission rates.
In addition to the aforementioned factors, it should also be noted that as many as 50% of THA readmissions are not related to the index surgery. This suggests that they may have been planned readmissions or were unpreventable. Understanding this dynamic allows administrators to address the modifiable factors that predict readmission, while also realizing that completely eliminating readmissions may not be feasible. This should also empower physicians to advocate for appropriate reimbursement models that provide adequate compensation for the care provided, without penalizing providers or patients for unpredictable circumstances.
Approaches to reduce 30-day readmissions
With the increase in access and indications, federal regulations attempt to encourage a higher emphasis on adequate care during the primary hospital admission. Proper patient selection and optimization is a vital aspect to reducing readmission after elective procedures. Patients must have access to an internist or primary care physician who manages their medical comorbidities. In the past, there has been a disconnect between the primary provider and secondary or multispecialty physicians. The orthopedic surgeon must have an invested relationship with all physicians and stakeholders involved in the care of their patients to ensure appropriate preoperative expectations and continuity of care. Optimizing the patient with preoperative medical clearance and communication with all providers and family members involved in the perioperative course are steps that should be included. The medical comorbidities that have been associated with higher readmission rates (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, bleeding disorder, history of cancer and psychoses) should be optimized to ensure the patient has the lowest possible risk for postoperative complications. Malnutrition can be an easily overlooked factor affecting the postoperative period, with the stress of responding to a surgical intervention. Albumin levels, zinc, and nitric oxide are all predictors of outcomes in terms of the body’s ability to heal and the immune system competency, and these levels should be obtained and brought within normal limits. Finally, because thromboembolic disease is one of the leading causes of readmission, following proper anticoagulation guidelines is pivotal to improve outcomes and decrease readmission rates in candidates for TJA.
Appropriate intraoperative processes can also help to reduce the risk of readmission. Management of the patient immediately before the surgical procedure and during all aspects of care in the operating room can have an impact on patient satisfaction and postoperative outcomes. Care efficiency and standardized protocols have an impact on quality of care and can improve readmission rates. Institutions that perform a higher volume of TJAs have lower rates of mortality, complications, and readmissions compared with those that perform lower volumes. Surgeons and hospitals must commit to providing resources and implementing processes that can improve their TJA volume. The implementation of dedicated arthroplasty operating rooms or running parallel rooms, increases procedural volume, and decreases surgical time and the duration of hospitalization.
In addition to establishing a surgical team/vision centered around quality care goals, heightened focus should be allocated to compliance with standardized surgical protocols. Preventing surgical wound infection, the primary cause of readmissions after TJA, starts before the operation, with perioperative measures that include proper skin preparation and prophylactic antibiotics. Intraoperatively, meticulous care is crucial to ensure the maintenance of the sterility of the operating field. Minimizing particle count in the operating room will also decrease risk of postoperative infection by using body exhaust suits, laminar flow, ultraviolet light, controlling operating room traffic, and antibiotic-loaded bone cement. Finally, the use of tourniquets can minimize blood loss and the need for transfusions, which may contribute to longer duration of stay and impact risk for readmission.
After surgical intervention, efforts should be directed towards minimizing risk of complications during in-hospital care and in the postdischarge period. Keeney and colleagues advocate for the multimodal treatment approach, which had a great impact on reducing surgically related complications after TKA. Appropriate anticoagulation and use of compression stockings are prophylactic measures for patients who suffer from thromboembolic disease, a common cause of readmission in the THA population. Appropriate antibiotic prophylaxis regimens are aimed at decreasing the risk of potential infection. Routine monitoring will also allow timely recognition of hematoma development, copious wound drainage, or need for early blood transfusion.
Several readmission reduction initiatives reported in the literature, focus on minimizing hospital length of stay and influencing discharge destination. Decreasing the duration of hospital stay became an approach to continuing managed care in patients when the diagnosis related group payment system was coming into play. This shifted care from the inpatient setting to an outpatient rehabilitation facility and lowered costs related to the hospitalization. However, discharging patients to home has been shown to decrease readmissions. In an attempt to achieve both of these goals, the use of patient management support systems have been implemented to provide rapid recovery after discharge, while minimizing patients’ risk to hospital acquired conditions. Edwards and colleagues used support teams by engaging with the patient at all phases of care and in collaboration with a “navigator” team member in the immediate postdischarge period. This system resulted in an increased home discharge rate of all TJA patients to 94%, decreased length of stay to less than 2 days, and decreasing readmission rate from 16% to 9.2%.
Postoperative care can consume up to 50% of the overall cost of the perioperative care cycle. The use of perioperative care teams and home monitoring systems, through mobile devices or electronic systems, can lead to better transition from the time of discharge to the first follow-up visit. Providing quality care requires the surgeon to become invested and equipped with the resources needed to empower patients to play an active role in their health care and optimize their outcomes. Patient activation is vital in the postoperative period, but starts from the initial preoperative appointment. An “activated” patient has improved quality of life, lower health-related costs, fewer complications, and greater satisfaction. Surgical outcome is the result of many components within the system and failure, at any 1 step, may result in an adverse outcome mitigating the risk for an unplanned readmission. As such, the optimization of the postoperative course and the decrease in 30-day readmission rates could be achieved by the improvement and perfection of every step in the surgical process.
Future Directions
Recent studies reported in the orthopedic surgery literature have delved into components of readmissions ranging from cost burden, risk factors, as well as proper coding and assessments. Although some success has been achieved in reducing the duration of stay through rapid recovery protocols without compromising readmission rates, gaps in our understanding of readmissions still exist. One study suggested that one-half of readmissions are not associated with a complication or the index admission.
Studies to bridge the gap in the literature would aid in providing a model to predict hospital readmission founded on evidence-based factors and guide medical management to minimize such risks. This review further highlights the disparities in our understanding of readmission factors, the dearth of studies in certain domains of risk factors, and the limited number of prospective studies. Also, the variation in criteria of what constitutes a readmission across studies and the arbitrary 30-day quality measure used by CMS, prevents effective pooling of the data. In fact, some variables cannot be studied quantitatively because of the significant heterogeneity and the lack of consistency, especially in reporting terminology. Several current studies focus extensively on the patient and provider factors, with a clear paucity in reported data for social, procedural, and diagnostic factors that influence readmission rates. There is also a need to further explore factors such as general medical and psychiatric health conditions including, but not limited to, depression, hypertension, and abnormal blood levels of triglycerides, cholesterol, and vitamin D. Patient compliance and accountability are also crucial factors that may impact risk of readmission and remain underreported. The patient’s and/or family member’s ability to process and provide adequate care in the postoperative period might have a direct impact on complications and lead to early unplanned readmission.
Furthermore, it is vital to understand the implications of not just the individual procedures and risk factors, but also the effects of multilevel interventions on readmission to significantly reduce incidence. For instance, factors that otherwise would not be a major cause of readmission could play a pivotal role when compounded with other factors. Unfortunately, many current readmission predictors, such as the LACE index, have poor discriminatory power as well as limited utility. Contrastingly, the American College of Surgeons Surgical Risk Calculator presents a strong example of the importance of clinical judgment to adjust and improve predictive power of adverse events, although it does not predict readmission risk specifically. Additionally, none of these predictors are sufficiently specific for orthopedics; in a surgical specialty with a variety of specialty-specific operations, a unique, specialized predictor is required. Without investigating the effects of various interventions, optimal interventions to prevent early readmission will remain a challenging task. A comprehensive and arthroplasty-specific model is needed to reduce early readmissions to prevent providers from further straining the medical and financial resources in the system, without actually improving the quality of delivered care.
Related posts:
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Patient Centeredness in Total Joint Replacement
Anterior Cruciate Ligament Injuries in Children and Adolescents
Planning, Building, and Maintaining a Successful Musculoskeletal Service Line
Tibial Stress Fractures in Athletes
Thumb Ligament Injuries in the Athlete
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