Lorraine Hutzler

Cost Burden of 30-Day Readmissions Following Medicare Total Hip and Knee Arthroplasty

The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospitals administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.

An Analysis of Causes of Readmission After Spine Surgery

Study Design. Retrospective review of medical records. Objective. We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions. Summary of Background Data. Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery. Methods. Using the hospitals administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patients initial admission. The readmission rate was calculated for each procedure. Results. A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures). Conclusion. Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.

The Effect of Discharge Disposition on 30-Day Readmission Rates After Total Joint Arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data.

EXECUTIVE SUMMARY The rate of unplanned 30‐day readmissions to the hospital after discharge is being used as a marker to compare the quality of care across hospitals and to set reimbursement levels for care. While the readmission rate can be reported using administrative data, the accuracy of these data is variable, and defining which readmissions are unplanned and preventable is often difficult. The purpose of this study was to review readmissions to a single orthopedic hospital to identify the causes for readmission and, in particular, which readmissions are planned versus unplanned. Using that hospitals administrative database of patient records from 2007 to 2009, we identified all patients who were readmitted to the hospital within 30 days of a previous hospitalization for a procedure. Readmissions were broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined as either surgical or nonsurgical complications (medical conditions not directly related to the procedure). Almost 30 percent of readmissions were planned. Of the unplanned readmissions, close to 60 percent were triggered by an infection or a concern for an infection. Nonsurgical complications accounted for 18.2 percent of unplanned readmissions. This study highlights the importance of careful data collection and abstraction when calculating early readmission rates. Preventing surgical site infection and better coordinating care between orthopedic surgeons and primary care and medical subspecialty physicians may significantly reduce readmission rates.

Staphylococcus aureus Decolonization Protocol Decreases Surgical Site Infections for Total Joint Replacement

We investigated the effects of implementation of an institution-wide screening and decolonization protocol on the rates of deep surgical site infections (SSIs) in patients undergoing primary knee and hip arthroplasties. 2058 patients were enrolled in this study: 1644 patients in the treatment group and 414 in the control group. The treatment group attended preoperative admission testing (PAT) clinic where they were screened for MSSA and MRSA colonization. All patients were provided a 5-day course of nasal mupirocin and a single preoperative chlorhexidine shower. Additionally, patients colonized with MRSA received Vancomycin perioperative prophylaxis. The control group did not attend PAT nor receive mupirocin treatment and received either Ancef or Clindamycin for perioperative antibiotic prophylaxis. There were a total of 6 deep infections in the control group (1.45%) and 21 in the treatment group (1.28%); this represented a decrease of 13% (P = .809) in the treatment versus control group. This decrease represented a positive trend in favor of staphylococcus screening, decolonization with mupirocin, and perioperative Vancomycin for known MRSA carriers.

The effect of severity of disease on cost burden of 30-day readmissions following total joint arthroplasty (TJA).

In order to control the unsustainable rise in healthcare costs the Federal Government is experimenting with the bundled payment model for total joint arthroplasty (TJA). In this risk sharing model, providers are given one payment, which covers the costs of the TJA, as well as any additional medical costs related to the procedure for up to 90 days. The amount and severity of comorbid conditions strongly influence readmission rates and costs of readmissions in TJA patients. We identified 2026 TJA patients from our database with APR-DRG SOI data for use in this study. Both the costs of readmission and the readmission rate tended to increase as severity of illness increased. The readmission burden also increased as SOI increased, but increased most markedly in the extreme SOI patients.

Patients' perceptions of care are associated with quality of hospital care: a survey of 4605 hospitals.

Favorable patient experience and low complication rates have been proposed as essential components of patient-centered medical care. Patients’ perception of care is a key performance metric and is used to determine payments to hospitals. It is unclear if there is a correlation between technical quality of care and patient satisfaction. The study authors correlated patient perceptions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems scores with accepted quality of care indicators. The Hospital Compare database (4605 hospitals) was used to examine complication rates and patient-reported experience for hospitals across the nation in 2011. The majority of the correlations demonstrated an inverse relationship between patient experience and complication rates. This negative correlation suggests that reducing these complications can lead to a better hospital experience. Overall, these results suggest that patient experience is generally correlated with the quality of care provided.

Correlation Between Physician Specific Discharge Costs, LOS, and 30-day Readmission Rates: An Analysis of 1,831 cases

There is currently wide variation in the use and cost of post acute care following total joint arthroplasty. Additionally the optimum setting to which patients should be discharged after surgery is controversial. Discharge patterns following joint replacement vary widely between physicians at our institution, however, only weak correlations were found between the cost of discharge and length of stay or readmission rates. The inter-physician variance in discharge cost did not correlate to a difference in quality, as measured by length of stay and readmission rates, but does imply there is significant opportunity to modify physician discharge practices without impacting patient outcomes and the quality of care.

The Persistence of Staphylococcus aureus Decolonization After Mupirocin and Topical Chlorhexidine: Implications for Patients Requiring Multiple or Delayed Procedures

Preoperative screening and decolonization of methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA, respectively) are advocated to reduce surgical site infections. We determined the rate and duration of decolonization in patients undergoing elective orthopedic surgery. Patients undergoing elective orthopedic surgery were seen in our preoperative testing program (PAT) and had their anterior nares cultured for MRSA and MSSA. All patients were treated with intranasal mupirocin and a topical chlorhexidine solution. A cohort of patients returned to PAT before a subsequent elective procedure and were recultured. All culture results and time between PAT visits were recorded, and the rates of successful initial and persistent decolonization were determined. Six hundred ten patients visited PAT 1290 times. Overall, 94 (70.1%) of 134 patients with initially MRSA- or MSSA-positive cultures remained decolonized at a mean time of 156 days (SD=140), whereas 40 patients (29.9%) were not decolonized by the time of repeat testing at a mean time of 213 days (SD=187). At repeat testing, there were 2 newly MRSA-positive and 35 newly MSSA-positive patients. Staphylococcus aureus decolonization with intranasal mupirocin and topical chlorhexidine was effective but not persistent in a significant proportion of patients. A small number of previously uncolonized patients became colonized. Staphylococcus aureus screening and decolonization protocols must be repeated before any readmission, regardless of prior colonization status.

Decreasing Total Joint Implant Costs and Physician Specific Cost Variation Through Negotiation

Reducing the cost of total joint implants can significantly reduce the cost of an episode of care without affecting the quality. In 2011 we began a program to decrease and standardize the pricing of total joint implants. In the first year of the intervention we preformed 1,090 and 1,022 unilateral total knee and total hip arthroplasties respectively. Based on our volume and pricing data, our institution saved over