Total Hip and Total Knee Arthroplasty and Readmissions

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are the first procedure-specific readmission measures to be added to Hospital Readmission Reduction Program (HRRP). These procedures are under the microscope for several reasons. First, their prevalence is on the rise as more patients undergo those surgeries. Individual Medicare beneficiaries generally have two hips and two knees, meaning they are candidates for multiple surgeries – procedures which are expensive. The average charge for a THA is $60,033; the TKA average is $63,543. Hospitalizations for those procedures are more expensive than stays for chronic conditions such as pneumonia, chronic obstructive lung disease, and heart failure. Another reason for the scrutiny is a wide variation in readmission rates across the country. The Centers for Medicare & Medicaid Services (CMS) posits the wide variation suggests differences in quality of care at the hospital level. A third factor is that the procedures are normally elective rather than life-saving. So providers have time to evaluate a patient’s readiness for surgery, and the rehabilitation necessary to achieve a good outcome before a procedure. As with the condition-specific readmissions, a predicative model based on the discharge diagnoses from the index admission is available. Table 1 (see below) lists the diagnoses that predict a patient has an approximately 50 percent or greater chance of readmission. Beside each diagnosis is the odds ratio (OR). The OR compares the magnitude of readmission risk associated with the diagnosis. An OR greater than one means that the diagnosis is associated with higher odds of readmission. As with the condition specific readmissions, patients with three or more chronic diseases are likely candidates for readmission following THK. The takeaway about this group of diagnoses is the importance of preparing such patients prior to surgery. Some patients may be poor candidates for these procedures, but they (or their caretakers) may be adamant about having surgery performed. Post-operative wound care, and medication reconciliation regarding blood thinners, are key strategies to prevent readmissions. Reducing THK readmission requires a comprehensive approach which include the period prior to surgery, the hospitalization, and the discharge. (10/2/2015)