Ingrid Hein

March 04, 2016

ORLANDO, Florida — Hospitals will have to get their readmission rates under control by April 1, when the Comprehensive Care for Joint Replacement bundled payment model comes into effect.

Two studies presented here at the American Academy of Orthopaedic Surgeons 2016 Annual Meeting — one looking at readmission rates after total hip arthroplasty and the other at readmission rates after total knee arthroplasty — put a spotlight on the fact that readmission rates related to these procedures are very high, largely due to surgical complications.

"I was surprised that with total hip arthroplasty, you have so many procedure-related readmissions," said study investigator Steven Kurtz, PhD, from Drexel University in Philadelphia.

"And five types of infection complications are among the top reasons for readmission after total knee arthroplasty," he told Medscape Medical News.

Dr Kurtz and his colleagues assessed readmission rates in patients 65 years and older who had undergone total hip or total knee arthroplasty from 2010 to 2013, using the Medicare national hospital claims database.

The 952,593 primary total knee arthroplasty patients identified were treated in 3848 hospitals, and the 442,333 primary total hip arthroplasty patients identified were treated in 3730 hospitals.

Readmission rates varied significantly from hospital to hospital.

Table. Median Readmission Rates

Arthroplasty Site 30-Day Rate, % 90-Day Rate, %
Knee 4.9 8.6
Hip 5.8 10.5

 

In the knee group, the five most frequent reasons for 30-day readmission were wound infection (6.2%), deep infection (4.5%), atrial fibrillation (3.9%), cellulitis, abscess of leg (3.0%), and pulmonary embolism (2.6%). These were also the five most frequent reasons for 90-day readmission.

In the hip group, the five most frequent reasons for 30-day readmission were dislocation (5.9%), deep infection (5.1%), wound infection (4.8%), periprosthetic fracture (4.4%), and hematoma (3.4%).

"Our initial hypothesis was that the hospital factors would be as important as clinical and patient factors. That wasn't the case," said Dr Kurtz.

The Comprehensive Care for Joint Replacement Model

The findings from these studies are especially relevant because the Comprehensive Care for Joint Replacement Model goes into effect at 789 hospitals in just a few weeks, he pointed out.

 
The whole bundle payment is a massive innovation, and it has the potential to innovate high-readmission hospitals out of business.
 

Under the new model, readmission is the most important metric the government will use to assess the ability of hospitals to provide quality care. Hospitals will be reimbursed one amount per "episode of care," which consists of assessment, surgery, postsurgical infection, and complications requiring hospital readmission within 90 days.

"The whole bundle payment is a massive innovation, and it has the potential to innovate high-readmission hospitals out of business," Dr Kurtz explained.

What's more, he said, it could hurt patients who are at higher risk, such as the elderly and the overweight. "There's a dark cloud to this," said Dr Kurtz. "You might be told, 'You're 80 years old, you don't need a joint replacement'."

Patients could be turned away or asked to modify their behavior before surgery. But not everyone sees this as a negative thing.

Helping Patients Modify Behavior

Results from a voluntary Comprehensive Care for Joint Replacement Model have been positive, said Joseph Bosco, MD, from the NYU Langone Medical Center in New York City.

In that institution, 30-day readmission rates decreased from 7.0% to 5.0% over the study period, and 90-day rates decreased from 13.0% to 7.7%.

Physicians had to identify risk factors and comorbidities preoperatively and focus on creating programs to help change modifiable risk factors, Dr Bosco explained. "We offered an aggressive smoking-cessation program and a high-BMI weight-loss program."

 
At some point, when we have more data, we'll have to say, 'Listen, you're too fat, we can't afford to pay for your complication'.
 

Most important, patients had to understand that their behavior has an effect on risk. When people ask about our infection rate, "we tell them it's 1% for the institution, but if you smoke, have diabetes, and are overweight, your risk is 20%," he said.

Even if a patient quits smoking for 6 weeks before surgery or loses weight only for surgery, it still decreases infection rates, he reported.

Although they don't have research yet to support the numbers, Dr Bosco estimates that 60% to 70% of patients work on modifying their habits and come back.

"There's about 30% that can't modify their behavior," he added. "We'll do their surgery; we don't have hard stops — yet. But at some point, when we have more data, we'll have to say, 'Listen, you're too fat, we can't afford to pay for your complication; society doesn't want to pay for your complications'."

The studies by Dr Kurtz's team were funded by Stryker. Dr Bosco reports that he is a paid consultant for and has received royalties from Genovel, is an editorial member of the Journal of Bone and Joint Surgery, and is a paid presenter for Pacira.

American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting: Abstracts 172 and 305. Presented March 2, 2016.

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