Unplanned Admissions Impact Savings from Rapid Recovery Protocols

    This single-center study highlights why joint replacement patients might visit the emergency department or be readmitted after discharge, as well as suggests strategies for reducing these unplanned admissions.

    Under bundled payment reimbursement model, total joint arthroplasty (TJA) patients’ unplanned hospital visits – either through emergency department (ED) visits or readmissions – will reduce cost savings from rapid recovery protocols, according to a recent study examining this topic.

    The Comprehensive Care for Joint Replacement model, which about 800 hospitals participate in, requires hospitals, physicians, and post-acute care facilities to coordinate the management of Medicare patients for the duration of their recovery and assume financial responsibility for any complication related to the index procedure.

    With bundled payment models in mind, researchers at Anne Arundel Medical Center in Annapolis, Maryland, conducted a study of the incidence, risk factors and cost associated with unplanned visits.

    “In this era of shorter LOS [length of stay] and bundled reimbursement models for TJAs, identifying and mitigating preventable causes for unplanned ED visits and readmissions will be critical to improving care and controlling costs,” they explained.

    Their retrospective study evaluated data from 655 consecutive TJAs (382 total knee and 273 total hip arthroplasties) performed by 2 high-volume surgeons over a 1-year period.  All surgeries were performed using an early discharge protocol.

    They found that 55 patients returned to the hospital within 30 days of surgery: 35 patients (5.3%) for ED visits without readmission (36 visits total) and 20 patients (3.1%) for readmission (22 readmissions total).

    Most visits to the ED were related to postoperative pain/swelling (36%) or medication-related side effects (22%) from opioids or anticoagulation/coagulopathy treatments. The 2 most common reasons for readmissions were postoperative ileus (23%) and wound infections (18%).

    Looking at risk factors for ED visits, the researchers found that patients with a history of avascular necrosis of the hip were more likely to have an unplanned ED visit (7.27 odds ratio [OR], 95% CI, 1.67-31.61; P<0.008).

    A subgroup analysis compared 1-day LOS patient with 2-day LOS patient and found no significant difference in ED visits (P=0.124).

    Risk factors for readmission included:

    • Body mass index (1.10 OR, 95% CI, 1.02-1.78; P<0.013)
    • More than 2 comorbidities (2.07 OR, 95% CI, 1.06-6.95, P<0.037)
    • Prior total knee arthroplasty (2.61 OR, 95% CI, 1.01-6.72; P <0.047)

    Although not statistically significant, it appeared that ambulating on the day of surgery may lower risk for readmission (0.13 OR, 95% CI, 0.02-1.10; P<0.061).

    The hospital costs for ED visits were $429 on average, for a total of $15,427. Readmissions averaged $6,484 per visit, totaling $142,654.

    Extrapolating these costs to their total TJA volume, the researchers estimated that their health system would lose more $42,000 for ED visits and more than $437,000 for readmissions, with a net loss of $484,377 for 2015.

    The researchers discussed several possibilities to manage these challenges including, but not limited to:

    • Calling high-risk patients with avascular necrosis of the hip on POD 1 and/or POD2
    • Implementing a multimodal pain management regimen to decrease opioid use
    • Providing preoperative education to decrease opioid-related ileus
    • Using aspirin in some patients to decrease anticoagulation side effects

    The authors noted limitations of their study. They included data from only 2 surgeons, and examined only a 30-day episode of care. In addition, patients could have gone to other facilities for ED visits or readmissions, which would not be accounted for in this study.

    The researchers added that further studies should focus on the effectiveness of strategies to reduce ED visits and readmissions.

    Sibia US, Mandelblatt AE, Callanan MA, MacDonald JH, King PJ. Incidence, risk factors, and costs for hospital returns after total joint arthroplasties. J Arthroplasty. 2016 Aug 12. pii: S0883-5403(16)30470-3. In Press. [Epub ahead of print]