A Preoperative Scale for Determining Surgical Readmission Risk After Total Hip Replacement
Authors: Siracuse BL, Chamberlain RS
JAMA Surg. 2016 Mar
In this study, investigators analyzed retrospective discharge data on 268,518 patients from New York and California (ie, the derivation cohort) and 153,560 patients from Florida and Washington (ie, the validation cohort) who underwent total hip replacement during 2006-2011.The goal was to determine the readmission rate and develop a scale using demographic and clinical characteristics to predict readmission risk.
Overall, 56% of patients were women, and 79% were white. The 30-day readmission rate was 5.89% for the derivation cohort used to develop the predictive scale and 5.82% for the validation cohort used to test the predictive scale. The most common discharge locations were rehabilitation center/skilled nursing facility (40%), home health care (39%), and home (20%). The most common reasons for readmission were prosthetic complications (13%), surgical site infections (13%), dislocation (11%), postoperative hemorrhage/hematoma (2%), and deep vein thrombosis/pulmonary embolism (2%).
The risk scale explained 89% of readmission variability. More than 95% of patients had a score of less than 30 points. A score of more than 40 points increased the likelihood of readmission by more than 15%.
Anesthesiologists often provide care to patients undergoing hip replacement as it is one of the more common surgical procedures performed in the United States, with approximately 350,000 total or revision hip replacements done in 2013.
The Perioperative Surgical Home model of care has anesthesiologists lead interdisciplinary teams to improve and coordinate all aspects of care. This includes assessing preoperative risk and designing an anesthetic and postoperative care regimen to minimize resource use, length of stay, and readmission. At the same time, the Affordable Care Act includes the Hospital Readmissions Reduction Program whereby hospitals suffer financial penalties for excess readmissions, including for hip replacements. Approximately 20% of all hospitalized Medicare patients are readmitted.
As a result, the Readmission After Total Hip Replacement Risk score developed by the authors can be quite handy for physicians aiming to assess readmission risk and for brainstorming ways to identify high-risk patients ahead of time and putting in place an optimal care plan. This general approach is also consistent with “precision medicine,” a term heard more and more frequently, referring to specifically tailoring treatment to the individual characteristics of each patient. These characteristics could be biomarkers of molecular or cellular activity, genetics, or clinical variables such as were identified in this study that can then be used to trigger targeted interventions.
Because most of the readmissions in this study were due to prosthetic complications, surgical site infections, and dislocation, the perioperative team at a particular hospital could confirm if that was the case for their hospital’s patients. Then, the focus would become examining patient-centered approaches to coordinate care to further reduce those specific adverse events. As an example, a program at one institution reduced readmission rates from 3.7% to 1.8% by enabling outpatient workup for deep vein thrombosis, increasing efforts to prevent surgical site infection, early follow-up after discharge, and increased physician education about the consequences of readmission.
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