Abstract
Background
Discharge disposition and length of stay (LOS) are widely recognized markers of healthcare utilization patterns of total hip and knee joint arthroplasty (TJA). These markers are commonly associated with increased postoperative complications, patient dissatisfaction, and higher costs. Area deprivation index (ADI) has been validated as a composite metric of neighborhood-level disadvantage. This study aims to determine the potential association between ADI and discharge disposition or extended LOS following revision TJA.
Methods
This study conducted a retrospective analysis of a consecutive series of revision hip and knee TJA patients from a single tertiary institution. Univariate and multivariate regression analysis was used to determine the association between ADI and discharge disposition or LOS, adjusting for patient demographics and comorbidities.
Results
1047 consecutive revision TJA patients were identified across 463 different neighborhoods. 193 (18.4 %) had an extended LOS, and 334 (31.9 %) were discharged to non-home facilities. Compared with Q1 (least deprived cohort), Q2 (odds ratio [OR] = 1.63; p = 0.030) and Q4 (most deprived cohort: OR = 2.04; p = 0.002) cohorts demonstrated higher odds of non-home discharge. Patients in the highest ADI quartile (most deprived cohort) were associated with increased odds of prolonged LOS following revision TJA compared to those in the lowest ADI quartile (OR = 2.63; p < 0.001).
Conclusion
This study suggests that higher levels of neighborhood-level disadvantage may be associated with higher odds of non-home discharge and prolonged LOS following revision TJA. Development of interventions based on the area deprivation index may improve discharge planning and reduce unnecessary non-home discharges in patients living in areas of socioeconomic deprivation.
Keywords: Socioeconomic factors; Postoperative complications; Social determinants of health; Arthroplasty, replacement, hip; Arthroplasty, replacement, knee
1. Introduction
Discharge disposition and length of stay (LOS) are well-established markers of healthcare utilization following total hip and knee joint arthroplasty (TJA). Previous studies have demonstrated that non-home discharge to a skilled nursing or rehab facility increases the risk of adverse postoperative events, readmission, and morbidity following primary and revision TJA.1, 2, 3 Additionally, several studies propose that implementing strategies to minimize LOS can substantially ameliorate the cost of care without compromising patient outcomes or satisfaction, while prolonged LOS can lead to patient dissatisfaction, increased cost burden, and increased risk of developing subsequent adverse events.4, 5, 6, 7, 8
Social, demographic, and economic factors play a critical role in discharge disposition and prolonged LOS in patients undergoing TJA.9, 10, 11, 12, 13 These studies primarily concentrate on identifying individual factors that influence healthcare utilization after surgery. However, they often fail to address the intersectionality of these variables as it relates to LOS and discharge disposition. Area deprivation index (ADI) is a metric that ranks neighborhoods by socioeconomic disadvantage, encompassing 17 variables related to education, employment, housing quality, and poverty.14, 15, 16 While ADI has been investigated in various settings within orthopaedics, the potential association between ADI and different outcomes remains inconsistent.17, 18, 19, 20, 21 In addition, a previous study by Wright et al. determined that various orthopaedic subspecialties had distinct ADI score distributions.22 These studies suggest that ADI need to be examined in the setting of different orthopaedic procedures to obtain the most accurate interpretation of its utility.
Revision TJA presents additional challenges in rehabilitation compared to primary TJA due to its surgical complexity. Patients, therefore, more often require an extended recovery period with increased demand for additional rehabilitation support. Several studies have demonstrated that patients undergoing revision TJA are at higher risk for prolonged LOS23 and discharge to a non-home facility. Several studies demonstrated that skilled nursing and rehabilitation facilities made up over one-third of discharges in patients who underwent revision TJA, a proportion higher than that of primary TJA patients.1,2 These results indicate a higher level of planning and postoperative care required for patients following revision TJA. While previous studies imply the significant influence of socioeconomic factors on healthcare utilization following TJA, the utility of ADI in the setting of revision TJA has yet to be investigated. Determining the correlation between community-level socioeconomic status and healthcare utilization can provide valuable insight into ways to improve preoperative planning, resource reallocation that optimize patient recovery following surgery. Therefore, this study aimed to determine the potential association between ADI and discharge disposition and extended LOS following revision TJA.
2. Methods
Approved by the Institutional Review Board, electronic health records of 1047 consecutive patients who underwent revision TJA between 2018, and 2022, were extracted and retrospectively reviewed. Demographics, including age, race, ethnicity, sex, residential zip code, body mass index (BMI), and insurance status, were recorded. Data on comorbidities as incorporated in the Charlson Comorbidity Index (CCI), alcohol use, substance use, history of depression, and the American Society of Anesthesiologists (ASA) were also collected. No patients in this cohort had a recorded ASA class above 4. Primary outcomes were discharge disposition and prolonged LOS. Prolonged LOS was defined as postoperative stay greater than the 75th percentile of this patient cohort.24,25 Discharge disposition was categorized as home or non-home discharge. Non-home discharge includes rehabilitation and skilled nursing facilities. Patients were considered to have a prolonged LOS if the number of days postoperatively was greater than the 75th percentile of the patient cohort.25,26
Area deprivation index (ADI) is a publicly available tool validated to the Census block group neighborhood level that indicates the national ranking of a zip code area in terms of the degree of socioeconomic disadvantage.14,16 An ADI can range between 1 and 100, with 1 representing the least disadvantaged and 100 representing the most disadvantaged neighborhoods.16 Most self-reported zip codes were five digits instead of the nine digits that ADI references to produce a score. Therefore, the mean score of all nine-digit zip codes within a five-digit zip code area has been utilized for analysis.21,27 ADI was then categorized into the following quartiles of the study cohort: quartile 1 (Q1; least deprived; <25th percentile), quartile 2 (Q2; 25th–50th percentile), quartile 3 (Q3; 50th–75th percentile) and quartile 4 (Q4; most deprived; >75th percentile).
Patient characteristics were compared between outcome groups (i.e., home vs. non-home discharge, normal vs. prolonged LOS) using an independent t-test or Chi-square test based on the variable type. Univariate and multivariate logistic regression was used to determine the association between ADI and discharge disposition or prolonged LOS. We adjusted the association accounting for the following covariates: age, sex (male, female), race (white, non-white), ethnicity (Hispanic, not Hispanic, unknown), BMI, insurance status (private, public, self-pay), CCI, ASA class (1–2, 3–4), alcohol and substance use, and history of depression. An alpha of 0.05 was considered statistically significant. Statistical analyses were performed using SPSS (SPSS Version 18.0, IBM Corp., Armonk, NY, USA).
3. Results
1047 patients were identified across 463 different neighborhoods throughout the United States. Prolonged LOS in this patient cohort was defined as hospitalization for over five days following surgery in accordance with the literature.24,25 Of the patients who underwent revision TJA, 193 (18.4 %) had an extended LOS, and 334 (31.9 %) were discharged to non-home facilities. The cohort with prolonged LOS consisted of older patients (p < 0.001), had a higher percentage of public insurance (p = 0.033), and had higher ADI (p = 0.015) compared to the normal LOS cohort (Table 1). A greater proportion of the patients discharged to non-home facilities were female (n = 176; p = 0.008). The cohort discharged to non-home facility was also older (p < 0.001) and had a greater proportion of patients covered by public insurance (74.3 %; p < 0.001) compared to the home discharge group (Table 1). No significant inter-group differences were found in other patient variables when comparing LOS and discharge disposition. The mean ADI was 25 and ranged from 1 to 86. ADI cutoffs for each quartile were as follows: Q1 (<13; n = 256), Q2 (13–22; n = 255), Q3 (23–33; n = 277), and Q4 (>33; n = 259).
Table 1.
Demographic data as means and counts by length of stay and discharge disposition.
| Length of stay |
Discharge Disposition |
|||||
|---|---|---|---|---|---|---|
| Parameters | Normal (n = 854) (81.6 %) |
Prolonged (n = 193) (18.4 %) |
P-value | Home (n = 709) (67.7 %) |
Non-home (n = 334) (31.9 %) |
P-value |
| Age (mean ± SD) | 67 ± 10 | 70 ± 10 | <0.001 | 65 ± 9 | 72 ± 9 | <0.001 |
| BMI (kg/m2; mean ± SD) | 30.05 ± 5.63 | 30.34 ± 7.35 | 0.543 | 30.16 ± 5.52 | 29.98 ± 6.90 | 0.651 |
| Gender | 0.345 | 0.008 | ||||
| Female | 390 (45.7) | 96 (49.7) | 310 (43.7) | 176 (52.7) | ||
| Male | 464 (54.3) | 97 (50.3) | 399 (56.3) | 158 (47.3) | ||
| Race | 0.954 | 0.100 | ||||
| White | 781 (91.5) | 176 (91.2) | 654 (92.2) | 302 (90.4) | ||
| Non-white | 45 (5.3) | 11 (5.7) | 31 (4.4) | 22 (6.6) | ||
| Not reported | 28 (3.3) | 6 (3.1) | 24 (3.4) | 10 (3.0) | ||
| Ethnicity | 0.491 | 0.221 | ||||
| Hispanic | 23 (2.7) | 3 (1.6) | 21 (3.0) | 5 (1.5) | ||
| Non-Hispanic | 788 (92.3) | 183 (94.8) | 652 (92.0) | 315 (94.3) | ||
| Not reported | 43 (5.0) | 7 (3.6) | 36 (5.1) | 14 (4.2) | ||
| Insurance status | 0.033 | <0.001 | ||||
| Public | 531 (62.2) | 130 (67.4) | 411 (58.0) | 248 (74.3) | ||
| Private | 313 (36.7) | 57 (29.5) | 289 (40.8) | 79 (23.7) | ||
| None recorded | 10 (1.2) | 6 (3.1) | 9 (1.3) | 7 (2.1) | ||
| Depression | 96 (11.2) | 29 (15.0) | 0.180 | 79 (11.1) | 44 (13.2) | 0.400 |
| Drug Abuse | 17 (2.0) | 4 (2.1) | 0.999 | 11 (1.6) | 8 (2.4) | 0.482 |
| CCI (mean ± SD) | 4 ± 2 | 4 ± 2 | 0.999 | 4 ± 2 | 4 ± 2 | 0.999 |
| Alcohol use | 297 (34.8) | 58 (30.1) | 0.393 | 251 (35.4) | 103 (30.8) | 0.302 |
| ADI (mean ± SD) | 23 ± 15 | 26 ± 17 | 0.015 | 23 ± 15 | 25 ± 16 | 0.050 |
ADI = area deprivation index; SD = standard deviation; BMI = body mass index; CCI= Charlson Comorbidity Index; LOS = length of stay.
Univariate logistic regression demonstrated a statistically significant association between ADI and discharge disposition (p = 0.03), with areas of greater deprivation associated with higher odds of discharge to a facility. Univariate logistic regression also found age (OR = 1.08; p < 0.001), sex (OR = 0.72; p = 0.010), insurance type (public insurance OR = 2.17; p < 0.001; no insurance OR = 2.78; p = 0.049), ASA score (OR = 3.82; p < 0.001), and CCI (OR = 1.23; p < 0.001) to be significant determinants of discharge disposition. Multivariate logistic regression demonstrated higher odds of non-home discharge in patients in the Q4 (OR = 2.04; p = 0.002) cohorts than in the Q1 cohort. Older age (OR = 1.07; p < 0.001) and an ASA score of 3 or 4 (OR = 3.12; p < 0.001) also had higher odds of non-home discharge following revision TJA (Table 2).
Table 2.
Significant results of univariate or multivariate logistic regression analysis to evaluate the association between area deprivation and non-home discharge following revision total joint arthroplasty.
| Univariate logistic regression |
Multivariate logistic regression |
|||||
|---|---|---|---|---|---|---|
| Variablesb | OR | 95 % CI | OR | 95 % CI | ||
| Age | 1.08a | 1.06 | 1.10 | 1.07a | 1.05 | 1.10 |
| Sex (Female) | 0.72a | 0.55 | 0.93 | 0.72 | 0.53 | 0.98 |
| Insurance (Private) | ||||||
| Public | 2.17a | 1.62 | 2.91 | 1.30 | 0.92 | 1.86 |
| No insurance | 2.78a | 1.00 | 7.68 | 1.51 | 0.41 | 5.59 |
| ASA score (1 or 2) | 3.82a | 2.87 | 5.08 | 3.12a | 2.27 | 4.30 |
| CCI | 1.23a | 1.14 | 1.31 | 0.99 | 0.90 | 1.08 |
| ADI (Q1) | ||||||
| Q2 | 1.45 | 0.99 | 2.12 | 1.63a | 1.05 | 2.53 |
| Q3 | 0.93 | 0.64 | 1.34 | 1.08 | 0.70 | 1.64 |
| Q4 | 1.37 | 0.93 | 2.00 | 2.04a | 1.29 | 3.23 |
OR = odds ratio; CI = confidence interval; ASA = American Society of Anesthesiology; CCI= Charlson comorbidity index; ADI= Area Deprivation Index.
p < 0.05.
The category included in brackets is the reference category used for logistic regression analysis.
Univariate logistic regression demonstrated a statistically significant association with hospital stay duration, with the Q4 cohort having 1.92 times higher odds of having an extended LOS following revision TJA (p = 0.005). Univariate logistic regression also found age (OR = 1.04; p < 0.001) and ASA score (OR = 3.91; p < 0.001) to be significant determinants of extended LOS. Multivariate logistic regression showed a significant positive association between ADI and prolonged LOS following revision TJA, with 2.63 higher odds of prolonged LOS in patients of the Q4 cohort than those in the Q1 cohort (p < 0.001). Q2 and Q3 had 1.36 and 1.10 higher odds of prolonged LOS, respectively, but these results were insignificant. Older age (OR = 1.02; p = 0.020) and a higher ASA score of 3 or 4 (OR = 3.72; p < 0.001) were again associated with higher odds of an extended LOS following revision TJA (Table 3).
Table 3.
Significant results of univariate or multivariate logistic regression analysis to evaluate the association between area deprivation and extended length of stay following revision total joint arthroplasty.
| Univariate logistic regression |
Multivariate logistic regression |
|||||
|---|---|---|---|---|---|---|
| Variablesb | OR | 95 % CI | OR | 95 % CI | ||
| Age | 1.04a | 1.02 | 1.05 | 1.02a | 1.00 | 1.05 |
| ASA score (1 or 2) | 3.91a | 2.74 | 5.59 | 3.72* | 2.53 | 5.47 |
| ADI (Q1) | ||||||
| Q2 | 1.26 | 0.79 | 2.03 | 1.36 | 0.81 | 2.27 |
| Q3 | 0.95 | 0.59 | 1.51 | 1.10 | 0.67 | 1.80 |
| Q4 | 1.92a | 1.22 | 3.03 | 2.63a | 1.58 | 4.39 |
OR = odds ratio; CI = confidence interval; ASA = American Society of Anesthesiology; ADI= Area Deprivation Index.
p < 0.05.
The category included in brackets is the reference category used for logistic regression analysis.
4. Discussion
To our best knowledge, this is one of the first studies to examine the relationship between neighborhood socioeconomic deprivation and healthcare utilization in revision total hip and knee joint arthroplasty. High ADI values were associated with increased probabilities of prolonged LOS and non-home discharge following revision TJA. Age and ASA scores were also significant after controlling for other demographics and comorbidities. Our study demonstrated the need to improve clinical pathway allocation and ensure optimal access to resources to potentially reduce the risk of adverse events after revision TJA in patients living in areas of socioeconomic deprivation.
The increased odds of non-home discharge in patients with higher ADIs following revision TJA accorded with the findings of previous studies. Khlopas et al. reported that higher ADI was associated with non-home discharge disposition following primary total knee arthroplasty, with a dramatic increase in cases when patients had an ADI higher than 60.17 Grits et al. and Mehta et al. found a similar trend in primary total hip arthroplasty after taking into account other confounders.19,21 Our study also demonstrated higher odds of prolonged LOS following revision TJA in patients with a higher ADI, consistent with other studies focusing on primary TJA. Many studies identified high ADI as an independent or synergistic contributor to prolonged LOS following total hip arthroplasty.17,19,28 There are several potential explanations for these results. One could be that for patients living in low socioeconomic neighborhoods, institutional postoperative care may appeal as a safer option following surgery. Patients residing in areas with higher ADI scores may experience limited financial resources and lack sufficient support systems in their current living conditions. Community resources such as urgent care clinics and home health services may be less readily available in these neighborhoods.21 The higher prevalence of chronic conditions in individuals from areas with greater socioeconomic deprivation could also add to the complexity of the recovery process, which may influence both the duration of stay and discharge disposition.29 Finally, it is important to note ADI's association with social determinants of health. ADI considers indicators related to poverty, education, housing, and employment, all of which significantly impact physical and mental health.30 Poor physical and mental health are well-established contributors to suboptimal postoperative recovery.12,31
Interestingly, our study found significantly higher odds of non-home discharge and prolonged LOS at a lower ADI quartile (Q2: ADI = 13–22) than previously determined (ADI>60) in patients following primary TJA.17,19 This difference may be explained, in part, by the complex nature of a revision arthroplasty that may entail monitoring and closer follow-up than its primary counterpart during postoperative recovery. Patients receiving revision TJA were more vulnerable to adverse events when socioeconomic disadvantage reduces their access to appropriate healthcare services.23,32 Another potential explanation for the difference between our study and previous studies may reside in the methodology for ADI stratification including a finer ADI stratification into deciles and quintiles.17,19 A finer stratification increased the distinction between subgroups and enabled a more nuanced analysis of the point at which the odds of non-home discharge and extended LOS changed. Additionally, the left skew of the ADI, indicating a higher concentration of patients from lesser deprived neighborhoods, could have contributed to the observed finding.
Multivariate logistic regression found that after accounting for covariates, older age and an ASA score higher than 3 were independent risk factors for non-home discharge and prolonged LOS following revision TJA. Previous investigations have also identified this association between age and ASA on healthcare utilization.1,33,34 This could be due to the inherent patient population undergoing revision arthroplasty, who are generally older and more likely to have chronic conditions than those who undergo a primary TJA.35,36 Patients of older age and with medical comorbidities may benefit from resources and support that may not be readily available at home. ADI rank can help healthcare providers identify individuals at higher risk of longer hospitalization or need additional support from institutional facilities. Recognition of these factors can facilitate the proper allocation of resources to enhance patient care.
There are several limitations to our study. First, despite the large sample size, the use of an institutional database presented the usual limitations of retrospectively reviewed data. We included patients receiving care at a single tertiary urban institution. Thus, our findings may not be generalizable to patients receiving care in other settings. While a national database would enhance the generalizability of the results of this study, this was not possible due to the lack of patient residential zip codes, which was necessary for the purposes of this study. Second, we recognized that our classification of self-reported race as white or non-white may be an oversimplified representation. However, subcategorization of the non-white cohort was difficult in our dataset due to the limited number of patients in each category. Third, ADI provides deprivation scores based on an extended nine-digit zip code. For the majority of the patients, only the five-digit zip code was self-reported. To mitigate any potential discrepancies, we utilized an established method that averaged the ADI score of all nine-digit zip codes within the neighborhood within the five-digit zip code area. Lastly, while ADI takes into account various prevalent factors, it does not contain all relevant determinants of socioeconomic status. ADI does not consider health literacy, transportation, or insurance, which can influence the patient's length of stay or discharge disposition.
In conclusion, neighborhood socioeconomic deprivation (high ADI) was associated with increased risks of non-home discharge and prolonged LOS following revision TJA. A patient's age and ASA score also influenced the probability of the two outcomes after surgery. The ADI threshold for revision TJA at which the odds of healthcare utilization increased was lower than previously reported in primary TJA. The study provided supportive evidence that ADI may be a valuable tool to consider for patient stratification prior to surgery, which has the potential to improve clinical pathway assignment, patient optimization, and discharge planning in revision TJA in patients living in areas of socioeconomic deprivation.
Authors’ contributions
All authors contributed to the study conception and design. Michelle Riyo Shimizu [Methodology, Resources, Writing-original draft preparation, Writing-review and editing]; Tony Lin-Wei Chen [Formal analysis and investigation, Writing-original draft preparation]; Anirudh Buddhiraju [Methodology, Writing-original draft preparation]; Blake Bacevich [Data collection, Formal analysis and investigation]; Ziwei Huang [Data collection, Formal analysis and investigation]; Young-Min Kwon [Writing-review and editing, Supervision]. All authors have reviewed and approved the final article.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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