Abstract
Purpose
Provided that total hip arthroplasties (THA) are some of the most common surgical procedures performed, there is a necessity to understand all factors that contribute to risks of adverse outcomes postoperatively and to find solutions to avoid these events with preventive measures. This retrospective cohort study sought to assess differences in (1) postoperative complication rates, (2) readmission rates and reasons, and (3) demographic variables that contribute to readmissions based on discharge destination within the first 30 days after a THA.
Methods
Patients undergoing THA (27130) between 2015 and 2020 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database based on procedural codes. Propensity score matching was then employed to reduce selection bias, and Chi-square tests and one-way analysis of variance (ANOVA) were performed. Multivariable analysis was then used to look for other factors associated with readmission risk.
Results
219,960 patients were identified with 189,841 discharged to home, 19,355 to a skilled nursing facility (SNF), and 10,764 to a rehabilitation facility. The rehabilitation and SNF cohorts both had greater rates of readmission (4.56 % home vs. 6.88 % SNF vs. 6.90 % rehabilitation, P<0.001) and any adverse event (AAE, 9.02 % vs. 18 % vs. 21.3 %, P<0.001) after matching. Older age, longer operative time, American Society of Anesthesiologists (ASA) classification four, chronic obstructive pulmonary disease (COPD), bleeding disorders, steroid use, and smoking were associated with an increased risk of readmission after THA.
Conclusion
Overall, THAs were shown to have low postoperative complications and readmissions in all patient populations despite differences in discharge destination which continues to demonstrate the safety and validity of this often elective procedure. However, the statistically significant risk of complications and readmissions in addition to the higher costs associated should be accounted for when considering patient discharges to a non-home facility.
Keywords: “Total hip arthroplasty”, “NSQIP”, “Discharge destination”, “Postoperative readmissions”
1. Introduction
Total hip arthroplasty (THA) is a common orthopaedic procedure performed in the United States that has been rapidly increasing in popularity with the aging global population.1,2 Additionally, multiple studies have demonstrated the short-term readmission rate for THA to be over 5 % and is often due to surgical (infection, joint dislocation, periprosthetic fracture, etc) or nonsurgical complications (thromboembolic event, etc).3, 4, 5 Similarly, Yakkanti et al. have reported various complication rates following unilateral and bilateral hip replacement. For example, the authors found that postoperative urinary retention occurred in about 2 % of patients, respiratory complications in approximately 1 %, and renal failure in over 1 %.6 Considering the prevalence of hip arthroplasty and related complications in the U.S., it is vital to patient care and costs to understand risk factors associated with such adverse events. Relevant factors could be preoperative, intraoperative, or postoperative in nature.
Multiple studies in the existing literature explore associations with postoperative discharge destination. One study by Riveros et al. found that surgical patients across multiple specialties were at a significantly higher risk of unplanned readmission within 30 days if they were discharged to a non-home destination.7 Such patients also had higher mortality and were significantly more likely to present with infection, pulmonary complications, bleeding requiring transfusion, and thromboembolism.7 Similarly, Pasqualani et al. found that patients undergoing THA were significantly more likely to be readmitted both 30 and 90 days after discharge to a skilled nursing facility (SNF) compared to home discharge.8 Patient costs have also been demonstrated to be significantly higher with discharge to rehabilitation facilities versus to home or SNFs.9
While all of these studies contribute to our knowledge of risks impairing postoperative recovery, there is a scarcity of data available detailing specific reasons for readmission by category of discharge destination. Therefore, we sought to conduct a thorough analysis to determine if recovery site (home, nursing facility, or rehabilitation program) was associated with certain causes of readmission after THA. Two prior studies have utilized the National Surgery Quality Improvement Program (NSQIP) to look at complication rates by discharge destination.10,11 However, both of these studies include patients prior to our window of 2015–2020 which incorporates the time period for mass implementation of Medicare bundle programs.12 Additionally, they did not perform a matched analysis and did not closely examine the reasons behind unplanned readmissions as this study does.
This study primarily aimed to (1) assess differences in postoperative complication rates, (2) look at differences in readmission rates and reasons, and (3) account for demographic differences that contribute to readmissions based on discharge destination within the first 30 days after surgery. Our specific interest was in examining the implications of a non-home discharge after THA.
2. Methods
The American College of Surgeons (ACS) NSQIP database was utilized to identify patients. The NSQIP database is a national database which collects surgical data from several participating institutions in the United States, with 685 institutions participating in the most recent iteration (2021).13 Relevant variables include demographics, preoperative comorbidities, operative variables, and early postoperative complications. Thirty days of postoperative data is included in the database. Random audits are performed to ensure accuracy of the data reported, and inter-rater disagreement rates have been found to be only 2 %.14,15
Patients who underwent total hip arthroplasty between 2015 and 2020 were identified using Current Procedural Terminology (CPT) code 27,130. Cases were excluded if they did not have data regarding operative time, functional status, sex, days from hospital admission to operation, total hospitalization time, body mass index (BMI), anesthesia, American Society of Anesthesiologists (ASA) classification, or history of dyspnea to ensure cases had sufficient demographic data for propensity score matching. Cases were additionally excluded if they did not have data regarding discharge destination, as this was the primary variable investigated in this study. Cases were then classified into one of three groups: discharge to home or permanent residence, discharge to a skilled nursing facility (SNF), or discharge to a rehabilitation center. Once the three cohorts were established, preoperative characteristics and outcome data were collected for each patient. Reasons for readmission were collected for patients who were readmitted to the hospital within 30 postoperative days.
A random subset of 5000 patients from the smallest cohort, the rehabilitation center discharge cohort, was created. This was done in order to maximize the strength of propensity score matching. The cohorts then underwent 1:1 propensity match using the nearest neighbor method. Cohorts were matched based on age, BMI, sex, race, ASA classification, functional status, smoking status, preoperative steroid use, and history of diabetes, hypertension, congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), and bleeding disorder.
RStudio software version 2023.06.1 + 524 (R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. To compare baseline demographics, complication rates, and readmission rates between cohorts, ANOVA was used for continuous variables and the Chi-squared analysis was used for categorical variables and binary variables. Multivariable logistic regression analysis was used to identify risk or protective factors for readmission based on demographics. P<0.05 was used as the benchmark for statistical significance throughout our analyses.
3. Results
3.1. Demographics
Between 2015 and 2020, 219,960 patients were identified to have undergone THA with 189,841 patients discharged to home, 19,355 to a SNF, and 10,764 to a rehabilitation facility. After 1:1 propensity score matching, 5000 patients were included in each cohort to provide the strongest match while maintaining the largest sample size possible.
Prior to matching, every demographic variable differed significantly between the three groups. After matching, the rehabilitation cohort had significantly longer operative times (P<0.001), longer length of stay (LOS, P<0.001), fewer individuals with outpatient status (P<0.001), and higher morbidity probabilities (P<0.001) than the SNF and home cohorts. The SNF cohort had significantly higher mortality probabilities (P<0.001) compared to the home and rehabilitation cohorts. In terms of comorbidities, the rehabilitation cohort demonstrated higher rates of individuals on dialysis (P<0.001) and with dyspnea on exertion (DOE, P<0.001). Both the SNF and rehabilitation cohorts had significantly higher rates of preoperative weight loss (p<0.001) and transfusion (P<0.001) compared to a home discharge destination. Further demographic information is outlined in Table 1.
Table 1.
Demographic and comorbidity characteristics for patients undergoing total hip arthroplasty by discharge destination.
| Home Unmatched (%) | Skilled Facility Unmatched (%) | Rehab Unmatched (%) | p-value | Home Matched (%) | Skilled Facility Matched (%) | Rehab Matched (%) | p-value | |
|---|---|---|---|---|---|---|---|---|
| Patients, N (%) | 189,841 (86.3) | 19,355 (8.80) | 10,764 (4.89) | – | 5000 (33.3) | 5000 (33.3) | 5000 (33.3) | – |
| Age (years, mean ± SD) | 64.4 ± 11.0 | 72.7 ± 10.7 | 71.5 ± 11.7 | <0.001 | 71.5 ± 10.1 | 71.3 ± 11.3 | 71.5 ± 11.7 | 0.431 |
| BMI (kg/m2, mean ± SD) | 30.2 ± 6.16 | 30.0 ± 6.99 | 30.2 ± 7.39 | <0.001 | 29.9 ± 6.38 | 30.2 ± 7.02 | 30.0 ± 7.21 | 0.110 |
| Male sex (%) | 89,759 (47.3) | 6038 (31.2) | 3707 (34.4) | <0.001 | 1737 (34.7) | 1730 (34.6) | 1747 (34.9) | 0.938 |
| Operative Time (mins) | 89.8 ± 36.5 | 98.8 ± 43.8 | 102 ± 53.3 | <0.001 | 88.4 ± 34.1 | 100 ± 45.4 | 102 ± 53.8 | <0.001 |
| Length of Stay | 1.87 ± 1.99 | 3.84 ± 2.89 | 4.46 ± 4.37 | <0.001 | 2.18 ± 2.30 | 4.02 ± 3.58 | 4.45 ± 4.55 | <0.001 |
| Outpatient status | 17,091 (9.00) | 302 (1.56) | 147 (1.37) | <0.001 | 420 (8.40) | 91 (1.82) | 73 (1.46) | <0.001 |
| ASA Class | 2.39 ± 0.588 | 2.73 ± 0.561 | 2.74 ± 0.583 | <0.001 | 2.74 ± 0.583 | 2.73 ± 0.575 | 2.75 ± 0.584 | 0.260 |
| 1 (no disturbance) | 7375 (3.88) | 129 (0.666) | 86 (0.799) | – | 46 (0.920) | 44 (0.880) | 37 (7.40) | – |
| 2 (mild disturbance) | 103,925 (54.7) | 6021 (31.1) | 3298 (30.6) | – | 1537 (30.7) | 1562 (31.2) | 1539 (30.8) | – |
| 3 (severe disturbance) | 75,708 (39.9) | 12,221 (63.1) | 6665 (61.9) | – | 3103 (62.1) | 3113 (62.3) | 3083 (61.7) | – |
| 4 (life-threatening disturbance) | 2825 (1.49) | 980 (5.06) | 713 (6.62) | – | 312 (6.24) | 279 (5.58) | 341 (6.82) | – |
| 5 (moribund) | 8 (0.00421) | 4 (0.0207) | 2 (0.0186) | – | 2 (0.0400) | 2 (0.0400) | 0 | – |
| Race | ||||||||
| White | 133,837 (70.5) | 15,908 (82.2) | 7337 (68.2) | – | 3509 (70.2) | 3436 (68.7) | 3424 (68.5) | – |
| Black | 14,405 (7.59) | 1966 (10.2) | 1369 (12.7) | – | 626 (12.5) | 635 (12.7) | 644 (12.9) | – |
| Asian | 2827 (1.49) | 309 (1.60) | 211 (1.96) | – | 103 (2.06) | 104 (2.08) | 101 (2.02) | – |
| Other | 1381 (0.727) | 80 (0.413) | 38 (0.353) | – | 15 (0.300) | 8 (0.160) | 13 (0.260) | – |
| Unknown | 37,391 (19.7) | 1092 (5.64) | 1809 (16.8) | – | 747 (14.9) | 817 (16.3) | 818 (16.4) | – |
| Morbidity Probability | 0.0258 ± 0.0103 | 0.0354 ± 0.0166 | 0.0361 ± 0.0171 | <0.001 | 0.0330 ± 0.0154 | 0.0354 ± 0.0176 | 0.0361 ± 0.0172 | <0.001 |
| Mortality Probability | 1.39e−3±2.08e−3 | 4.33e−3±8.40e−3 | 4.26e−3±8.05e−3 | <0.001 | 3.08e−3±5.25e−3 | 4.29e−3±9.62e−3 | 4.26e−3±7.65e−3 | <0.001 |
| Dependent functional status (partial or total) | 1977 (10.4) | 1191 (6.15) | 676 (6.28) | <0.001 | 322 (6.44) | 330 (6.60) | 323 (6.46) | 0.939 |
| Current smoker | 23,502 (12.4) | 2253 (11.6) | 1295 (12.0) | 8.02e−3 | 610 (12.2) | 628 (12.6) | 618 (12.4) | 0.861 |
| Comorbidities N (%) | ||||||||
| Congestive heart failure | 499 (0.263) | 215 (1.11) | 132 (1.23) | <0.001 | 56 (1.12) | 64 (1.28) | 62 (1.24) | 0.749 |
| Renal Failure | 75 (0.0395) | 38 (0.196) | 20 (0.186) | <0.001 | 5 (0.100) | 6 (0.120) | 10 (0.200) | 0.367 |
| Dialysis | 294 (0.155) | 141 (0.728) | 98 (0.910) | <0.001 | 12 (0.240) | 39 (0.780) | 42 (0.840) | <0.001 |
| Steroid use | 6553 (3.45) | 1070 (5.53) | 565 (5.25) | <0.001 | 265 (5.30) | 244 (4.88) | 250 (5.00) | 0.614 |
| Weight loss | 313 (0.165) | 113 (0.584) | 68 (0.632) | <0.001 | 10 (0.200) | 35 (0.700) | 30 (0.600) | <0.001 |
| Bleeding disorder | 3131 (1.65) | 947 (4.89) | 513 (4.77) | <0.001 | 272 (5.44) | 246 (4.92) | 248 (4.96) | 0.422 |
| Ascites | 26 (0.0137) | 11 (0.0568) | 9 (0.0836) | <0.001 | 1 (0.0200) | 4 (0.0800) | 6 (0.120) | 0.178 |
| Preoperative transfusion | 157 (0.0827) | 111 (0.573) | 74 (0.687) | <0.001 | 5 (0.100) | 35 (0.700) | 35 (0.700) | <0.001 |
| Diabetes | 21,489 (11.3) | 3527 (18.2) | 2032 (18.9) | <0.001 | 911 (18.2) | 990 (19.8) | 949 (19.0) | 0.132 |
| IDDM | 4732 (2.49) | 1084 (5.60) | 612 (5.69) | – | 266 (5.32) | 295 (5.90) | 286 (5.72) | – |
| NIDDM | 16,757 (8.83) | 2443 (12.6) | 1420 (13.2) | – | 645 (12.9) | 695 (13.9) | 663 (13.3) | – |
| DOE | 7224 (3.81) | 1564 (8.08) | 908 (8.44) | <0.001 | 361 (7.22) | 367 (7.34) | 426 (8.52) | 0.0264 |
| COPD | 6107 (3.22) | 1573 (8.13) | 794 (7.38) | <0.001 | 346 (6.92) | 323 (6.46) | 360 (7.20) | 0.335 |
BMI: body mass index; COPD: chronic obstructive pulmonary disease; DOE: dyspnea on exertion; Dialysis: acute or chronic renal failure requiring dialysis within 2 weeks of indexed procedure; IDDM: insulin-dependent diabetes mellitus; NIDDM: non-insulin-dependent diabetes mellitus.
3.2. Short-term complications
In the unmatched analysis of short-term complications, all analyzed variables were found to be significantly different between the three groups. After matching, the rehabilitation and SNF cohorts both had significantly greater rates of readmission (6.9 % vs. 6.88 % vs. 4.56 % for rehabilitation, SNF, and home respectively, P<0.001), any adverse event (AAE, 21.3 % vs. 18 % vs. 9.02 %, p<0.001), postoperative transfusion (13 % vs. 10.7 % vs. 4.14 %, P<0.001), urinary tract infections (UTI, 2.06 % vs. 1.70 % vs. 0.96 %, P<0.001), surgical site infections (SSI, 2.14 % vs. 1.88 % vs. 1.46 %, P = 0.04), return to the operating room (4.18 % vs. 3.72 % vs. 2.2 %, P<0.001), and extended LOS (27.9 % vs. 22.8 % vs. 6.7 %, P<0.001) compared to discharges to home. The rehabilitation group had significantly higher rates of pulmonary embolism (0.9 % vs. 0.4 % vs. 0.26 %, P<0.001), stroke (0.56 % vs. 0.1 % vs. 0.16 %, P<0.001), and deep vein thrombosis (DVT, 1.1 % vs. 0.58 % vs. 0.44 %, P<0.001) compared to patients discharged to SNF or home. Finally, the SNF cohort continued to demonstrate significantly higher rates of sepsis (0.84 % vs. 0.66 % vs. 0.26 %, P<0.001), pneumonia (1.32 % vs. 0.82 % vs. 0.3 %, P<0.001), and unplanned intubation (0.44 % vs. 0.32 % vs. 0.14 %, P = 0.02) compared to discharges to rehabilitation facilities and home respectively. Further complication outcomes are shown in Table 2.
Table 2.
Incidence of adverse events for patients undergoing total hip arthroplasty by discharge destination.
| Home Unmatched |
Skilled Facility Unmatched |
Rehab Unmatched |
Home Matched |
Skilled Facility Matched |
Rehab Matched |
Overall Matched |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No | Rate (%) | No | Rate (%) | No | Rate | p-value | No | Rate (%) | No | Rate (%) | No | Rate (%) | p-value | No | Rate (%) | |
| Any adverse event | 11,361 | 5.98 | 3559 | 18.4 | 2260 | 21.0 | <0.001 | 451 | 9.02 | 902 | 18.0 | 1064 | 21.3 | <0.001 | 2417 | 16.1 |
| Death | 117 | 0.0616 | 90 | 0.465 | 47 | 0.437 | <0.001 | 15 | 0.300 | 26 | 0.520 | 21 | 0.420 | 0.229 | 62 | 0.413 |
| Wound dehiscence | 242 | 0.127 | 50 | 0.258 | 14 | 0.130 | <0.001 | 13 | 0.260 | 13 | 0.260 | 7 | 0.140 | 0.335 | 35 | 0.233 |
| Sepsis | 376 | 0.198 | 144 | 0.744 | 66 | 0.613 | <0.001 | 13 | 0.260 | 42 | 0.840 | 33 | 0.660 | <0.001 | 88 | 0.587 |
| Pulmonary embolism | 393 | 0.207 | 89 | 0.460 | 70 | 0.650 | <0.001 | 13 | 0.260 | 20 | 0.400 | 45 | 0.900 | <0.001 | 78 | 0.520 |
| Renal complication | 150 | 0.0790 | 68 | 0.351 | 50 | 0.465 | <0.001 | 11 | 0.220 | 18 | 0.360 | 22 | 0.440 | 0.161 | 51 | 0.340 |
| Myocardial infarction | 281 | 0.148 | 110 | 0.568 | 76 | 0.706 | <0.001 | 16 | 0.320 | 22 | 0.440 | 30 | 0.600 | 0.112 | 68 | 0.453 |
| Cardiac arrest | 64 | 0.0337 | 33 | 0.170 | 17 | 0.158 | <0.001 | 6 | 0.120 | 11 | 0.220 | 6 | 0.120 | 0.337 | 23 | 0.153 |
| Stroke | 83 | 0.0437 | 41 | 0.212 | 55 | 0.511 | <0.001 | 8 | 0.160 | 5 | 0.100 | 28 | 0.560 | <0.001 | 41 | 0.273 |
| Transfusion | 5063 | 2.67 | 2133 | 11.0 | 1406 | 13.1 | <0.001 | 207 | 4.14 | 535 | 10.7 | 649 | 13.0 | <0.001 | 1391 | 9.27 |
| DVT | 535 | 0.282 | 139 | 0.718 | 106 | 0.985 | <0.001 | 22 | 0.440 | 29 | 0.580 | 55 | 1.10 | <0.001 | 106 | 0.707 |
| UTI | 1201 | 0.633 | 313 | 1.62 | 228 | 2.12 | <0.001 | 48 | 0.960 | 85 | 1.70 | 103 | 2.06 | <0.001 | 236 | 1.57 |
| Pneumonia | 326 | 0.172 | 216 | 1.12 | 96 | 0.892 | <0.001 | 15 | 0.300 | 66 | 1.32 | 41 | 0.820 | <0.001 | 122 | 0.813 |
| Intubation issues | 124 | 0.0653 | 80 | 0.413 | 35 | 0.325 | <0.001 | 7 | 0.140 | 22 | 0.440 | 16 | 0.320 | 0.0221 | 45 | 0.300 |
| SSI | 2027 | 1.68 | 365 | 1.89 | 216 | 2.01 | <0.001 | 73 | 1.46 | 94 | 1.88 | 107 | 2.14 | 0.0375 | 274 | 1.83 |
| Return to the OR | 2945 | 1.55 | 713 | 3.68 | 418 | 3.88 | <0.001 | 110 | 2.20 | 186 | 3.72 | 209 | 4.18 | <0.001 | 505 | 3.37 |
| Extended LOS | 7276 | 3.83 | 4064 | 21.0 | 3034 | 28.2 | <0.001 | 335 | 6.70 | 1141 | 22.8 | 1395 | 27.9 | <0.001 | 2871 | 19.1 |
| Readmission | 5254 | 2.77 | 1373 | 7.09 | 693 | 6.44 | <0.001 | 228 | 4.56 | 344 | 6.88 | 345 | 6.90 | <0.001 | 917 | 6.11 |
Any adverse event (AAE): superficial and deep surgical site infection, organ space infection, wound dehiscence, renal complication, intubation (fail to wean or reintubation), post-operative transfusion, pneumonia, DVT, PE, UTI, stroke, cardiac arrest, MI, return to the OR, death; DVT: deep vein thrombosis; UTI: urinary tract infection; SSI: surgical site infection; LOS: Length of stay (extended: greater than 1 standard deviation above the mean); OR: operating room; Intubation issues: re-intubation or failure to wean from intubation; Renal complication: progressive renal insufficiency or renal failure.
3.3. Readmissions
Amongst the three unmatched cohorts, patients discharged to rehabilitation centers or SNFs tended to have significantly higher rates of readmission for a multitude of reasons. After propensity score matching, the rehabilitation cohort continued to demonstrate significantly higher rates of readmission for altered mental status (0.18 % vs. 0.04 % vs. 0.04 %, P = 0.02) and falls (0.1 % vs. 0.02 % vs. 0 %, P = 0.02) compared to the SNF and home cohorts respectively. Both the rehabilitation and SNF discharge groups showed greater rates of readmission for renal complications (0.14 % vs. 0.12 % vs. 0 %, P = 0.04) and dislocations of a hip prosthesis (0.4 % vs. 0.36 % vs. 0.12 %, P = 0.02) compared to the home discharge group. Finally, patients discharged to a SNF persisted in demonstrating higher rates of readmission for pulmonary embolism (0.24 % vs. 0.06 % vs. 0.1 %, P = 0.03), pneumonia (0.34 % vs. 0.14 % vs. 0.1 %, P = 0.01), SSI (1.26 % vs. 1.02 % vs. 0.72 %, P = 0.02), and fever (0.08 % vs. 0 % vs. 0 %, P = 0.02). Further information on readmission reasons is found in Table 3.
Table 3.
Reason for readmission for patients undergoing total hip arthroplasty by discharge destination.
| Home Unmatched |
Skilled Facility Unmatched |
Rehab Unmatched |
Home Matched |
Skilled Facility Matched |
Rehab Matched |
Overall Matched |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No | Rate (%) | No | Rate (%) | No | Rate | p-value | No | Rate (%) | No | Rate (%) | No | Rate (%) | p-value | No | Rate (%) | |
| Wound dehiscence | 103 | 0.0543 | 26 | 0.134 | 6 | 0.0557 | <0.001 | 1 | 0.0200 | 4 | 0.0800 | 4 | 0.0800 | 0.377 | 9 | 0.0600 |
| Sepsis | 131 | 0.0690 | 51 | 0.263 | 18 | 0.167 | <0.001 | 8 | 0.160 | 13 | 0.260 | 7 | 0.140 | 0.330 | 28 | 0.187 |
| Pulmonary embolism | 175 | 0.0922 | 25 | 0.129 | 15 | 0.139 | 0.107 | 5 | 0.100 | 12 | 0.240 | 3 | 0.0600 | 0.0349 | 20 | 0.133 |
| Renal complication | 60 | 0.0316 | 24 | 0.124 | 13 | 0.121 | <0.001 | 0 | 0 | 6 | 0.120 | 7 | 0.140 | 0.0365 | 13 | 0.0867 |
| Myocardial infarction | 80 | 0.0421 | 18 | 0.0930 | 9 | 0.0836 | 2.25e−3 | 5 | 0.100 | 4 | 0.0800 | 5 | 0.100 | 0.931 | 14 | 0.0933 |
| Cardiac arrest | 5 | 2.63e−3 | 0 | 0 | 1 | 9.29e−3 | 0.327 | 0 | 0 | 1 | 0.0200 | 0 | 0 | 0.368 | 1 | 6.67e−3 |
| Stroke | 50 | 0.0263 | 14 | 0.0723 | 12 | 0.111 | <0.001 | 4 | 0.0800 | 3 | 0.0600 | 7 | 0.140 | 0.395 | 14 | 0.0933 |
| Transfusion | 8 | 4.21e−3 | 6 | 0.0310 | 2 | 0.0186 | <0.001 | 0 | 0 | 1 | 0.0200 | 2 | 0.0400 | 0.368 | 3 | 0.0200 |
| DVT | 73 | 0.0385 | 17 | 0.0878 | 9 | 0.0836 | 1.31e−3 | 6 | 0.120 | 3 | 0.0600 | 5 | 0.100 | 0.606 | 14 | 0.0933 |
| UTI | 93 | 0.0490 | 37 | 0.191 | 13 | 0.121 | <0.001 | 5 | 0.100 | 11 | 0.220 | 7 | 0.140 | 0.295 | 23 | 0.153 |
| Pneumonia | 104 | 0.0548 | 60 | 0.310 | 22 | 0.204 | <0.001 | 5 | 0.100 | 17 | 0.340 | 7 | 0.140 | 0.0138 | 29 | 0.193 |
| Electrolyte Abnormalities | 27 | 0.0142 | 14 | 0.0723 | 5 | 0.0465 | <0.001 | 4 | 0.0800 | 4 | 0.0800 | 3 | 0.0600 | 0.913 | 11 | 0.0733 |
| SSI |
929 |
0.489 |
211 |
1.09 |
105 |
0.975 |
<0.001 |
36 |
0.720 |
63 |
1.26 |
51 |
1.02 |
0.0248 |
150 |
1.00 |
| C. diff |
27 |
0.0142 |
14 |
0.0723 |
2 |
0.0186 |
<0.001 |
2 |
0.0400 |
5 |
0.100 |
0 |
0 |
0.0662 |
7 |
0.0467 |
| Meningitis/Encephalopathy |
20 |
0.0105 |
11 |
0.0568 |
4 |
0.0372 |
<0.001 |
1 |
0.0200 |
1 |
0.0200 |
2 |
0.0400 |
0.779 |
4 |
0.0267 |
| Fever |
38 |
0.0200 |
11 |
0.0568 |
4 |
0.0372 |
4.78e−3 |
0 |
0 |
4 |
0.0800 |
0 |
0 |
0.0183 |
4 |
0.0267 |
| Anemia |
63 |
0.0332 |
21 |
0.108 |
20 |
0.186 |
<0.001 |
7 |
0.140 |
6 |
0.120 |
4 |
0.0800 |
0.662 |
17 |
0.113 |
| Diabetic Complications |
6 |
3.16e−3 |
3 |
0.0155 |
0 |
0 |
0.0302 |
2 |
0.0400 |
1 |
0.0200 |
0 |
0 |
0.368 |
3 |
0.0200 |
| Pain |
173 |
0.0911 |
17 |
0.0878 |
13 |
0.121 |
0.602 |
11 |
0.220 |
4 |
0.0800 |
9 |
0.180 |
0.196 |
24 |
0.160 |
| Femur/Pelvic Fracture |
217 |
0.114 |
59 |
0.305 |
24 |
0.223 |
<0.001 |
9 |
0.180 |
11 |
0.220 |
10 |
0.200 |
0.905 |
30 |
0.200 |
| Hip/Thigh Contusion |
19 |
0.0100 |
4 |
0.0207 |
3 |
0.0279 |
0.125 |
2 |
0.0400 |
2 |
0.0400 |
2 |
0.0400 |
1.00 |
6 |
0.0400 |
| Hip Dislocation | 62 | 0.0326 | 15 | 0.0775 | 8 | 0.0743 | 1.60e−3 | 3 | 0.0600 | 4 | 0.0800 | 5 | 0.100 | 0.779 | 12 | 0.0800 |
| Hemorrhage/Hematoma/Seroma |
120 |
0.0632 |
28 |
0.145 |
11 |
0.102 |
<0.001 |
3 |
0.0600 |
8 |
0.160 |
5 |
0.100 |
0.305 |
16 |
0.107 |
| Hip Periprosthetic Fracture |
266 |
0.140 |
40 |
0.207 |
31 |
0.288 |
<0.001 |
5 |
0.100 |
8 |
0.160 |
13 |
0.260 |
0.151 |
26 |
0.173 |
| Unspecified Periprosthetic Fracture |
65 |
0.0342 |
15 |
0.0775 |
5 |
0.0465 |
0.0130 |
5 |
0.100 |
3 |
0.0600 |
1 |
0.0200 |
0.263 |
9 |
0.0600 |
| Broken Hip Prosthesis |
7 |
3.69e−3 |
1 |
5.17e−3 |
1 |
9.29e−3 |
0.657 |
0 |
0 |
1 |
0.0200 |
1 |
0.0200 |
0.607 |
2 |
0.0133 |
| Dislocated Hip Prosthesis |
243 |
0.128 |
65 |
0.336 |
34 |
0.316 |
<0.001 |
6 |
0.120 |
18 |
0.360 |
20 |
0.400 |
0.0198 |
44 |
0.293 |
| Dislocated Unspecified Prosthesis | 26 | 0.0137 | 12 | 0.0620 | 7 | 0.0650 | <0.001 | 2 | 0.0400 | 5 | 0.100 | 3 | 0.0600 | 0.496 | 10 | 0.0667 |
| Mechanical Loosening Hip Prosthesis | 22 | 0.0116 | 2 | 0.0103 | 5 | 0.0465 | 8.56e−3 | 1 | 0.0200 | 0 | 0 | 0 | 0 | 0.368 | 1 | 6.67e−3 |
| Other Hip Mechanical Complication | 13 | 6.85e−3 | 6 | 0.0310 | 1 | 9.29e−3 | 3.57e−3 | 0 | 0 | 2 | 0.0400 | 0 | 0 | 0.135 | 2 | 0.0133 |
| Other Unspecified Mechanical Complication | 7 | 3.69e−3 | 8 | 0.0413 | 2 | 0.0186 | <0.001 | 0 | 0 | 1 | 0.0200 | 3 | 0.0600 | 0.174 | 4 | 0.0267 |
| AMS | 41 | 0.0216 | 16 | 0.0827 | 11 | 0.102 | <0.001 | 2 | 0.0400 | 2 | 0.0400 | 9 | 0.180 | 0.0230 | 13 | 0.0867 |
| Hypotension | 21 | 0.0106 | 6 | 0.0310 | 3 | 0.0279 | 0.0334 | 3 | 0.0600 | 0 | 0 | 1 | 0.0200 | 0.174 | 4 | 0.0267 |
| Intestinal Obstruction/Constipation | 92 | 0.0485 | 24 | 0.124 | 13 | 0.121 | <0.001 | 3 | 0.0600 | 8 | 0.160 | 3 | 0.0600 | 0.167 | 14 | 0.0933 |
| Cellulitis of LE | 69 | 0.0363 | 20 | 0.103 | 11 | 0.102 | <0.001 | 1 | 0.0200 | 2 | 0.0400 | 3 | 0.0600 | 0.600 | 6 | 0.0400 |
| Weakness |
19 |
0.0100 |
3 |
0.0155 |
1 |
9.29e−3 |
0.771 |
2 |
0.0400 |
0 |
0 |
1 |
0.0200 |
0.368 |
3 |
0.0200 |
| Edema |
10 |
5.27e−3 |
1 |
5.17e−3 |
1 |
9.29e−3 |
0.858 |
1 |
0.0200 |
0 |
0 |
0 |
0 |
0.368 |
1 |
6.67e−3 |
| ARD |
16 |
8.43e−3 |
8 |
0.0413 |
6 |
0.0557 |
<0.001 |
2 |
0.0400 |
4 |
0.0800 |
2 |
0.0400 |
0.606 |
8 |
0.0533 |
| Walking Abnormalities |
13 |
6.85e−3 |
3 |
0.0155 |
1 |
9.29e−3 |
0.420 |
0 |
0 |
1 |
0.0200 |
3 |
0.0600 |
0.174 |
4 |
0.0267 |
| Fall |
26 |
0.0137 |
6 |
0.0310 |
7 |
0.0650 |
<0.001 |
0 |
0 |
1 |
0.0200 |
5 |
0.100 |
0.0302 |
6 |
0.0400 |
| Postoperative Care |
24 |
0.0126 |
4 |
0.0207 |
1 |
9.29e−3 |
0.610 |
1 |
0.0200 |
3 |
0.0600 |
0 |
0 |
0.174 |
4 |
0.0267 |
| Other Complication | 38 | 0.0200 | 10 | 0.0517 | 4 | 0.0372 | 0.0156 | 1 | 0.0200 | 2 | 0.0400 | 3 | 0.0600 | 0.606 | 6 | 0.0400 |
DVT: deep vein thrombosis; UTI: urinary tract infection; SSI: surgical site infection; Intubation issues: unplanned intubation; Renal complication: progressive renal insufficiency or acute renal failure; Transfusion: bleeding requiring transfusion; C. diff: Clostridium difficile infection; AMS: altered mental status; Cellulitis of LE: cellulitis of lower extremity; ARD: acute respiratory distress.
3.4. Multivariable analysis for readmission
After accounting for all other variables, older age (odds ratio [OR]: 1.00, 95 % confidence interval [CI]: 1.00–1.00), longer operative time (OR: 1.00, 95 % CI: 1.00–1.00), ASA classification of 4 (OR: 1.09, 95 % CI: 1.04–1.14), history of COPD (OR: 1.03, 95 % CI: 1.01–1.05), history of bleeding disorder (OR: 1.03, 95 % CI: 1.02–1.05), steroid use (OR: 1.03, 95 % CI: 1.01–1.05), and smoking (OR: 1.02, 95 % CI: 1.01–1.03) were all associated with an increased risk of readmission (Table 4).
Table 4.
Odds of readmission after total hip arthroplasty as related to patient demographics, comorbidities, and procedure.
| Multivariable Analysisa |
|||
|---|---|---|---|
| OR Coef. | 95 % CI | P-value | |
| Overall |
0.918 |
0.867–0.972 |
0.00332 |
| Age (1-year intervals) | 1.00 | 1.00–1.00 | <0.001 |
| Operative Time (1 min intervals) | 1.00 | 1.00–1.00 | <0.001 |
| BMI (1 kg/m2 intervals) | 1.00 | 1.00–1.00 | 0.119 |
| Total LOS (1 day intervals) | 1.00–1.00 | 0.149 | |
| Sex | |||
| Female | Ref | – | – |
| Male | 0.994–1.01 | 0.651 | |
| ASA class | |||
| 1 | Ref | – | – |
| 2 | 1.01 | 0.972–1.06 | 0.538 |
| 3 | 1.03 | 0.989–1.08 | 0.155 |
| 4 | 1.09 | 1.04–1.14 | <0.001 |
| 5 | 1.23 | 0.970–1.56 | 0.0872 |
| Diabetes mellitus | |||
| IDDM | Ref | – | – |
| NIDDM | 0.990 | 0.971–1.01 | 0.318 |
| None | 0.987 | 0.970–1.00 | 0.117 |
| COPD | |||
| No | Ref | – | – |
| Yes | 1.03 | 1.01–1.05 | <0.001 |
| Bleeding Disorder | |||
| No | Ref | – | – |
| Yes | 1.03 | 1.02–1.05 | <0.001 |
| Steroid Use | |||
| No | Ref | – | – |
| Yes | 1.03 | 1.01–1.05 | <0.001 |
| Smoking | |||
| No | Ref | – | – |
| Yes | 1.02 | 1.01–1.03 | 0.00194 |
OR: Odds Ratio; Coef: coefficient; 95 % CI: 95 % Confidence Interval; Ref: reference; BMI: body mass index; LOS: length of stay ASA: American Society of Anesthesiology; NIDDM: Non-Insulin Dependent Diabetes Mellitus; IDDM: Insulin-Dependent Diabetes Mellitus.
Variables are adjusted for all baseline characteristics; Reference discharge destination: Home.
4. Discussion
Overall, patients discharged to non-home facilities tended to be older, identify as women, have a higher ASA classification, have more comorbidities, have a longer operative time, and were non-smokers. These characteristics are consistent with prior studies on THA by discharge destination that showed higher rates of comorbidities, more advanced age, female, higher ASA classification, longer operative times, and non-smokers to all be associated with discharges to non-home locations.10,11,16, 17, 18, 19 After matching and accounting for these demographic variations, the results continued to demonstrate higher rates of adverse events and unplanned readmissions with discharge to a SNF or rehabilitation center when compared to discharge to home.
Looking at 30-day postoperative complications, this study demonstrated significantly higher rates of surgical complications in discharges to non-home locations which is consistent with the majority of current literature on the subject. Similar to this study, Keswani et al. also identified higher rates of thromboembolic events following discharge to non-home facilities.11 Several other studies have shown a correlation between discharge to non-home locations and extended hospital LOS.20, 21, 22 Additionally, prior studies have identified higher rates of readmission following a THA with a discharge to non-home facilities.22, 23, 24, 25 Conversely, Shah et al. showed contradictory findings in their study as they found higher rates of unplanned readmissions and adverse events in home discharges after a THA when compared to non-home discharges.10 Furthermore, Pablo et al. reported that inpatient discharges were associated with a shorter LOS when compared to home discharges.17 Several of these researchers have attributed the higher incidence of complications in non-home discharge populations at least in part to the significantly greater prevalence of risk factors such as age and comorbidities in these groups and the higher likelihood that more severe patient cases are sent to facilities for care.10,11,16,18,19,21,23 Despite controlling for the majority of patient variables with matching, the SNF and rehabilitation cohorts still had significantly higher rates of certain comorbidities such as preoperative transfusion and DOE that cannot be ignored as possible confounders. While the results demonstrate that discharge to facility is associated with greater risk of complications, there likely is a connection between the individual patient factors that determine discharge destination and their risk of complications as well.
Along these same lines, readmission rates were found to be overall higher in non-home discharge populations with particularly higher rates of infections and accidents. As outlined above, multiple prior studies have corroborated this association between discharge to a non-home location and unplanned readmission22, 23, 24, 25 with little research showing opposite results.10 Several previous papers also correlate the risk of unplanned readmission with the medical complexity of patients who tend to be discharged to non-home care facilities.25,26 As this study corrected for multiple demographic variations between cohorts through matching, higher risk of readmission with discharge to places other than home is likely due to a combination of more factors than just medical complexity and risk factors of the individual patients. Since the match was unable to account for all variance in risk factors, the health of the patients at discharge may play a more significant role in their readmission risk than their destination. This, however, is outside of the scope of this paper, given the confines of the NSQIP database. Rahman et al. noted that the greatest risk of unplanned readmission after discharge to a SNF was related to the rehospitalization rate of that particular SNF.27 Thus, the quality of the care provided by non-home facilities and their ability to properly meet the needs of individuals with multiple complex medical issues following a THA likely factors in to the reasons behind the risk of readmission with non-home discharges. Improving the capacity of facilities to prevent postoperative complications after discharge and recommending patients to consider discharges to facilities with low readmission rates are potential strategies to consider to lower the overall unplanned readmission risk and complication rates after THA.
Given that the results of this study demonstrate significantly higher risk of readmission and short-term complications in individuals discharged to facility care after matching for demographic variations, physicians and care teams should heavily consider the risks and benefits associated with their specific discharge plan for each patient. At present, our study identified that about 86 % of patients in our subject pool were discharged to home, 9 % to SNFs, and 5 % to rehabilitation centers. Recent studies have begun to demonstrate that significantly higher costs of total joint arthroplasties are associated with discharge to non-home locations, especially in African American populations.28, 29, 30, 31 In light of the number of patients recovering in non-home facilities, the elevated risks of complications, and the drastic increase in overall cost of non-home disposition, our study supports the notion of making every effort to discharge patients to their home, especially following an elective procedure.
In addition to discharge destination, our multivariable analysis identified several other factors that impact a patient's risk of unplanned readmission after a THA, which include older age, greater operative time, ASA class 4, COPD, bleeding disorders, preoperative steroid use, and history of smoking. The relationship between more medical comorbidities like COPD and bleeding disorders corresponds with findings of prior studies on readmissions after THA.25,26 Tayne et al. similarly found high ASA classifications and longer operative times to be associated with increased risk of unplanned readmission.19 However, unlike Tayne et al.,19 the present results do not support an association between identifying as a woman and risk of readmission.
Though this study has identified statistically significant results in looking at complications and readmissions after THA, it is not without limitations. As NSQIP has a limited amount of postoperative complications specifically reported in their databases, this study was unable to account for some complications of interest such as fractures, dislocations, and hematomas/seromas prior to discharge. Similarly, reported rates of readmission reasons relied on the accuracy of the international classification of diseases (ICD) codes provided for each patient. Lastly, this study could only account for readmissions and complications within the first 30 days of the postoperative period given that this is the allotted time frame used by the NSQIP database. However, Ali et al. found that the 30-day readmission rate is an adequate representation of the overall readmissions rate after THA, as more than 75 % of unplanned readmissions occur within the first 30 days after surgery.3 Additionally, Ramkumar et al. found that the rate of readmissions after THA only increased from 5.6 % at 30 days to 7.7 % at 90 days.4 Thus, the short-term window of 30 days after THA likely provides an appropriate and valid look at the reasons for and risks of readmission in this patient population.
5. Conclusion
In general, this study demonstrates that THA overall has a very low risk of postoperative complications and unplanned readmissions regardless of discharge destination. As an often elective procedure, THA is a valid and safe option to alleviate significant hip pain and disability in the vast majority of patients. However, the statistically significant differences in readmissions and postoperative complications by discharge destination identify considerations that physicians and patients should account for prior to selecting a postoperative discharge to non-home destination. Additionally, this study contributes to current discussions surrounding the balance between high costs and medical benefits of discharges to destinations other than home by showing higher overall complications despite factoring in the majority of differences in patient demographics. However, the role of patient health and wellbeing likely still has a role in the difference in outcomes by discharge destination that interplays with additional social and environmental factors to worsen patient outcomes in facilities. Overall, home discharge is a safe option for patients and should be considered for all patients after a THA.
Ethical statement
No data was derived from unethically sourced materials. All procedures were performed in compliance with relevant laws and institutional guidelines.
Funding statement
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Guardian consent
Informed consent was not required from any study participants as all data was de-identified prior to any research activities. Additionally, no minors were included in this study.
CRediT authorship contribution statement
Sarah Cole: Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Visualization. Maria Peri: Resources, Writing – original draft. Sarah Whitaker: Resources, Writing – original draft. Brady Ernst: Conceptualization, Validation, Writing – review & editing, Supervision. Conor O'Neill: Methodology, Validation, Writing – review & editing, Supervision. James Satalich: Validation, Writing – review & editing, Supervision. Alexander Vap: Validation, Supervision.
Acknowledgement
None of the authors of this article have any acknowledgements.
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