Home Health Care Is Associated With an Increased Risk of Emergency Department Visit, Readmission, and Cost of Care Without Reducing Risk of Complication Following Total Hip Arthroplasty: A Propensity-Score Analysis

Discharge with home health services following primary total shoulder arthroplasty does not adversely affect 90-day ED visits or readmissions

PURPOSE

Discharging patients with the addition of home health services (HHS) has been postulated to reduce the risk for perioperative complications and, thereby, 90-day ED visits and readmissions following elective total shoulder arthroplasty (TSA).

METHODS

A retrospective review of primary anatomic (aTSA) and reverse shoulder arthroplasty (rTSA) cases from January 2016 through April 2024 was performed. Demographic data, including age, marital status, body mass index (BMI), smoking status, self-identified race, Area Deprivation Index (ADI) score, modified 5-item fragility index (mFI-5), and surgical indication was collected. Discharge with or without HHS, and whether a patient had access to a postoperative home health aide (HHA), were also recorded. Regression analysis was utilized to determine the association between discharge with HHS and both postoperative 90-day ED return and readmission.

RESULTS

There were 327 patients included, including 161 (49%) aTSA and 166 (51%) rTSA. A total of 121 (37%) patients were discharged with HHS, of which 49 (40%) also had access to a HHA during the postoperative period. There was no significant difference in patients who were discharged with HHS compared with those who were discharged without HHS with regards to either 90-day return to the ED (OR 1.15, 95% CI 0.58-2.30, P = 0.692) or all-cause unplanned 90-day readmissions (OR 0.79, 95% CI 0.29-2.19, P = 0.652).

CONCLUSIONS

Discharge with HHS following elective TSA, even in the setting of increased patient age and fragility, results in similar 90-day postoperative healthcare utilization compared with those discharged to self-care.

LEVEL OF EVIDENCE

Level III (Retrospective cohort).

Discharge with home health care is associated with increased complications, readmission, and mortality following total shoulder arthroplasty

BACKGROUND

Patients undergoing primary anatomic and reverse total shoulder arthroplasty (TSA) are often discharged with home health care (HHC) to provide access to at-home services and facilitate postoperative recovery and continued medical management. The purpose of this study was to evaluate the short-term postoperative outcomes of patients following primary TSA discharged with HHC, including medical and surgical complications, total cost of care, and total hospital length of stay (LOS).

METHODS

The Nationwide Readmissions Database was reviewed for patients who underwent elective primary TSA between 2016 and 2020 for a retrospective cohort analysis. Patients were stratified by discharge status following the inpatient admission, with 32,497 patients discharged with HHC and 116,402 patients discharged routinely with self-care. Patient demographics, preoperative medical comorbidities, postoperative medical and surgical complications within 180 days, cost of admission, and total hospital LOS were compared between the 2 discharge groups using χ2 analyses. Further multivariate analysis was conducted to control for independent prognosticators on the effect of HHC on postoperative outcomes.

RESULTS

Discharge with HHC was correlated with significantly increased rates of all-cause medical complications (odds ratio [OR] 1.6, P < .001), surgical site infection (SSI) (OR 2.8, P < .001), hospital readmission (OR 1.3, P < .001), and death (OR 2.1, P < .001) within 180 days of primary TSA. Multivariate analysis suggests these correlations are independent risk factors and not due to patient demographics or preoperative medical comorbidities. Although discharge with HHC was found to be associated with increased hospital LOS (1.8 vs. 1.3 days, P < .001), there were no significant observed differences in cost of care.

CONCLUSION

This study demonstrates that discharge with HHC compared with routine discharge while accounting for several preoperative comorbidities and demographic variables is associated with increased medical complications, SSI, readmission, and death within 180 days of TSA, but no increase in the overall patient cost. These findings suggest HHC disposition status can serve as a prognosticator for postoperative complications and can help guide clinician decision making when determining appropriate surgical candidacy.

Associated Risk of Medicaid and Medicare Payer Status on Outcomes Following Total Joint Arthroplasty: A 10-Year Report

BACKGROUND

This study examined the association between insurance type (Medicaid, Medicare, and private) and 90-day complications and patient-reported outcomes (PROs) following primary total joint arthroplasty (TJA).

METHODS

Data from a single health system comprised of six hospitals was queried to include patients who underwent TJA from 2013 to 2023. The cohort consisted of 65,300 TJA cases (49,936 patients), with 52.6% privately insured, 42.64% Medicare, and 4.77% Medicaid. Medicaid patients were younger, with higher body mass index, smoking rates, and preoperative opioid usage (P < 0.001). Patients were categorized by insurance type and demographic information, comorbidities, 90-day outcomes, complications, and PROs were analyzed.

RESULTS

Medicaid patients had 81.7% higher emergency department visit odds than those privately insured and 63.6% more than Medicare (P < 0.0001). Medicaid payer status was associated with 63.3% increased odds of developing deep vein thrombosis compared to private insurance (P = 0.0119). Medicaid and Medicare patients faced 24.3 and 31.1% greater readmission odds than privately insured (P < 0.0001), respectively. Medicare patients had higher odds of urinary tract infections, periprosthetic joint infections, dislocation, and fracture (P < 0.0001). Conversely, private-payer patients were less likely to take preoperative medications and had fewer 90-day postoperative complications (P < 0.0001). Medicaid patients reported the lowest preoperative and postoperative Patient Reported Outcomes Measurement Information System Mental and Physical scores, Knee Injury and Osteoarthritis Outcome Score, and Hip Injury and Osteoarthritis Outcome Score, although they exhibited the greatest improvement in Knee Injury and Osteoarthritis Outcome Score and Hip Injury and Osteoarthritis Outcome Score scores after surgery.

CONCLUSIONS

Insurance payer type is significantly associated with postoperative outcomes, with Medicaid and Medicare patients experiencing higher complication rates and lower PROs than their privately insured counterparts. These disparities underscore the necessity for tailored preoperative and postoperative management in TJA patients based on insurance status.

Dynamic Prediction of Post-Acute Care Needs for Hospitalized Medicine Patients

OBJECTIVES

Use patient demographic and clinical characteristics at admission and time-varying in-hospital measures of patient mobility to predict patient post-acute care (PAC) discharge.

DESIGN

Retrospective cohort analysis of electronic medical records.

SETTING AND PARTICIPANTS

Patients admitted to the two participating Hospitals from November 2016 through December 2019 with ≥72 hours in a general medicine service.

METHODS

Discharge location (PAC vs home) was the primary outcome, and 2 time-varying measures of patient mobility, Activity Measure for Post-Acute Care (AM-PAC) Mobility "6-clicks" and Johns Hopkins Highest Level of Mobility, were the primary predictors. Other predictors included demographic and clinical characteristics. For each day of hospitalization, we predicted discharge to PAC using the demographic and clinical characteristics and most recent mobility data within a random forest (RF) for survival, longitudinal, and multivariate (RF-SLAM) data. A regression tree for the daily predicted probabilities of discharge to PAC was constructed to represent a global summary of the RF.

RESULTS

There were 23,090 total patients and compared to PAC, those discharged home were younger (64 vs 71), had shorter length of stay (5 vs 8 days), higher AM-PAC at admission (43 vs 32), and average AM-PAC throughout hospitalization (45 vs 35). AM-PAC was the most important predictor, followed by age, and whether the patient lives alone. The area under the hospital day-specific receiver operating characteristic curve ranged from 0.76 to 0.79 during the first 5 days. The global summary tree explained 75% of the variation in predicted probabilities for PAC from the RF. Sensitivity (75%), specificity (70%), and accuracy (72%) were maximized at a PAC probability threshold of 40%.

CONCLUSIONS AND IMPLICATIONS

Daily assessment of patient mobility should be part of routine practice to help inform care planning by hospital teams. Our prediction model could be used as a valuable tool by multidisciplinary teams in the discharge planning process.