Race, Bundled Payment Policy, and Discharge Destination After TKA: The Experience of an Urban Academic Hospital

Racial disparities in post-operative complications and discharge destination following total joints arthroplasty: a national database study

INTRODUCTION

The objective of this study was to explore race-based differences in 30-day complication rates following total joint arthroplasty (TJA) using a large national database.

METHODS

Patients undergoing primary, elective THA and TKA between 2012 and 2018 were retrospectively reviewed using the ACS-NSQIP. We compared Black and Hispanic patients with non-Hispanic White patients using multivariate statistical models adjusting for demographic, operative, and medical characteristics.

RESULTS

A total of 324,795 and 200,023 patients undergoing THA and TKA, respectively, were identified. After THA, compared to White patients, Black and Hispanic patients were more likely to be diagnosed with VTE (p < 0.001), receive a blood transfusion (p < 0.001), and to be discharged to an inpatient facility (p < 0.001). After TKA, compared to White patients, Black and Hispanic patients were more likely to experience a major complication (p < 0.001 and p = 0.008, respectively), be diagnosed with VTE (p < 0.001), and be discharged to a facility (p < 0.001).

CONCLUSIONS

Our findings indicate higher rates of VTE, blood transfusions, and discharge to an inpatient facility for Black and Hispanic patients when compared to White patients following TJA, though we are unable to comment on the etiology of these disparities. These results may contribute to a growing divide with respect to outcomes and access to TJA for these at-risk patient populations.

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty, a National Registry Study

BACKGROUND

The purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry.

METHODS

Adult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA.

RESULTS

On multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions.

CONCLUSION

Black, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities

BACKGROUND

Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States.

METHODS

A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data.

RESULTS

A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05).

CONCLUSIONS

This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Racial Disparities in Total Joint Arthroplasty

PURPOSE OF REVIEW

The primary aim of this review was to evaluate recently published total joint arthroplasty (TJA) studies in order to accurately summarize the current concepts regarding racial and ethnic disparities in total joint arthroplasty.

RECENT FINDINGS

Many studies found that racial and ethnic disparities in TJA are present in all phases of arthroplasty care including access to, utilization of, and postoperative outcomes after TJA. Factors that limit patient access to TJA-increased patient comorbidities, lower socioeconomic status, and Medicaid/uninsured status-are also disproportionately associated with underrepresented patient populations. Minority patients are more likely to require more intensive postoperative rehabilitation and non-home discharge placement. This in turn potentially adds additional concerns regarding hospital/provider reimbursement in light of the current Medicare/Medicaid model for arthroplasty surgeons, thus creating a recurrent cycle in which disparities in TJA reflect the complex interplay of overall health disparities and access inequalities associated with racial and ethnic biases. Literature demonstrating evidenced-based interventions to minimize these disparities is sparse, but the multifactorial cause of disparities in TJA highlights the need for multifaceted solutions on both a systemic and individual level.

Where Do We Stand Today on Racial and Ethnic Health Inequities? Analysis of Primary Total Knee Arthroplasty from a 2011-2017 National Database

BACKGROUND

The objective of this study was to present contemporary national data on the state of racial and ethnic disparities pertaining to primary total knee arthroplasty (TKA) in the USA.

METHODS

The 2011-2017 National Surgical Quality Improvement Program was used to capture all patients who underwent primary TKA. The study outcomes were differences in demographic, comorbidity burden, perioperative factors, procedure utilization, hospital length of stay (LOS), and 30-day outcomes. The five major minority groups as defined by the National Institutes of Health were compared to non-Hispanic Whites.

RESULTS

In total, 262,954 patient records were analyzed, with racial identification available on 230,712 patients (87.7%). White patients accounted for 72.5% of all TKA procedures. There were higher rates of diabetes, hypertension, anemia, and prolonged surgery times among racial and ethnic minorities (p < 0.001). Baseline disparities were especially pronounced among non-Hispanic Blacks/African Americans who were also like to have higher rates of tobacco smoking and CHF (p < 0.001). After controlling for baseline differences, significant disparities in outcomes persisted, especially among Blacks/African Americans and Hispanics/Latinos who had higher odds for experiencing complications and readmissions (p < 0.001). All racial and ethnic groups, except Asians, had longer LOS (p < 0.001). Asian patients had significantly lower rates of readmissions, reoperations, and overall complications (p < 0.001).

CONCLUSION

Racial and ethnic disparities remain a public health challenge for patients undergoing TKA. While initiatives aimed at improving preoperative disease-burden and comorbidity profiles represent an important step, they alone are insufficient to fully account for or eliminate the disparities in TKA outcomes.

Establishing an Orthopedic Excess Hospital Days in Acute Care Program

BACKGROUND

Excess days in acute care (EDAC) after total joint arthroplasty (TJA) represent a large economic burden. We developed an Orthopedic EDAC program that triages TJA patients to the appropriate service line (orthopedic vs medicine) and level of care (observation vs inpatient) on re-presentation. We developed and used evidence-based protocols for the treatment of TJA patients who are rehospitalized.

METHODS

We defined Orthopedic EDAC as the length of stay (LOS) during readmission and observation stays. Our target population included TJA and revision TJA patients. Patients between April 2017 and September 2017 and between October 2017 and September 2018 were defined as pre-implementation and post-implementation of the Orthopedic EDAC program, respectively.

RESULTS

A total of 2,662 patients underwent TJA and revision TJA during the pre-implementation and post-implementation periods. Twenty-three patients were managed on observation status during the study period. Readmissions decreased from 49 (6.1%) during pre-implementation to 37 (2.0%) during post-implementation (P = .004). By design, more rehospitalized patients were on the orthopedic surgery service after implementation of the Orthopedic EDAC program (n = 49; 70%) versus before (n = 22; 35%; P = .028). EDAC LOS decreased from 7.75 days to 4.73 days (P = .005).

CONCLUSION

In this single-center, before-after pilot of a novel Orthopedic EDAC program, we demonstrated a reduction in readmissions and Orthopedic EDAC LOS, as well as improved continuity of care for TJA patients on representation.

Does eccentric-concentric resistance training improve early functional outcomes compared to concentric resistance training after total knee arthroplasty?

BACKGROUND

Total knee arthroplasty (TKA) is the preferred surgical treatment of end stage osteoarthritis of the knee. However, up to 20% of patients are dissatisfied after TKA. Moreover, kinesiophobia is negatively correlated with functional outcomes.

RESEARCH QUESTION

The aim of this study was to compare the effects of combined concentric-eccentric versus concentric program on muscular strength assessment and quality of life, after total knee arthroplasty in elderly people.

METHOD

A prospective study including 20 subjects (72.1 ± 6.3 years), following a rehabilitation program after TKA was performed. Subjects were randomized in combined eccentricconcentric (ECC-CON, n = 10) versus concentric (CN, n = 10) early rehabilitation protocols. There were no significant differences between groups with respect to demographic data. Data were collected before and after protocol: performance-based physical function (timed up and go test, 10-meter walk test, isokinetic assessment), Selfreported physical function and quality of life (Lequesne-ISK, WOMAC, OAKHQOL) and kinesiophobia assessment (TSK-CF). The Gaussian distribution for the whole population of this study was tested by a Kolmogorov-Smirnov test. Statistical analysis was performed using non-parametric Mann-Whitney U or Fisher's exact probability test, as appropriate.

RESULTS AND CONCLUSION

Performance-based physical function tests showed a significant improvement after early rehabilitation in the ECC-CON group for timed up and go (p = 0.0002) and 10-meter walk test (p = 0.001). Operated hamstring muscle peak torque was significantly improved in the ECC-CON group (p = 0.03). Self-reported physical function and quality of life tests were significantly better in the ECC-CON group for ISK (p = 0.03) and WOMAC (p = 0.04). Self-reported kinesiophobia significantly decreased after rehabilitation in both groups (p = 0.01) whilst there were no differences between groups. Early combined eccentric-concentric rehabilitation after TKA appears to be associated with improved outcomes compared to classic concentric rehabilitation protocols, on both physical function and quality of life. This information is new. Assessment and care of kinesiophobia should be considered in rehabilitation protocols standards.

Factors Affecting Discharge Disposition After Primary Simultaneous Bilateral Joint Arthroplasty

BACKGROUND

Predicting discharge destination following total joint arthroplasty (TJA) is important, as discharge destination has major implications for post-operative costs, clinical outcomes, and readmissions. Few studies have looked at factors affecting discharge destination for patients following primary simultaneous bilateral total joint arthroplasty.

QUESTIONS/PURPOSES

The purpose of this study was to describe clinical and social factors that relate to a discharge to home versus rehabilitation facility (RF) for patients after primary simultaneous bilateral total hip arthroplasty (PSBTHA) or primary simultaneous bilateral total knee arthroplasty (PSBTKA).

METHODS

The inclusion criteria for this retrospective cohort study were all patients after PSBTHA or PSBTKA at a metropolitan orthopedic specialty hospital between February 1, 2016, and March 31, 2018. Exclusion criteria were revisions, differing weight-bearing status, bed-rest orders, and non-standard hip precautions. Social and clinical demographic data were collected. Multiple regression analysis was conducted to determine which factors related most to discharge plan.

RESULTS

Of 253 PSBTHA patients, 153 were discharged home and 100 to an RF. Regression analysis found a posterolateral approach to be the only significant factor associated with an RF discharge. Of 619 PSBTKA patients, 136 were discharged home and 483 to RF. Increased body mass index and older age increased the likelihood of discharge to an RF. Patients with an adductor-only nerve block were more likely to be sent to RF.

CONCLUSION

These findings shed light on the variables that contribute to discharge destination after PSBTHA and PSBTKA. Such information allows for safe pre-operative discharge planning and assists with discharge to the appropriate level of patient care. Future studies might investigate the effect of surgeon experience, surgical technique, and pre-operative discussion with a physical therapist on the discharge disposition of patients undergoing bilateral total joint arthroplasty.