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Gordon AM, Ng MK, Elali F, Piuzzi NS, Mont MA. A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Healthcare Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient. J Arthroplasty 2024:S0883-5403(24)00341-3. [PMID: 38615971 DOI: 10.1016/j.arth.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Socioeconomic status (SES) has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in: 1) medical complications; 2) emergency department (ED) utilizations; 3) readmissions; and 4) costs of care. METHODS A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index (ECI). This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P-values less than 0.003 were significant. RESULTS High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = 0.0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = 0.001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < 0.0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = 0.0008). The 90-day expenditures ($15,066 versus $12,459; P < 0.0001) were higher in patients who have a high ADI. CONCLUSION Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform healthcare policy and improve post-discharge care. The SES metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.
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Affiliation(s)
- Adam M Gordon
- Questrom School of Business, Boston University, Boston, MA; Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Faisal Elali
- SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, New York
| | - Nicolas S Piuzzi
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Michael A Mont
- Rubin Institute of Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland(.).
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Bains SS, Dubin JA, Hameed D, Douglas S, Gilmor R, Salib CG, Nace J, Mont M, Delanois RE. Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty. Eur J Orthop Surg Traumatol 2024:10.1007/s00590-024-03913-x. [PMID: 38581454 DOI: 10.1007/s00590-024-03913-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/14/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications. METHODS A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors. RESULTS After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05). CONCLUSION Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.
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Affiliation(s)
- Sandeep S Bains
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Jeremy A Dubin
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Daniel Hameed
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Scott Douglas
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Ruby Gilmor
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Christopher G Salib
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - James Nace
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Michael Mont
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA
| | - Ronald E Delanois
- LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA.
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Baxter SN, Johnson AH, Brennan JC, MacDonald JH, Turcotte JJ, King PJ. Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty. Arch Orthop Trauma Surg 2024; 144:1803-1811. [PMID: 38206446 DOI: 10.1007/s00402-023-05186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't. MATERIALS AND METHODS A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05. RESULTS 48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04). CONCLUSION Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.
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Affiliation(s)
- Samantha N Baxter
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Andrea H Johnson
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Jane C Brennan
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - James H MacDonald
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Justin J Turcotte
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA.
| | - Paul J King
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
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Dubin JA, Bains SS, Hameed D, Monárrez R, Gilmor R, Chen Z, Nace J, Delanois RE. The Utility of the Area Deprivation Index in Assessing Complications After Total Joint Arthroplasty. JB JS Open Access 2024; 9:e23.00115. [PMID: 38577548 PMCID: PMC10984656 DOI: 10.2106/jbjs.oa.23.00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Background Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year. Methods A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128). Results Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications. Conclusions Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeremy A. Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Sandeep S. Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Daniel Hameed
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Rubén Monárrez
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Ruby Gilmor
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
| | - Ronald E. Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland
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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Income. J Arthroplasty 2024:S0883-5403(24)00236-5. [PMID: 38492822 DOI: 10.1016/j.arth.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Pan X, Xu J, Rullán PJ, Pasqualini I, Krebs VE, Molloy RM, Piuzzi NS. Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020). J Knee Surg 2024; 37:254-266. [PMID: 36963431 DOI: 10.1055/a-2062-0468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.
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Affiliation(s)
- Xuankang Pan
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - James Xu
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Pedro J Rullán
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ignacio Pasqualini
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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Singh JA. Does the money matter? Disparities in total joint replacement outcomes by income. Osteoarthritis Cartilage 2024; 32:121-123. [PMID: 37944662 DOI: 10.1016/j.joca.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Jasvinder A Singh
- Department of Medicine at the School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Medicine Service, VA Medical Center, Birmingham, AL, USA; Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, USA.
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Pasqualini I, Tidd JL, Klika AK, Jones G, Johnson JK, Piuzzi NS. High Risk of Readmission After THA Regardless of Functional Status in Patients Discharged to Skilled Nursing Facility. Clin Orthop Relat Res 2024:00003086-990000000-01465. [PMID: 38227380 DOI: 10.1097/corr.0000000000002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/17/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The postoperative period and subsequent discharge planning are critical in our continued efforts to decrease the risk of complications after THA. Patients discharged to skilled nursing facilities (SNFs) have consistently exhibited higher readmission rates compared with those discharged to home healthcare. This elevated risk has been attributed to several factors but whether readmission is associated with patient functional status is not known. QUESTIONS/PURPOSES After controlling for relevant confounding variables (functional status, age, gender, caregiver support available at home, diagnosis [osteoarthritis (OA) versus non-OA], Charlson comorbidity index [CCI], the Area Deprivation Index [ADI], and insurance), are the odds of 30- and 90-day hospital readmission greater among patients initially discharged to SNFs than among those treated with home healthcare after THA? METHODS This was a retrospective, comparative study of patients undergoing THA at any of 11 hospitals in a single, large, academic healthcare system between 2017 and 2022 who were discharged to an SNF or home healthcare. During this period, 13,262 patients were included. Patients discharged to SNFs were older (73 ± 11 years versus 65 ± 11 years; p < 0.001), less independent at hospital discharge (6-click score: 16 ± 3.2 versus 22 ± 2.3; p < 0.001), more were women (71% [1279 of 1796] versus 56% [6447 of 11,466]; p < 0.001), insured by Medicare (83% [1497 of 1796] versus 52% [5974 of 11,466]; p < 0.001), living in areas with greater deprivation (30% [533 of 1796] versus 19% [2229 of 11,466]; p < 0.001), and had less assistance available from at-home caregivers (29% [527 of 1796] versus 57% [6484 of 11,466]; p < 0.001). The primary outcomes assessed in this study were 30- and 90-day hospital readmissions. Although the system automatically flags readmissions occurring within 90 days at the various facilities in the overall healthcare system, readmissions occurring outside the system would not be captured. Therefore, we were not able to account for potential differential rates of readmission to external healthcare systems between the groups. However, given the large size and broad geographic coverage of the healthcare system analyzed, we expect the readmissions data captured to be representative of the study population. The focus on a single healthcare system also ensures consistency in readmission identification and reporting across subjects. We evaluated the association between discharge disposition (home healthcare versus SNF) and readmission. Covariates evaluated included age, gender, primary payer, primary diagnosis, CCI, ADI, the availability of at-home caregivers for the patient, and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks basic mobility score in the hospital. The adjusted relative risk (ARR) of readmission within 30 and 90 days of discharge to SNF (versus home healthcare) was estimated using modified Poisson regression models. RESULTS After adjusting for the 6-clicks mobility score, age, gender, ADI, OA versus non-OA, living environment, CCI, and insurance, patients discharged to an SNF were more likely to be readmitted within 30 and 90 days compared with home healthcare after THA (ARR 1.46 [95% CI 1.01 to 2.13]; p= 0.046 and ARR 1.57 [95% CI 1.23 to 2.01]; p < 0.001, respectively). CONCLUSION Patients discharged to SNFs after THA had a slightly higher likelihood of hospital readmission within 30 and 90 days compared with those discharged with home healthcare. This difference persisted even after adjusting for relevant factors like functional status, home support, and social determinants of health. These results indicate that for suitable patients, direct home discharge may be a safer and more cost-effective option than SNFs. Clinicians should carefully consider these risks and benefits when making postoperative discharge plans. Policymakers could consider incentives and reforms to improve care transitions and coordination across settings. Further research using robust methods is needed to clarify the reasons for higher SNF readmission rates. Detailed analysis of patient complexity, care processes, and causes of readmission in SNFs versus home health could identify areas for quality improvement. Prospective cohorts or randomized trials would allow stronger conclusions about cause-and-effect. Importantly, no patients should be unfairly "cherry-picked" or "lemon-dropped" based only on readmission risk scores. With proper support and care coordination, even complex patients can have good outcomes. The goal should be providing excellent rehabilitation for all, while continuously improving quality, safety, and value across settings. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Joshua L Tidd
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Alison K Klika
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA
| | - Gabrielle Jones
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, OH, USA
- Center for Value-Based Care Research, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicolas S Piuzzi
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, OH, USA
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Johnson JK, Pasqualini I, Tidd J, Klika AK, Jones G, Piuzzi NS. Considering Mobility Status and Home Environment in Readmission Risk After Total Knee Arthroplasty. J Bone Joint Surg Am 2023; 105:1987-1992. [PMID: 37856575 DOI: 10.2106/jbjs.23.00581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Discharge disposition following total knee arthroplasty (TKA) offers varying levels of post-acute care monitoring depending on the medical status of the patient and his or her ability to function independently. Discharge disposition following TKA is associated with 30-day and 90-day hospital readmission, but prior studies have not consistently considered confounding due to mobility status after TKA, available caregiver support, and measures of home area deprivation. The purpose of this study was to examine 30-day and 90-day readmission risk for patients discharged to a skilled nursing facility (SNF) following TKA after controlling specifically for these factors, among other covariates. METHODS This was a retrospective cohort study of patients undergoing TKA at any of 11 hospitals in a single, large, academic health-care system between January 2, 2017, and August 31, 2022, who were discharged to an SNF or home health care (HHC). The adjusted relative risk of readmission within 30 and 90 days of discharge to an SNF compared with HHC was estimated using modified Poisson regression models. RESULTS There were 15,212 patients discharged to HHC and 1,721 patients discharged to SNFs. Readmission within 30 days was 7.1% among patients discharged to SNFs and 2.4% among patients discharged to HHC; readmission within 90 days was 12.1% for the SNF group and 4.8% for the HHC group. The adjusted relative risk after discharge to an SNF was 1.07 (95% confidence interval [CI], 0.79 to 1.46; p = 0.65) for 30-day readmission and 1.45 (95% CI, 1.16 to 1.82; p < 0.01) for 90-day readmission. CONCLUSIONS Discharge to an SNF compared with HHC was independently associated with 90-day readmission, but not with 30-day readmission, after controlling for mobility status after TKA, available caregiver support, and home Area Deprivation Index, among other covariates. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joshua K Johnson
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
- Center for Value-Based Care Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Joshua Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Gabrielle Jones
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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Baidya J, Gordon AM, Nian PP, Schwartz J, Golub IJ, Abdelgawad AA, Kang KK. Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care? Arch Orthop Trauma Surg 2023; 143:7073-7080. [PMID: 37697051 DOI: 10.1007/s00402-023-05045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. METHODS A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. RESULTS Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001). CONCLUSIONS Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joydeep Baidya
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Adam M Gordon
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA.
- Questrom School of Business, Boston University, Boston, MA, USA.
| | - Patrick P Nian
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Jake Schwartz
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Ivan J Golub
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Amr A Abdelgawad
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
| | - Kevin K Kang
- Department of Orthopaedic Surgery and Rehabilitation, Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, NY, 11219, USA
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Tucker KK, Mont MA. Working Toward Health Equity and Diversity in Our Field of Hip and Knee Arthroplasty. J Arthroplasty 2023; 38:2202-2203. [PMID: 37821155 DOI: 10.1016/j.arth.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
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Dubin JA, Bains SS, Chen Z, Salib CG, Nace J, Mont MA, Delanois RE. Race Associated With Increased Complication Rates After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2220-2225. [PMID: 37172792 DOI: 10.1016/j.arth.2023.04.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications. METHODS A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients. RESULTS The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455). CONCLUSION Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.
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Affiliation(s)
- Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Christopher G Salib
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Tidd JL, Piuzzi NS. Letter to the Editor on "The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Gender and Race: Is Frailty Equitably Detrimental?". J Arthroplasty 2023; 38:e28-e29. [PMID: 37573089 DOI: 10.1016/j.arth.2023.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/26/2023] [Indexed: 08/14/2023] Open
Affiliation(s)
- Joshua L Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio; College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Kapur S, Sakyi KS, Lohia P, Goble DJ. Potential Factors Associated with Healthcare Utilization for Balance Problems in Community-Dwelling Adults within the United States: A Narrative Review. Healthcare (Basel) 2023; 11:2398. [PMID: 37685432 PMCID: PMC10486920 DOI: 10.3390/healthcare11172398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Falls are the leading cause of mortality and chronic disability in elderly adults. There are effective fall prevention interventions available. But only a fraction of the individuals with balance/dizziness problems are seeking timely help from the healthcare system. Current literature confirms the underutilization of healthcare services for the management of balance problems in adults, especially older adults. This review article explores factors associated with healthcare utilization as guided by the Andersen Healthcare Utilization Model, a framework frequently used to explore the factors leading to the use of health services. Age, sex, race/ethnicity, BMI, and comorbidities have been identified as some of the potential predisposing factors; socioeconomic status, health insurance, and access to primary care are the enabling and disabling factors; and severity of balance problem, perceived illness, and its impact on daily activities are the factors affecting need for care associated with healthcare utilization for balance or dizziness problems. Knowledge about these barriers can help direct efforts towards improved screening of vulnerable individuals, better access to care, and education regarding effective fall prevention interventions for those who are at risk for underutilization. This can aid in timely identification and management of balance problems, thereby reducing the incidence of falls.
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Affiliation(s)
- Shweta Kapur
- School of Health Sciences, Oakland University, Rochester, MI 48309, USA; (S.K.); (K.S.S.); (D.J.G.)
| | - Kwame S. Sakyi
- School of Health Sciences, Oakland University, Rochester, MI 48309, USA; (S.K.); (K.S.S.); (D.J.G.)
| | - Prateek Lohia
- Department of Internal Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Daniel J. Goble
- School of Health Sciences, Oakland University, Rochester, MI 48309, USA; (S.K.); (K.S.S.); (D.J.G.)
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Akinyoola LA, Gunderson Z, Sun S, Fitzgerald R, Caltoum CB, Christman TW, Bielski R, Loder RT. Association of Socioeconomic Status With Relapse After Ponseti Method Treatment of Idiopathic Clubfeet. Foot & Ankle Orthopaedics 2022; 7:24730114221119180. [PMID: 36046551 PMCID: PMC9421036 DOI: 10.1177/24730114221119180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The Ponseti method is today’s standard treatment of idiopathic talipes equinovarus (ITEV). Compliance with foot abduction bracing (FABO) and socioeconomic factors have been shown to impact treatment outcome. We wished to further study socioeconomic factors using the Area Deprivation Index (ADI), a more comprehensive way to evaluate socioeconomic status, which has not been done before. Methods: All TEV patients from 2010 through 2019 treated with the Ponseti method were reviewed. Standard demographic variables, as well as the number of casts to complete initial correction, FABO compliance, and occurrence of relapse were tabulated. Socioeconomic level was quantified with the 2018 ADI. Results: There were 168 children; 151 had typical and 17 complex TEV. Average follow-up was 4.3 ± 1.8 years; relapse occurred in 46%. There were no significant differences in the percentage of relapse by sex, race, or ADI. FABO noncompliance was present in 46%. Relapse increased with increasing time of follow-up and FABO noncompliance (76% vs 21%, P < 10−6). Multivariate logistic regression analysis revealed that only FABO compliance and length of follow-up were associated with relapse. The OR of relapse for FABO noncompliance was 17.9 (7.6, 42.4, P < 10–6) and for follow-up >4 years the OR was 4.97 (2.1, 11.70, P = .0003). Conclusion: The outcome of the Ponseti method for TEV treatment is dependent on local circumstances. In our state, socioeconomic status, as determined by the ADI, was not associated with the occurrence of relapse. Thus, each center needs to assess its results, and analyze its own reasons for relapse. There were no other demographic variables associated with relapse except FABO compliance and length of follow-up. Parents should be strongly advised that FABO compliance and follow-up appears paramount to achieving the best results, and that complex TEV are at greater risk for relapse. Level of Evidence: Level IV, case series
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Affiliation(s)
| | | | - Seungyup Sun
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan Fitzgerald
- University of South Florida College of Medicine, Tampa, FL, USA
| | | | - Tyler W. Christman
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Robert Bielski
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Randall T. Loder
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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