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Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status

Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

Background

Total hip replacements (THRs) are the sixth most common surgical procedure performed in the USA. Readmission rates are estimated at between 4.0 and 10.9%, and mean costs are between $10,000 and $19,000. Readmissions are influenced by the quality of care received. We sought to examine differences in readmissions by insurance payer, race and ethnicity, and income status.

Methods

We analyzed all THRs from 2007 to 2011 in California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Primary outcomes were readmission at 30 and 90 days after THR. Descriptive statistics were calculated, and multivariate logistic regression analysis was used to estimate adjusted odds ratio (OR) for readmissions. Statistical significance was evaluated at the < 0.05 alpha level.

Results

A total of 274,851 patients were included in the analyses. At 30 days (90 days), 5.6% (10.2%) patients had been readmitted. Multivariate logistic regression analysis showed that patients insured by Medicaid (OR 1.23, 95%CI 1.17–1.29) and Medicare (OR 1.58, 95%CI 1.44–1.73) had increased odds of 30-day readmission, as did patients living in areas with lower incomes, Black patients, and patients treated at lower volume hospitals. Ninety-day readmissions showed similar significant results.

Conclusions

The present study has shown that patients on public insurance, Black patients, and patients who live in areas with lower median incomes have higher odds of readmission. Future research should focus on further identifying racial and socioeconomic disparities in readmission after THR with an eye towards implementing strategies to ameliorate these differences.

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References

  1. HCUPnet. A tool for identifying, tracking, and analyzing national hospital statistics. Rockville, MD. 2013. https://hcupnet.ahrq.gov/#setup. Accessed 10 Sept 2013.

  2. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004;86-A(5):963–74.

    Article  Google Scholar 

  3. Xu HF, White RS, Sastow DL, Andreae MH, Gaber-Baylis LK, Turnbull ZA. Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York. J Clin Anesth. 2017;43:24–32. https://doi.org/10.1016/j.jclinane.2017.09.008.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rosenthal JA, Lu X, Cram P. Availability of consumer prices from us hospitals for a common surgical procedure. JAMA Intern Med. 2013;173(6):427–32. https://doi.org/10.1001/jamainternmed.2013.460.

    Article  PubMed  Google Scholar 

  5. Bernatz JT, Tueting JL, Anderson PA. Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis. PLoS One. 2015;10(4):e0123593. https://doi.org/10.1371/journal.pone.0123593.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Weiss A, Elixhauser A, Steiner C. Readmissions to US hospitals by procedure, 2010: statistical brief# 154. Rockville: Agency for Health Care Policy and Research (US); 2006.

    Google Scholar 

  7. Oronce CIA, Shao H, Shi L. Disparities in 30-day readmissions after total hip arthroplasty. Med Care. 2015;53(11):924–30. https://doi.org/10.1097/mlr.0000000000000421.

    Article  PubMed  Google Scholar 

  8. Kiridly DN, Karkenny AJ, Hutzler LH, Slover JD, Iorio R, Bosco JA 3rd. The effect of severity of disease on cost burden of 30-day readmissions following total joint arthroplasty (TJA). J Arthroplast. 2014;29(8):1545–7. https://doi.org/10.1016/j.arth.2014.03.035.

    Article  Google Scholar 

  9. Bosco JA 3rd, Karkenny AJ, Hutzler LH, Slover JD, Iorio R. Cost burden of 30-day readmissions following Medicare total hip and knee arthroplasty. J Arthroplast. 2014;29(5):903–5. https://doi.org/10.1016/j.arth.2013.11.006.

    Article  Google Scholar 

  10. Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplast. 2016;31(7):1400–6.e3. https://doi.org/10.1016/j.arth.2016.01.022.

    Article  Google Scholar 

  11. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160(8):1074–81. https://doi.org/10.1001/archinte.160.8.1074.

    Article  CAS  PubMed  Google Scholar 

  12. Federal Register/Vol. 78, No. 160. Government Publishing Office. 2013. http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. Accessed 2 June 2017.

  13. Federal Register/Vol. 76, No. 160. 2011. https://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-19719.pdf. Accessed 2 June 2017.

  14. Boccuti C, Casillas G. Aiming for fewer hospital U-turns: the Medicare hospital readmission reduction program. Henry J Kaiser Fam Found. 2015:1–10.

  15. National Quality Measures C. Total hip arthroplasty (THA) and/or total knee arthroplasty (TKA): hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA. Agency for Healthcare Research and Quality (AHRQ), Rockville MD. 2015. https://www.qualitymeasures.ahrq.gov/summaries/summary/49200/total-hip-arthroplasty-tha-andor-total-knee-arthroplasty-tka-hospitallevel-30day-allcause-riskstandardized-readmission-rate-rsrr-following-elective-primary-tha-andor-tka.

  16. The Patient Protection and Affordable Care Act. Washington, DC.

  17. Federal Register/Vol. 77, No. 170. 2012. http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-19719.pdf. Accessed 10 Sept 2013.

  18. Dummit LA, Kahvecioglu D, Marrufo G, Rajkumar R, Marshall J, Tan E, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodes. JAMA. 2016;316(12):1267–78. https://doi.org/10.1001/jama.2016.12717.

    Article  PubMed  Google Scholar 

  19. Bundled Payments for Care Improvement (BPCI) Initiative: general information. https://innovation.cms.gov/initiatives/Bundled-Payments/index.html. Accessed 29 Aug 2015.

  20. Press MJ, Rajkumar R, Conway PH. Medicare’s new bundled payments: design, strategy, and evolution. JAMA. 2016;315(2):131–2. https://doi.org/10.1001/jama.2015.18161.

    Article  CAS  PubMed  Google Scholar 

  21. Paxton EW, Inacio MC, Singh JA, Love R, Bini SA, Namba RS. Are there modifiable risk factors for hospital readmission after total hip arthroplasty in a US healthcare system? Clin Orthop Relat Res. 2015;473(11):3446–55. https://doi.org/10.1007/s11999-015-4278-x.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ricciardi BF, Oi KK, Daines SB, Lee YY, Joseph AD, Westrich GH. Patient and perioperative variables affecting 30-day readmission for surgical complications after hip and knee arthroplasties: a matched cohort study. J Arthroplast. 2017;32(4):1074–9. https://doi.org/10.1016/j.arth.2016.10.019.

    Article  Google Scholar 

  23. Clement RC, Derman PB, Graham DS, Speck RM, Flynn DN, Levin LS, et al. Risk factors, causes, and the economic implications of unplanned readmissions following total hip arthroplasty. J Arthroplast. 2013;28(8 Suppl):7–10. https://doi.org/10.1016/j.arth.2013.04.055.

    Article  Google Scholar 

  24. Saucedo JM, Marecek GS, Wanke TR, Lee J, Stulberg SD, Puri L. Understanding readmission after primary total hip and knee arthroplasty: who's at risk? J Arthroplast. 2014;29(2):256–60. https://doi.org/10.1016/j.arth.2013.06.003.

    Article  Google Scholar 

  25. Pugely AJ, Callaghan JJ, Martin CT, Cram P, Gao Y. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. J Arthroplast. 2013;28(9):1499–504. https://doi.org/10.1016/j.arth.2013.06.032.

    Article  Google Scholar 

  26. Schairer WW, Sing DC, Vail TP, Bozic KJ. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthop Relat Res. 2014;472(2):464–70. https://doi.org/10.1007/s11999-013-3121-5.

    Article  PubMed  Google Scholar 

  27. Tayne S, Merrill CA, Smith EL, Mackey WC. Predictive risk factors for 30-day readmissions following primary total joint arthroplasty and modification of patient management. J Arthroplast. 2014;29(10):1938–42. https://doi.org/10.1016/j.arth.2014.05.023.

    Article  Google Scholar 

  28. Mednick RE, Alvi HM, Krishnan V, Lovecchio F, Manning DW. Factors affecting readmission rates following primary total hip arthroplasty. J Bone Joint Surg Am. 2014;96(14):1201–9. https://doi.org/10.2106/jbjs.m.00556.

    Article  PubMed  Google Scholar 

  29. Inneh IA, Lewis CG, Schutzer SF. Focused risk analysis: regression model based on 5,314 total hip and knee arthroplasty patients from a single institution. J Arthroplast. 2014;29(10):2031–5. https://doi.org/10.1016/j.arth.2014.05.007.

    Article  Google Scholar 

  30. Joynt KE, Orav E, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675–81. https://doi.org/10.1001/jama.2011.123.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107–15. https://doi.org/10.1136/annrheumdis-2013-203494.

    Article  PubMed  Google Scholar 

  32. HCUP. Overview of the state inpatient databases. Healthcare cost and utilization project. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed 4 Feb 2017.

  33. HCUP. HCUP quality control procedures. Agency for Healthcare Research and Quality, Rockville, MD. 2016. https://www.hcup-us.ahrq.gov/db/quality.jsp. Accessed 20 Nov 2017.

  34. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130–9. https://doi.org/10.1097/01.mlr.0000182534.19832.83.

    Article  PubMed  Google Scholar 

  35. LaPar DJ, Bhamidipati CM, Mery CM, Stukenborg GJ, Jones DR, Schirmer BD, et al. Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252(3):544–51. https://doi.org/10.1097/SLA.0b013e3181e8fd75.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Barnett JC, Vornovitsky MS. Health insurance coverage in the United States: 2015. US Census Bureau, Current Population Reports, Report 2016 (P60–257).

  37. Parker K, Horowitz J, Mahl B. On views of race and inequality, blacks and whites are worlds apart. Pew Research Center. Retrieved from http://www.pewsocialtrends.org/files/2016/06/ST_2016; 2016.

  38. Girotti ME, Shih T, Revels S, Dimick JB. Racial disparities in readmissions and site of care for major surgery. J Am Coll Surg. 2014;218(3):423–30. https://doi.org/10.1016/j.jamcollsurg.2013.12.004.

    Article  PubMed  Google Scholar 

  39. Tsai TC, Orav EJ, Joynt KE. Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care. Ann Surg. 2014;259(6):1086–90. https://doi.org/10.1097/SLA.0000000000000326.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Zhang W, Lyman S, Boutin-Foster C, Parks ML, Pan TJ, Lan A, et al. Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty. J Bone Joint Surg Am. 2016;98(15):1243–52. https://doi.org/10.2106/jbjs.15.01009.

    Article  PubMed  Google Scholar 

  41. Ravi P, Sood A, Schmid M, Abdollah F, Sammon JD, Sun M, et al. Racial/ethnic disparities in perioperative outcomes of major procedures: results from the National Surgical Quality Improvement Program. Ann Surg. 2015;262(6):955–64. https://doi.org/10.1097/sla.0000000000001078.

    Article  PubMed  Google Scholar 

  42. Adelani MA, Keller MR, Barrack RL, Olsen MA. The impact of hospital volume on racial differences in complications, readmissions, and emergency department visits following total joint arthroplasty. J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2017.09.034.

  43. Nwachukwu BU, Kenny AD, Losina E, Chibnik LB, Katz JN. Complications for racial and ethnic minority groups after total hip and knee replacement: a review of the literature. J Bone Joint Surg Am. 2010;92(2):338–45. https://doi.org/10.2106/jbjs.i.00510.

    Article  PubMed  PubMed Central  Google Scholar 

  44. J. J. Utah is nation’s fastest-growing state, Census Bureau Reports. US Census Bureau. http://www.census.gov2017/. Accessed 8 Feb 2017.

  45. Avram V, Petruccelli D, Winemaker M, de Beer J. Total joint arthroplasty readmission rates and reasons for 30-day hospital readmission. J Arthroplast. 2014;29(3):465–8. https://doi.org/10.1016/j.arth.2013.07.039.

    Article  Google Scholar 

  46. Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which hospital and clinical factors drive 30- and 90-day readmission after TKA? J Arthroplast. 2016;31(10):2099–107. https://doi.org/10.1016/j.arth.2016.03.045.

    Article  Google Scholar 

  47. Shaparin N, White R, Andreae M, Hall C, Kaufman A. A longitudinal linear model of patient characteristics to predict failure to attend an inner-city chronic pain clinic. J Pain. 2014;15(7):704–11. https://doi.org/10.1016/j.jpain.2014.03.004.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Andreae MH, White RS, Chen KY, Nair S, Hall C, Shaparin N. The effect of initiatives to overcome language barriers and improve attendance: a cross-sectional analysis of adherence in an inner city chronic pain clinic. Pain Med. 2016;18(2):265–74. https://doi.org/10.1093/pm/pnw161.

    Article  PubMed Central  Google Scholar 

  49. Andreae MH, Gabry JS, Goodrich B, White RS, Hall C. Antiemetic prophylaxis as a marker of health care disparities in the National Anesthesia Clinical Outcomes Registry. Anesth Analg. 2017;126(2):1–599. https://doi.org/10.1213/ane.0000000000002582.

    Article  Google Scholar 

  50. Slover JD, Walsh MG, Zuckerman JD. Sex and race characteristics in patients undergoing hip and knee arthroplasty in an urban setting. J Arthroplast. 2010;25(4):576–80. https://doi.org/10.1016/j.arth.2009.03.002.

    Article  Google Scholar 

  51. Warth LC, Callaghan JJ, Wells CW, Liu SS, Klaassen A, Gao Y, et al. Demographic and comorbid disparities based on payer type in a total joint arthroplasty cohort: implications in a changing health care arena. Iowa Orthop J. 2011;31:64–8.

    PubMed  PubMed Central  Google Scholar 

  52. Martin CT, Callaghan JJ, Liu SS, Gao Y, Warth LC, Johnston RC. Disparity in total joint arthroplasty patient comorbidities, demographics, and postoperative outcomes based on insurance payer type. J Arthroplast. 2012;27(10):1761–5.e1. https://doi.org/10.1016/j.arth.2012.06.007.

    Article  Google Scholar 

  53. Fleischut PM, Eskreis-Winkler JM, Gaber-Baylis LK, Giambrone GP, Faggiani SL, Dutton RP, et al. Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute. Am J Med Qual. 2015;30(2):172–9. https://doi.org/10.1177/1062860614525989.

    Article  PubMed  Google Scholar 

  54. Cozowicz C, Poeran J, Memtsoudis SG. Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery. Br J Anaesth. 2015;115(Suppl 2):ii57–67. https://doi.org/10.1093/bja/aev381.

    Article  PubMed  Google Scholar 

  55. Liu J, Ma C, Elkassabany N, Fleisher LA, Neuman MD. Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty. Anesth Analg. 2013;117(4):1010–6. https://doi.org/10.1213/ANE.0b013e3182a1bf1c.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Basques BA, Toy JO, Bohl DD, Golinvaux NS, Grauer JN. General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am. 2015;97(6):455–61. https://doi.org/10.2106/jbjs.n.00662.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Atchabahian A, Andreae M. Long-term functional outcomes after regional anesthesia: a summary of the published evidence and a recent Cochrane review. Refresh Course Anesthesiol. 2015;43(1):15–26. https://doi.org/10.1097/ASA.0000000000000033.

    Article  Google Scholar 

  58. Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 2013;118(5):1046–58. https://doi.org/10.1097/ALN.0b013e318286061d.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296–301. https://doi.org/10.1073/pnas.1516047113.

    Article  CAS  PubMed  Google Scholar 

  60. Wiznia DH, Zaki T, Maisano J, Kim CY, Halaszynski TM, Leslie MP. Influence of medical insurance under the affordable care act on access to pain management of the trauma patient. Reg Anesth Pain Med. 2017;42(1):39–44. https://doi.org/10.1097/aap.0000000000000502.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Freburger JK, Holmes GM, L-JE K, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in post-acute rehabilitation care for joint replacement. Arthritis Care Res (Hoboken). 2011;63(7):1020–30. https://doi.org/10.1002/acr.20477.

    Article  Google Scholar 

  62. Goodman SM, Parks ML, McHugh K, Fields K, Smethurst R, Figgie MP, et al. Disparities in outcomes for African Americans and Whites undergoing total knee arthroplasty: a systematic literature review. J Rheumatol. 2016;43(4):765–70. https://doi.org/10.3899/jrheum.150950.

    Article  PubMed  Google Scholar 

  63. Keeney JA, Nam D, Johnson SR, Nunley RM, Clohisy JC, Barrack RL. Socioeconomically disadvantaged CMS beneficiaries do not benefit from the readmission reduction initiatives. J Arthroplast. 2015;30(12):2082–5. https://doi.org/10.1016/j.arth.2015.06.031.

    Article  Google Scholar 

  64. Keeney JA, Nam D, Johnson SR, Nunley RM, Clohisy JC, Barrack RL. The impact of risk reduction initiatives on readmission: THA and TKA readmission rates. J Arthroplast. 2015;30(12):2057–60. https://doi.org/10.1016/j.arth.2015.06.007.

    Article  Google Scholar 

  65. Jordan CJ, Goldstein RY, Michels RF, Hutzler L, Slover JD, Bosco JA 3rd. Comprehensive program reduces hospital readmission rates after total joint arthroplasty. Am J Orthop (Belle Mead NJ). 2012;41(11):E147–51.

    Google Scholar 

  66. Jiang HJ, Boutwell AE, Maxwell J, Bourgoin A, Regenstein M, Andres E. Understanding patient, provider, and system factors related to Medicaid readmissions. Jt Comm J Qual Patient Saf. 2016;42(3):115–21. https://doi.org/10.1016/S1553-7250(16)42014-3.

    Article  PubMed  Google Scholar 

  67. Coughlin TA, Long SK, Clemans-Cope L, Resnick D. What difference does medicaid make? Assessing cost effectiveness, access, and financial protection under Medicaid for low-income adults. Kaiser Commission Medicaid and the Uninsured. 2013.

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Correspondence to Robert S. White.

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White, R.S., Sastow, D.L., Gaber-Baylis, L.K. et al. Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status. J. Racial and Ethnic Health Disparities 5, 1202–1214 (2018). https://doi.org/10.1007/s40615-018-0467-0

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