key: cord-0856538-25xd9kam
authors: DeMik, David E.; Carender, Christopher N.; Glass, Natalie A.; Callaghan, John J.; Bedard, Nicholas A.
title: Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases
date: 2020-08-25
journal: J Arthroplasty
DOI: 10.1016/j.arth.2020.08.039
sha: f51707a5377be5453cda661c74e96fedf6e30de8
doc_id: 856538
cord_uid: 25xd9kam

INTRODUCTION: There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study was to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA. METHODS: Patients undergoing primary THA were identified using ICD and CPT codes in the ACS NSQIP and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed. RESULTS: In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (p<0.0001). 84,832 THA patients were identified in Humana, with an increase in home discharge from 56.6% to 72.8% (p<0.0001). LOS decreased and proportion of patients with an ASA score ≥3 or CCI ≥2 increased significantly for both home and non-home going patients. Patients discharged home had a decrease in readmissions in both databases. CONCLUSIONS: Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

Demand for total hip arthroplasty (THA) in the United States (US) has significantly 68 increased, growing from approximately 160,000 procedures per year in 2000 to nearly 375,000 69 in 2014 (1). This increase is projected to continue and exceed 600,000 procedures by 2030 (1). 70

Total joint arthroplasty (TJA) is a major contributor to US medical costs, accounting for $7 71 billion in expenditures (2). Significant costs and increasing demand for TJA has led to 72 development of alternative payment models, such as the Bundle Payments for Care 73 Improvement (BPCI) in 2011 or Comprehensive Care for Joint Replacement (CJR) in 2016 74 through the Centers for Medicare and Medicaid Services (CMS) (2,3). These new payment 75 models seek to promote value and shift risk from insurers to hospitals and surgeons. Discharge 76 destination has been demonstrated to be a significant contributor to the cost of a TJA episode 77 of care; additionally, discharge destination may influence rates of complications and 78 readmissions following TJA (4-9). Bozic et al. reported the post-discharge time period to be 79 responsible for 36% of payments in TJA, with costs related to post-acute care facilities and 80 readmissions accounting for 70% and 11% of post-discharge payments, respectively (9). 81

Given the substantial contribution of discharge to care facilities on overall cost of care 82 and association with postoperative complications, limiting discharge to these facilities has the 83 potential to improve the value of THA care. The purpose of this study was to assess if more 84 patients are being discharged to home after primary THA in recent years. Additionally, we 85 sought to assess if duration of hospitalization was decreasing, patient comorbidity was 86 increasing and if changes in hospitalization or discharge were associated with a resulting 87 increase in readmissions or readmissions. 88 discharged to home or not home locations, as defined by the claims database. Home discharge 134 locations were home and home with home health. Not granted by our institution's institutional review board. All data used in this study are de-145 identified and in compliance with the Health Insurance Portability and Accountability Act. 146

Analyses were completed using SAS software version 9.4 (SAS Institute, Inc., Cary, NC) 147 and data from each of the two databases were analyzed independently. In both the ACS NSQIP 148 and Humana databases, the Cochrane-Armitage trend test was utilized to evaluate trends in 149 LOS, reoperation, readmission, or comorbidity from 2011-2017 in home discharged and non-150 home discharged patients. The trend test was utilized to evaluate whether there was an 151 increase in proportion of the patients discharging to home destinations whether there were 152 changes in 30-day readmission (ACS NSQIP and Humana), 30-day reoperation (ACS NSQIP), and 153 90-day readmission (Humana), and proportion of patients with an ASA score ≥ 3 (ACS NSQIP) or 154 J o u r n a l P r e -p r o o f reoperation and higher comorbidity was increasing over time in patients discharged home and 156 not discharged home and whether this change in time differed between groups. Odds ratios 157 (OR) and 95% confidence intervals (95% CI) for readmission, reoperation, and greater 158 comorbidity burden were reported. Generalized linear models were used to evaluate change in 159 hospital LOS from 2011-2017. 160 161

In the ACS NSQIP database, 155,637 patients underwent THA and 54.7% were female. A 163 total of 125,296 (80.5%) patients were discharged home and 30,342 (19.5%) patients were 164 discharged to non-home locations. Full demographic information formation is provided in Table  165 1. In 2011, 72.2% of patients were discharged to home and 27.8% of patients discharged to a 166 non-home location. By 2017, the percentage of patients discharging home increased to 87.0% 167 and those not discharging home decreased to 13.0% (p<0.0001). From 2011 to 2017, the 168 percentage of patients discharged home with an ASA score ≥3 increased from 33.8% to 40.3% 169 (p<0.0001). For patients who did not discharge home, there was also an increase in patients 170 with an ASA score ≥3, from 56.4% in 2011 to 67.4% in 2017 (p<0.0001). Trends in comorbidity 171 burden and discharge destination are shown in Figure 1 . 172 LOS, 30-day readmission, and 30-day reoperation by year for ACS NSQIP patients is 173 provided in Table 2 This study found that more patients are being discharged to home after primary THA 208 and patients are having shorter hospital LOS with fewer readmissions. Reoperations were also 209 found to have decreased for patients discharged home. These improvements occurred despite 210 a significant increase in the proportion of patients with a higher degree of medical comorbidity, 211 as assessed by ASA classification and CCI score. 

Appendix 1 -Included ACS NSQIP Concurrent CPT Codes 1214