title: Does the Risk Assessment and Prediction Tool predict discharge disposition after joint replacement?
abstract: BACKGROUND
  Payers of health services and policymakers place a major focus on cost containment in health care. Studies have shown that early planning of discharge is essential in reducing length of stay and achieving financial benefit; tools that can help predict discharge disposition would therefore be of use. The Risk Assessment and Prediction Tool (RAPT) is a preoperative survey constructed to predict discharge disposition after total joint arthroplasty (TJA). The RAPT was developed and tested on a population of Australian patients undergoing joint replacement, but its validity in other populations is unknown. A low RAPT score is reported to indicate a high risk of needing any form of inpatient rehabilitation after TJA, including short-term nursing facilities.
  
  
  OBJECTIVE
  This study attempts (1) to assess predictive accuracy of the RAPT on US patients undergoing total hip and knee arthroplasty (THA/TKA); and (2) to determine predictive accuracy of each individual score (1-12).
  
  
  METHODS
  Between June 2006 and December 2011, RAPT scores of 3213 patients (1449 THAs; 1764 TKAs) were prospectively captured during the preoperative clinical visit. Scores were stored along with other clinical data, including discharge disposition, in a dedicated database on a secure server. The database was queried by the nursing case manager to retrieve the RAPT scores of all patients captured during this time period. Binary logistic regression was used to analyze the scores and determine predictive accuracy.
  
  
  RESULTS
  Overall predictive accuracy was 78%. RAPT scores<6 and >10 (of 12) predicted with >90% accuracy discharge to inpatient rehabilitation and home, respectively. Predictive accuracy was lowest for scores between 7 and 10 at 65.2% and almost 50% of patients received scores in this range. Based on our findings, the risk categories in our populations should be high risk<7, intermediate risk 7 to 10, and low risk>10.
  
  
  CONCLUSIONS
  The RAPT accurately predicted discharge disposition for high- and low-risk patients in our cohort. Based on our data, intermediate-risk patients should be defined as those with scores of 7 to 10. Predictive accuracy for these patients could potentially be improved through the identification and addition of other factors correlated to discharge disposition. The RAPT allows for identification of patients who are likely to be discharged home or to rehabilitation, which may facilitate preoperative planning of postoperative care. Additionally, it identifies intermediate-risk patients and could be used to implement targeted interventions to facilitate discharge home in this group of patients.
  
  
  METHODS
  Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Viktor J
authors.initials: VJ
authors.lastname: Hansen
authors.forename: Kirill
authors.initials: K
authors.lastname: Gromov
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Lebrun
authors.forename: Harry E
authors.initials: HE
authors.lastname: Rubash
authors.forename: Henrik
authors.initials: H
authors.lastname: Malchau
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Freiberg
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000534:rehabilitation; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D018570:Risk Assessment / Q000379:methods*
references.citation: J Arthroplasty. 2012 Aug;27(7):1261-6
references.pmid: 22209159
references.citation: J Arthroplasty. 2006 Sep;21(6 Suppl 2):151-6
references.pmid: 16950078
references.citation: Physiotherapy. 2014 Jun;100(2):176-81
references.pmid: 23830717
references.citation: Clin Orthop Relat Res. 1997 Dec;(345):134-9
references.pmid: 9418630
references.citation: J Arthroplasty. 2003 Sep;18(6):775-9
references.pmid: 14513453
references.citation: Ann Phys Rehabil Med. 2012 Feb;55(1):4-15
references.pmid: 22177789
references.citation: Arch Intern Med. 2009 Jun 22;169(12):1113-21; discussion 1121-2
references.pmid: 19546411
references.citation: J Bone Joint Surg Am. 2006 Mar;88(3):480-5
references.pmid: 16510811
references.citation: Clin Orthop Relat Res. 2013 Jan;471(1):206-14
references.pmid: 22864619
references.citation: J Bone Joint Surg Am. 2004 May;86(5):963-74
references.pmid: 15118039
references.citation: J Bone Joint Surg Am. 2005 Mar;87(3):570-6
references.pmid: 15741624
references.citation: Health Aff (Millwood). 2012 Jun;31(6):1329-38
references.pmid: 22571844
references.citation: BMC Health Serv Res. 2012 Mar 23;12:73
references.pmid: 22443109
references.citation: Clin Orthop Relat Res. 2005 Dec;441:19-29
references.pmid: 16330981