title: Are There Modifiable Risk Factors for Hospital Readmission After Total Hip Arthroplasty in a US Healthcare System?
abstract: BACKGROUND
  Although total hip arthroplasty (THA) is a successful procedure, 4% to 11% of patients who undergo THA are readmitted to the hospital. Prior studies have reported rates and risk factors of THA readmission but have been limited to single-center samples, administrative claims data, or Medicare patients. As a result, hospital readmission risk factors for a large proportion of patients undergoing THA are not fully understood.
  
  
  OBJECTIVE
  (1) What is the incidence of hospital readmissions after primary THA and the reasons for readmission? (2) What are the risk factors for hospital readmissions in a large, integrated healthcare system using current perioperative care protocols?
  
  
  METHODS
  The Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) was used to identify all patients with primary unilateral THAs registered between January 1, 2009, and December 31, 2011. The KPTJRR's voluntary participation is 95%. A logistic regression model was used to study the relationship of risk factors (including patient, clinical, and system-related) and the likelihood of 30-day readmission. Readmissions were identified using electronic health and claims records to capture readmissions within and outside the system. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Of the 12,030 patients undergoing primary THAs included in the study, 59% (n = 7093) were women and average patient age was 66.5 years (± 10.7).
  
  
  RESULTS
  There were 436 (3.6%) patients with hospital readmissions within 30 days of the index procedure. The most common reasons for readmission were infection and inflammatory reaction resulting from internal joint prosthetic (International Classification of Diseases, 9(th) Revision, Clinical Modification [ICD-9-CM] 996.66, 7.0%); other postoperative infection (ICD-9-CM 998:59, 5.5%); unspecified septicemia (ICD-9-CM 038.9, 4.9%); and dislocation of a prosthetic joint (ICD-9-CM 996.42, 4.7%). In adjusted models, the following factors were associated with an increased likelihood of 30-day readmission: medical complications (OR, 2.80; 95% CI, 1.59-4.93); discharge to facilities other than home (OR, 1.89; 95% CI, 1.39-2.58); length of stay of 5 or more days (OR, 1.80; 95% CI, 1.22-2.65) versus 3 days; morbid obesity (OR, 1.74; 95% CI, 1.25-2.43); surgeries performed by high-volume surgeons compared with medium volume (OR, 1.53; 95% CI, 1.14-2.08); procedures at lower-volume (OR, 1.41; 95% CI, 1.07-1.85) and medium-volume hospitals (OR, 1.81; 95% CI, 1.20-2.72) compared with high-volume ones; sex (men: OR, 1.51; 95% CI, 1.18-1.92); obesity (OR, 1.32; 95% CI, 1.02-1.72); race (black: OR, 1.26; 95% CI, 1.02-1.57); increasing age (OR, 1.03; 95% CI, 1.01-1.04); and certain comorbidities (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, and psychoses).
  
  
  CONCLUSIONS
  The 30-day hospital readmission rate after primary THA was 3.6%. Modifiable factors, including obesity, comorbidities, medical complications, and system-related factors (hospital), have the potential to be addressed by improving the health of patients before this elective procedure, patient and family education and planning, and with the development of high-volume centers of excellence. Nonmodifiable factors such as age, sex, and race can be used to establish patient and family expectations regarding risk of readmission after THA. Contrary to other studies and the finding of increased hospital volume associated with lower risk of readmission, higher volume surgeons had a higher risk of patient readmission, which may be attributable to the referral patterns in our organization.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Kaiser Permanente, Surgical Outcomes and Analysis, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA. Liz.w.paxton@kp.org.
authors.forename: Elizabeth W
authors.initials: EW
authors.lastname: Paxton
authors.affiliation: Kaiser Permanente, Surgical Outcomes and Analysis, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
authors.forename: Maria C S
authors.initials: MC
authors.lastname: Inacio
authors.affiliation: Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Jasvinder A
authors.initials: JA
authors.lastname: Singh
authors.affiliation: Kaiser Permanente, Surgical Outcomes and Analysis, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Love
authors.affiliation: Department of Orthopaedic Surgery, Permanente Medical Group, Oakland, CA, USA.
authors.forename: Stefano A
authors.initials: SA
authors.lastname: Bini
authors.affiliation: Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Irvine, CA, USA.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Namba
mesh_terms: D000367:Age Factors; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D002140:California / Q000453:epidemiology; D015897:Comorbidity; D005260:Female; D006254:Hawaii / Q000453:epidemiology; D006279:Health Maintenance Organizations; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010359:Patient Readmission; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D012042:Registries; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome
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