title: Discharge Disposition After Joint Replacement and the Potential for Cost Savings: Effect of Hospital Policies and Surgeons.
abstract: BACKGROUND
  Up to 55% of total joint arthroplasty costs come from post-acute care, with large variability dependent on a patient's discharge location. At our institution, we identified a group of surgeons using a preoperative discharge planning protocol emphasizing the merits of home discharge. We hypothesized that using the protocol would increase patients' odds for discharge home.
  
  
  METHODS
  Administrative data from 14,315 total hip and knee arthroplasties performed over a 3-year period were retrospectively analyzed to determine predictors of patient discharge location. Bayesian hierarchical logistic regression modeling was used to account for the complex multilevel structure within the data as we considered patient-, surgeon-, and hospital-level predictors. A simplified case-control data structure with logistic regression analysis was also used to better understand the impact of the preoperative discharge planning protocol.
  
  
  RESULTS
  A variety of patient- and surgeon-level variables are predictive of patients being discharged home after total joint arthroplasty including a patient's length of stay, age, illness severity, and insurance, as well as surgeon's affiliation. In the case-control data, patients exposed to the rapid recovery protocol had 45% increased odds of being discharged home compared to patients not exposed to the protocol.
  
  
  CONCLUSIONS
  Although patient factors are known to play a role in predicting postdischarge destination, this analysis describes additional surgeon- and hospital-level factors that predict discharge location. Exogenous factors based on how surgeons and hospital staff practice and interact with patients may impact the postdischarge decision-making process and provide a cost savings opportunity.
authors.affiliation: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: London
authors.affiliation: Center for Connected Care, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Seth
authors.initials: S
authors.lastname: Vilensky
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Colin
authors.initials: C
authors.lastname: O'Rourke
authors.affiliation: Euclid Hospital, Cleveland Clinic, Euclid, Ohio.
authors.forename: Michelle
authors.initials: M
authors.lastname: Schill
authors.affiliation: Euclid Hospital, Cleveland Clinic, Euclid, Ohio.
authors.forename: Lynn
authors.initials: L
authors.lastname: Woicehovich
authors.affiliation: Euclid Hospital, Cleveland Clinic, Euclid, Ohio.
authors.forename: Mark I
authors.initials: MI
authors.lastname: Froimson
mesh_terms: D000328:Adult; D000368:Aged; D019645:Arthroplasty, Replacement, Knee / Q000191:economics / Q000706:statistics & numerical data*; D001499:Bayes Theorem; D017046:Cost Savings; D005260:Female; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D066231:Surgeons
keywords: bundled payments; cost savings; discharge disposition; total joint rehab; total knee arthroplasty