Should All Patients Be Included in Alternative Payment Models for Primary Total Hip Arthroplasty and Total Knee Arthroplasty?
Alternative payment models in total joint replacement incentivize cost effective health care delivery and reward reductions in length of stay (LOS), complications, and readmissions. If not adjusted for patient comorbidities, they may encourage restrictive access to health care.



We prospectively evaluated 802 consecutive primary total hip arthroplasty and total knee arthroplasty patients evaluating comorbidities associated with increased LOS and readmissions.



During this 9-month period, 115 patients (14.3%) required hospitalization >3 days and 16 (1.99%) were readmitted within 90 days. Univariate analysis demonstrated that preoperative narcotic use, heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and liver disease were more likely to require hospitalization >3 days. In multivariate analysis, CKD and COPD were independent risk factors for LOS >3 days. A Charlson comorbidity index >5 points was associated with increased LOS and readmissions.



Patients with CKD, COPD, and Charlson comorbidity index >5 points should not be included in alternative payment model for THA and TKA.
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Joshua C
JC
Rozell
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Paul M
PM
Courtney
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Jonathan R
JR
Dattilo
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Chia H
CH
Wu
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Gwo-Chin
GC
Lee
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D015897:Comorbidity; D005260:Female; D005102:Health Expenditures; D006297:Health Services Accessibility; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D018579:Patient Selection; D011446:Prospective Studies; D012051:Reimbursement Mechanisms; D012307:Risk Factors; D055815:Young Adult
alternative payment model; bundled payment; comorbidity; readmission; total joint arthroplasty