title: Are Readmissions After THA Preventable?
abstract: BACKGROUND
  Readmissions after total joint arthroplasty have become a key quality measure in elective surgery in the United States. The Affordable Care Act includes the Hospital Readmission Reduction Program, which calls for reduced payments to hospitals with excessive readmissions. This policy uses a method to determine excess readmission ratios and calculate readmission payment adjustments to hospitals, however, it is unclear whether readmission rates are an effective quality metric. The reasons or conditions associated with readmission after elective THA have been well established but the extent to which readmissions can be prevented after THA remains unclear.
  
  
  OBJECTIVE
  (1) Are unplanned readmissions after THA associated with orthopaedic or medical causes? (2) Are these readmissions preventable? (3) When during the course of aftercare are orthopaedic versus medical readmissions more likely to occur?
  
  
  METHODS
  We retrospectively evaluated all 1096 elective THAs for osteoarthritis performed between January 1, 2011 and June 30, 2014 at a major academic medical center. Of those, 69 patients (6%) who met inclusion criteria were readmitted in our healthcare system within 90 days of discharge after the index procedure during the study period. Fifty patients were readmitted within 30 days of discharge after the index procedure (5%). We defined a readmission as any unplanned inpatient or observation status admission to the hospital spanning at least one midnight. A panel of physicians not involved in the care of these patients used available criteria and existing consensus guidelines to evaluate the medical records, radiographs, and operative reports to identify whether the underlying reason for readmission was orthopaedic versus medical. They subsequently were classified as either nonpreventable or potentially preventable readmissions, based on any care that may have occurred during the index hospitalization. To make such determinations, consensus specialty society guidelines were used whenever possible for each readmission diagnosis.
  
  
  RESULTS
  A total of 50 of 1096 patients (5% of those who underwent THA during the period in question) were readmitted within 30 days and 69 of 1096 (6%) were readmitted within 90 days of their index procedures. Thirty-one patients were readmitted for orthopaedic reasons (31/69; 45%) and 38 of 69 were readmitted for medical reasons (55%). Three readmissions (three of 69; 4%) were identified as potentially preventable. Of these potentially preventable readmissions, one was orthopaedic (hip dislocation) and two were medical. Thirty-day readmissions were more likely to be orthopaedic than 90-day readmissions (odds ratio, 4.06; 95% CI, 1.18-13.96; p = 0.026).
  
  
  CONCLUSIONS
  Using a panel of expert reviewers, available existing criteria, and consensus methodology, it appears only a small percentage of readmissions after THA are potentially preventable. Orthopaedic readmissions occur earlier during the postoperative course. Currently, existing policies and readmission penalties may not serve as valuable external quality metrics. The readmission rates in our study may represent the threshold for expected readmission rates after THA. Future studies should enroll larger numbers of patients and have independent review panels in efforts to refine criteria for what constitutes preventable readmissions.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA. Dsw56@case.edu.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Weinberg
authors.affiliation: Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Kraay
authors.affiliation: Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Fitzgerald
authors.affiliation: Department of Orthopaedic Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
authors.forename: Vasu
authors.initials: V
authors.lastname: Sidagam
authors.affiliation: MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Wera
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D015897:Comorbidity; D057286:Electronic Health Records; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009820:Ohio; D010359:Patient Readmission; D018579:Patient Selection; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult