title: The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program.
abstract: OBJECTIVE
  The purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients.
  
  
  METHODS
  Between April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6 = 'high risk', between 6 and 9 = 'medium risk', and >9 = 'low risk' for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility.
  
  
  RESULTS
  70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility.
  
  
  CONCLUSIONS
  The RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.
authors.affiliation: Adult Reconstructive Division, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1616, New York, NY 10003, USA.
authors.forename: James
authors.initials: J
authors.lastname: Slover
authors.affiliation: Department Network Integration, NYU Medical Center, 360 Park Avenue South, New York, NY 10010, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Mullaly
authors.affiliation: Center for Clinical Research, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA. Electronic address: raj.karia@nyumc.org.
authors.forename: Raj
authors.initials: R
authors.lastname: Karia
authors.affiliation: Vice Chair Clinical Affairs NYUHJD, Department of Orthopaedic Surgery, 333 EAST 38th Street, 6th Floor, New York, NY 10016, USA.
authors.forename: John
authors.initials: J
authors.lastname: Bendo
authors.affiliation: Clinical Process Optimization & Quality, Strategic Areas and Program Development, Division of Cardaic Surgery, 530 First Avenue, Suite 9V, New York, NY 10016, USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Ursomanno
authors.affiliation: Department of Cardiothoracic Surgery, Chair of the Department of Cardiothoracic Surgery, 530 1st Avenue, Suite 9V, New York, NY 10016, USA.
authors.forename: Aubrey
authors.initials: A
authors.lastname: Galloway
authors.affiliation: William and Susan Jaffe Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Iorio
authors.affiliation: Department of Orthopaedic Surgery, Vice Chair for Clinical Affairs, NYU Center for Musculoskeletal Care, 333 East 38th Street, 4th Floor, New York, NY 10016, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Bosco
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000534:rehabilitation; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation; D004185:Disability Evaluation; D005260:Female; D005102:Health Expenditures; D019918:Heart Valve Prosthesis Implantation / Q000534:rehabilitation; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D018570:Risk Assessment; D013123:Spinal Fusion / Q000534:rehabilitation
keywords: Arthroplasty; Bundled payment; Cardiac valve replacement; Risk Assessment and Prediction Tool; Spinal fusions; Total joint replacement; Value base care