title: Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis.
abstract: Discharge destination, either home or skilled care facility, after total knee arthroplasty (TKA) may be associated with significant variation in postacute care outcomes. The purpose of this study was to characterize the 30-day postdischarge outcomes after primary TKA relative to discharge destination.
  
  
  
  All primary unilateral TKAs performed for osteoarthritis from 2011-2014 were identified in the National Surgical Quality Improvement Program database. Propensity scores based on predischarge characteristics were used to adjust for selection bias in discharge destination. Propensity-adjusted multivariable logistic regressions were used to examine associations between discharge destination and postdischarge complications.
  
  
  
  Among 101,256 primary TKAs identified, 70,628 were discharged home and 30,628 to skilled care facilities. Patients discharged to facilities were more frequently were female, older, higher body mass index class, higher Charlson comorbidity index and American Society of Anesthesiologists scores, had predischarge complications, received general anesthesia, and classified as nonindependent preoperatively. Propensity adjustment accounted for this selection bias. Patients discharged to skilled care facilities after TKA had higher odds of any major complication (odds ratio = 1.25; 95% confidence interval, 1.13-1.37) and readmission (odds ratio = 1.81; 95% confidence interval, 1.50-2.18). Skilled care was associated with increased odds for respiratory, septic, thromboembolic, and urinary complications. Associations with death, cardiac, and wound complications were not significant.
  
  
  
  After controlling for predischarge characteristics, discharge to skilled care facilities vs home after primary TKA is associated with higher odds of numerous complications and unplanned readmission. These results support coordination of care pathways to facilitate home discharge after hospitalization for TKA whenever possible.
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
authors.forename: Alexander S
authors.initials: AS
authors.lastname: McLawhorn
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Fu
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
authors.forename: William W
authors.initials: WW
authors.lastname: Schairer
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Sculco
authors.affiliation: Chief Value Medical Officer, Hospital for Special Surgery, New York, New York.
authors.forename: Catherine H
authors.initials: CH
authors.lastname: MacLean
authors.affiliation: Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Padgett
mesh_terms: D000368:Aged; D000768:Anesthesia, General; D019645:Arthroplasty, Replacement, Knee / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007297:Inpatients; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D057216:Propensity Score; D058996:Quality Improvement; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: aftercare; alternative payment models; episode of care; medicare; postoperative complications; total knee arthroplasty