CORRInsights®: Which Clinical and Patient Factors Influence the National Economic Burden of Hospital Readmissions After Total Joint Arthroplasty

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Medicare's Bundled Payments for Care Improvement (BPCI) initiative is a cost-control program containing four payment and service-delivery models intended to reduce expenditures while preserving or enhancing quality of care [2, 4]. As a high-value procedure, Medicare identified total joint arthroplasty for bundled payments in an effort to address its potentially high costs.
Hospital readmission rate, formalized in the Affordable Care Act through the Medicare Hospital Readmissions Reduction Program [3], is a major quality and cost-control metric used by hospitals, clinicians, and policymakers alike [6]. BPCI holds hospitals and/or Accountable Care Organizations financially responsible for readmissions for any reason between 30 and 90 days after discharge following THA or TKA. The design and effective implementation of these “risk sharing” or “risk transfer” policies are points of active discussion with profound implications that demand objective data and metrics.
In their study, Kurtz and colleagues offer a first look at the Nationwide Readmissions Database (NRD) from the Healthcare Cost and Utilization Project, an important and fascinating new dataset used to calculate the per-patient cost of 90-day readmissions for TKA and THA. This study challenges orthopaedic surgeons to use this information as a catalyst for reducing the mounting costs related to joint arthroplasty services in our aging US-population.
The most-effective method of improving patient care and reducing readmissions is to avoid complications. Most important, by far, is reducing the risk of prosthetic joint infection. Kurtz and colleagues found that in TKAs, infection dwarfs the impact of deep vein thrombosis/pulmonary embolism, hematoma, or fracture. For THA, infection is responsible for more than one-third of readmissions, followed closely by dislocation, fracture hematoma, and deep vein thrombosis/pulmonary embolism.
The health and social benefits of effective arthroplasty in relieving pain and restoring function for patients with joint disease is profound, durable, and highly cost-effective [1]. However, the individual benefits vary. Because joint disease is often polyarticular, the impact of treatment of a single joint on total health and mobility may be limited, even if the effect on pain and function in that joint is profound. Comorbidities, such as heart disease, may vastly increase risk for readmission, independent of the outcome in the joint or limb.
On a global level, the core goals of arthroplasty surgery and immediate perioperative care boil down to two statements: (1) Restore function and mobility in the affected joint for the remainder of a patient's life and (2) avoid complications.
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