Visits to the Emergency Department After Joint Replacement: Commentary on an article by Micaela A. Finnegan, BA, et al.

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The article by Finnegan et al. highlights a somewhat underrecognized occurrence, an unplanned visit to the emergency department following hip or knee replacement surgery.
The authors specifically sought to determine how many patients return to the emergency department within 30 days of discharge, if this visit was related to pain, and what factors were related to an increased risk of visits to the emergency department.
They accomplished this by performing an observational, population-based study using 2 large databases: the State Inpatient Database and the State Emergency Department database for 3 states. This represents an example of the current trend of using large databases for population-based research, which allow us to answer questions that could not be answered any other way. This article focused specifically on the correlation with an event that is perceived to be uncommon: a visit to the emergency department after a hip or knee replacement without any identifiable risk factors. This is an important question for the surgeons involved in these procedures but also for health-care policy-makers who should know the numbers related to emergency department visits.
We should be aware that utilizing different databases will produce different results. In this article, 3 specific states were evaluated: New York, California, and Florida. There may be differences between these and other states or other countries. These differences should not diminish the results, but should make us look at them with acknowledgment of this limitation.
The advantage of the study is that it did identify complications that do not require readmission, which has been one of the limitations of using 30-day readmission rates as a proxy for the complication rate. The finding that a visit to the emergency department was a much more frequent occurrence than readmission is important, and the main reason for a visit to the emergency department was pain. This highlights the fact that we have a long way to go to optimize and standardize pain management after a major elective surgical procedure as these visits most likely would not have occurred if an appropriate pain management strategy had been implemented.
Finnegan et al. also found that black patients and those with Medicaid were far more likely to return for pain-related issues. It is hypothesized that racial disparities in the pain experience make recurrence of pain more likely in these patients. However, it could also be inferred that patients from a lower socioeconomic status have less access to proper pain management; this situation should be addressed by health-care providers, who should not allow this double standard to occur.
This study does not pretend to be an outcome study, but merely a population-based study that was effective in identifying gaps in the continuum of care for patients undergoing total hip or knee replacement.
The authors recognize the limitations of this administrative database study and suggest areas of future research into the subject, specifically improving pain management for a vulnerable population undergoing total hip and knee replacement.
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