Paxton Elizabeth W, Inacio Maria C S, Singh Jasvinder A, Love Rebecca, Bini Stefano A, Namba Robert S
Kaiser Permanente, Surgical Outcomes and Analysis, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
Clin Orthop Relat Res. 2015 Nov;473(11):3446-55. doi: 10.1007/s11999-015-4278-x.
Although total hip arthroplasty (THA) is a successful procedure, 4% to 11% of patients who undergo THA are readmitted to the hospital. Prior studies have reported rates and risk factors of THA readmission but have been limited to single-center samples, administrative claims data, or Medicare patients. As a result, hospital readmission risk factors for a large proportion of patients undergoing THA are not fully understood.
QUESTIONS/PURPOSES: (1) What is the incidence of hospital readmissions after primary THA and the reasons for readmission? (2) What are the risk factors for hospital readmissions in a large, integrated healthcare system using current perioperative care protocols?
The Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) was used to identify all patients with primary unilateral THAs registered between January 1, 2009, and December 31, 2011. The KPTJRR's voluntary participation is 95%. A logistic regression model was used to study the relationship of risk factors (including patient, clinical, and system-related) and the likelihood of 30-day readmission. Readmissions were identified using electronic health and claims records to capture readmissions within and outside the system. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Of the 12,030 patients undergoing primary THAs included in the study, 59% (n = 7093) were women and average patient age was 66.5 years (± 10.7).
There were 436 (3.6%) patients with hospital readmissions within 30 days of the index procedure. The most common reasons for readmission were infection and inflammatory reaction resulting from internal joint prosthetic (International Classification of Diseases, 9(th) Revision, Clinical Modification [ICD-9-CM] 996.66, 7.0%); other postoperative infection (ICD-9-CM 998:59, 5.5%); unspecified septicemia (ICD-9-CM 038.9, 4.9%); and dislocation of a prosthetic joint (ICD-9-CM 996.42, 4.7%). In adjusted models, the following factors were associated with an increased likelihood of 30-day readmission: medical complications (OR, 2.80; 95% CI, 1.59-4.93); discharge to facilities other than home (OR, 1.89; 95% CI, 1.39-2.58); length of stay of 5 or more days (OR, 1.80; 95% CI, 1.22-2.65) versus 3 days; morbid obesity (OR, 1.74; 95% CI, 1.25-2.43); surgeries performed by high-volume surgeons compared with medium volume (OR, 1.53; 95% CI, 1.14-2.08); procedures at lower-volume (OR, 1.41; 95% CI, 1.07-1.85) and medium-volume hospitals (OR, 1.81; 95% CI, 1.20-2.72) compared with high-volume ones; sex (men: OR, 1.51; 95% CI, 1.18-1.92); obesity (OR, 1.32; 95% CI, 1.02-1.72); race (black: OR, 1.26; 95% CI, 1.02-1.57); increasing age (OR, 1.03; 95% CI, 1.01-1.04); and certain comorbidities (pulmonary circulation disease, chronic pulmonary disease, hypothyroidism, and psychoses).
The 30-day hospital readmission rate after primary THA was 3.6%. Modifiable factors, including obesity, comorbidities, medical complications, and system-related factors (hospital), have the potential to be addressed by improving the health of patients before this elective procedure, patient and family education and planning, and with the development of high-volume centers of excellence. Nonmodifiable factors such as age, sex, and race can be used to establish patient and family expectations regarding risk of readmission after THA. Contrary to other studies and the finding of increased hospital volume associated with lower risk of readmission, higher volume surgeons had a higher risk of patient readmission, which may be attributable to the referral patterns in our organization.
Level III, therapeutic study.
尽管全髋关节置换术（THA）是一种成功的手术，但接受THA的患者中有4%至11%会再次入院。先前的研究报告了THA再入院率及风险因素，但仅限于单中心样本、行政索赔数据或医疗保险患者。因此，对于大部分接受THA的患者，医院再入院风险因素尚未完全明确。
问题/目的：（1）初次THA术后医院再入院的发生率及再入院原因是什么？（2）在使用当前围手术期护理方案的大型综合医疗系统中，医院再入院的风险因素有哪些？
利用凯撒医疗集团（KP）全关节置换登记系统（TJRR）识别2009年1月1日至2011年12月31日期间登记的所有初次单侧THA患者。KPTJRR的自愿参与率为95%。采用逻辑回归模型研究风险因素（包括患者、临床和系统相关因素）与30天再入院可能性之间的关系。通过电子健康和索赔记录识别再入院情况，以获取系统内外的再入院信息。计算比值比（OR）和95%置信区间（CI）。在纳入研究的12,030例接受初次THA的患者中，59%（n = 7093）为女性，患者平均年龄为66.5岁（±10.7）。
在初次手术30天内有436例（3.6%）患者再次入院。最常见的再入院原因是关节假体内部感染和炎症反应（国际疾病分类第9版临床修订本[ICD-9-CM] 996.66，7.0%）；其他术后感染（ICD-9-CM 998:59，5.5%）；未明确的败血症（ICD-9-CM 038.9，4.9%）；以及人工关节脱位（ICD-9-CM 996.42，4.7%）。在调整模型中，以下因素与30天再入院可能性增加相关：医疗并发症（OR，2.80；95% CI，1.59 - 4.93）；出院至非家中机构（OR，1.89；95% CI，1.39 - 2.58）；住院时间为5天或更长时间（OR，1.80；95% CI，1.22 - 2.65）与3天相比；病态肥胖（OR，1.74；95% CI，1.25 - 2.43）；高手术量外科医生进行的手术与中等手术量相比（OR，1.53；95% CI，1.14 - 2.08）；低手术量（OR，1.41；95% CI，1.07 - 1.85）和中等手术量医院（OR，1.81；95% CI，1.20 - 2.72）与高手术量医院相比；性别（男性：OR，1.51；95% CI，1.18 - 1.92）；肥胖（OR，1.32；95% CI，1.02 - 1.72）；种族（黑人：OR，1.26；95% CI，1.02 - 1.57）；年龄增长（OR，1.03；95% CI，1.01 - 1.04）；以及某些合并症（肺循环疾病、慢性肺部疾病、甲状腺功能减退和精神病）。
初次THA术后30天医院再入院率为3.6%。可改变的因素，包括肥胖、合并症、医疗并发症和系统相关因素（医院），有可能通过在这种择期手术前改善患者健康状况、患者及家属教育与规划以及发展高手术量卓越中心来解决。不可改变的因素，如年龄、性别和种族，可用于设定患者及家属对THA术后再入院风险的预期。与其他研究以及医院手术量增加与再入院风险降低的发现相反，高手术量外科医生的患者再入院风险更高，这可能归因于我们机构的转诊模式。
III级，治疗性研究。
