Keswani Aakash, Tasi Michael C, Fields Adam, Lovy Andrew J, Moucha Calin S, Bozic Kevin J
Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, New York.
Department of Orthopaedic Surgery, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
J Arthroplasty. 2016 Jun;31(6):1155-1162. doi: 10.1016/j.arth.2015.11.044. Epub 2016 Jan 20.
This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination.
Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables.
A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001).
SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.
本研究旨在比较择期全关节置换术（TJA）患者按出院目的地划分的出院后不良事件风险，确定住院出院安置及出院后不良事件的风险因素，并根据这些风险因素对TJA患者进行分层，以确定最合适的出院目的地。
在国家外科质量改进计划数据库中识别出2011年至2013年接受择期初次全髋关节或膝关节置换术的患者。使用围手术期变量进行双变量和多变量分析。
共分析了106360例TJA患者。最常见的出院目的地包括回家（70%）、熟练护理机构（SNF）（19%）和住院康复机构（IRF；11%）。双变量分析显示，SNF和IRF患者出院后不良事件发生率更高（所有P≤0.001）。在控制患者特征、合并症和出院前并发症发生率的多变量分析中，SNF和IRF患者更有可能发生出院后严重不良事件（SNF：比值比[OR]：1.46，P≤0.001；IRF：OR：1.59，P≤0.001）和非计划再入院（SNF：OR：1.42，P≤0.001；IRF：OR：1.38，P≤0.001）。在按出院后不良结局的最强独立风险因素（OR：≥1.15，P≤0.05）对患者进行分层后，我们发现回家出院是将出院后30天严重不良事件发生率（6个风险水平中的5个P≤0.05）和非计划30天再入院率（7个风险水平中的6个P≤0.05）降至最低的最佳策略。多变量分析显示，出院前严重不良事件发生率、女性性别、功能状态、体重指数>40、吸烟、糖尿病、肺部疾病、高血压和美国麻醉医师协会3/4级是不住院出院的独立预测因素（所有P≤0.001）。
与回家相比，SNF或IRF出院增加了出院后不良事件的风险。术前应处理不住院出院和出院后不良事件的可改变风险因素，以改善不同出院环境下的患者结局。
