McLawhorn Alexander S, Fu Michael C, Schairer William W, Sculco Peter K, MacLean Catherine H, Padgett Douglas E
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
Chief Value Medical Officer, Hospital for Special Surgery, New York, New York.
J Arthroplasty. 2017 Sep;32(9S):S113-S118. doi: 10.1016/j.arth.2017.01.039. Epub 2017 Feb 1.
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.
全膝关节置换术（TKA）后出院目的地，无论是回家还是入住专业护理机构，可能与急性后期护理结果的显著差异相关。本研究的目的是描述初次TKA术后相对于出院目的地的30天出院后结果。
在国家外科质量改进计划数据库中识别出2011年至2014年因骨关节炎进行的所有初次单侧TKA手术。基于出院前特征的倾向评分用于调整出院目的地的选择偏倚。倾向调整后的多变量逻辑回归用于检验出院目的地与出院后并发症之间的关联。
在识别出的101256例初次TKA手术中，70628例出院回家，30628例入住专业护理机构。入住专业护理机构的患者更常为女性、年龄较大、体重指数类别较高、Charlson合并症指数和美国麻醉医师协会评分较高、出院前有并发症、接受全身麻醉且术前被归类为非独立生活。倾向调整消除了这种选择偏倚。TKA术后入住专业护理机构的患者发生任何重大并发症（优势比=1.25；95%置信区间，1.13 - 1.37）和再次入院（优势比=1.81；95%置信区间，1.50 - 2.18）的几率更高。专业护理与呼吸、感染、血栓栓塞和泌尿系统并发症的几率增加相关。与死亡、心脏和伤口并发症的关联不显著。
在控制出院前特征后，初次TKA术后入住专业护理机构与回家相比，发生多种并发症和计划外再次入院的几率更高。这些结果支持协调护理路径，以便在TKA住院后尽可能促进回家出院。
