Division of Behavioral Science and Community Health, UConn Health, Farmington, Connecticut.
Center for Population Health, UConn Health, Farmington, Connecticut.
J Bone Joint Surg Am. 2019 Nov 20;101(22):2044-2050. doi: 10.2106/JBJS.18.01112.
Racial and ethnic disparities in hospital readmissions following total joint arthroplasty present opportunities for reducing cost and improving health equity. Despite efforts to reduce readmissions following total joint arthroplasty in the general population, no studies have documented the impact of these efforts on racial and ethnic disparities in total joint arthroplasty readmissions. The purpose of this study was to determine whether comprehensive efforts to reduce hospital readmissions following total joint arthroplasty have impacted racial and ethnic disparities in readmission rates during the period from 2005 to 2015.
We conducted a retrospective analysis comparing patients readmitted and not readmitted to the hospital within 30 days of a total joint arthroplasty by estimating logistic regression models for clustered data using generalized estimating equations (GEEs) in R. Connecticut hospital discharge data for patients admitted for International Classification of Diseases, Ninth Revision (ICD-9) procedure codes 81.51 and 81.54 (Current Procedural Terminology [CPT] codes 27130 and 27447) during the 2005 to 2015 U.S. Centers for Medicare & Medicaid Services (CMS) fiscal years were analyzed. Models included quadratic terms to capture nonlinear time trends in readmissions, as well as terms for the statistical interaction between race or ethnicity and both the linear and quadratic time trends in predicting the odds of readmission.
There were 102,510 total admissions to Connecticut hospitals for total joint arthroplasty from 2005 to 2015. The 30-day (all-cause) readmission rate declined from 5.1% in 2005 to 3.6% in 2015, with a steeper downward trend observed from 2009 to 2015. The results from logistic models indicated that black patients (odds ratio [OR], 1.68; p < 0.0001) and Hispanic patients (OR, 1.48; p < 0.0001) were significantly more likely to be readmitted within 30 days of discharge following a total joint arthroplasty than white patients over the study period. The significant interaction of black race and the quadratic time trend in models capturing nonlinear trends in readmission over time indicated that the readmission rates for black patients increased compared with those for white patients from 2005 through 2008 and decreased relative to those for white patients from 2009 to 2015 (OR, 0.24; p = 0.030).
Data from Connecticut hospitals show that 30-day readmissions following a total joint arthroplasty declined by 1.5 percentage points from 2005 to 2015, and that this decline was much more pronounced among black patients, resulting in the narrowing of racial disparities in readmission following a surgical procedure.
Racial and ethnic minorities have historically been at increased risk for complications and readmission following hospital-based surgical care. This analysis of readmission following total joint arthroplasty reveals that such disparities are remediable and should foster further research on the primary drivers of and remedies for readmission disparities.
全关节置换术后住院再入院的种族和民族差异为降低成本和改善公平性提供了机会。尽管为减少普通人群中全关节置换术后的再入院率做出了努力，但没有研究记录这些努力对全关节置换术后再入院率的种族和民族差异的影响。本研究的目的是确定全面减少全关节置换术后住院再入院的努力是否影响了 2005 年至 2015 年期间全关节置换术后再入院率的种族和民族差异。
我们通过使用 R 中的广义估计方程（GEE）对聚类数据进行逻辑回归模型估计，比较了在全关节置换术后 30 天内再次入院和未再次入院的患者。分析了 2005 年至 2015 年美国医疗保险和医疗补助服务中心（CMS）财政年度期间，康涅狄格州医院因国际疾病分类，第 9 版（ICD-9）手术代码 81.51 和 81.54（当前操作术语[CPT]代码 27130 和 27447）入院的患者的出院数据。模型包括二次项，以捕获再入院率的非线性时间趋势，以及种族或族裔与线性和二次时间趋势之间的统计学交互项，以预测再入院的可能性。
2005 年至 2015 年间，康涅狄格州共有 102510 例全关节置换术入院。30 天（所有原因）再入院率从 2005 年的 5.1%下降到 2015 年的 3.6%，从 2009 年到 2015 年呈更陡峭的下降趋势。逻辑模型的结果表明，黑人患者（比值比[OR]，1.68；p<0.0001）和西班牙裔患者（OR，1.48；p<0.0001）在全关节置换术后 30 天内再次入院的可能性明显高于白人患者在整个研究期间。黑人种族与捕获随时间变化的再入院非线性趋势的二次时间趋势的显著交互作用表明，与白人患者相比，黑人患者的再入院率从 2005 年到 2008 年增加，而从 2009 年到 2015 年与白人患者相比有所下降（OR，0.24；p=0.030）。
康涅狄格州医院的数据显示，2005 年至 2015 年全关节置换术后 30 天的再入院率下降了 1.5 个百分点，黑人患者的下降幅度更为明显，导致术后手术再入院的种族差异缩小。
历史上，少数民族在基于医院的外科护理后并发症和再入院的风险更高。对全关节置换术后再入院的分析表明，这种差异是可以纠正的，应该进一步研究再入院差异的主要驱动因素和补救措施。
