Readmission Rates and Diagnoses Following Total Hip Replacement in Relation to Insurance Payer Status, Race and Ethnicity, and Income Status
Total hip replacements (THRs) are the sixth most common surgical procedure performed in the USA. Readmission rates are estimated at between 4.0 and 10.9%, and mean costs are between $10,000 and $19,000. Readmissions are influenced by the quality of care received. We sought to examine differences in readmissions by insurance payer, race and ethnicity, and income status.
We analyzed all THRs from 2007 to 2011 in California, Florida, and New York from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Primary outcomes were readmission at 30 and 90 days after THR. Descriptive statistics were calculated, and multivariate logistic regression analysis was used to estimate adjusted odds ratio (OR) for readmissions. Statistical significance was evaluated at the < 0.05 alpha level.
A total of 274,851 patients were included in the analyses. At 30 days (90 days), 5.6% (10.2%) patients had been readmitted. Multivariate logistic regression analysis showed that patients insured by Medicaid (OR 1.23, 95%CI 1.17–1.29) and Medicare (OR 1.58, 95%CI 1.44–1.73) had increased odds of 30-day readmission, as did patients living in areas with lower incomes, Black patients, and patients treated at lower volume hospitals. Ninety-day readmissions showed similar significant results.
The present study has shown that patients on public insurance, Black patients, and patients who live in areas with lower median incomes have higher odds of readmission. Future research should focus on further identifying racial and socioeconomic disparities in readmission after THR with an eye towards implementing strategies to ameliorate these differences.
KeywordsHealthcare disparities Total hip replacement Primary payer status Readmission Administrative database Outcomes research
Compliance with Ethical Standards
The Weill Cornell Medicine Institutional Review Board approved all study activities.
Conflict of Interest
The authors declare that they have no conflict of interest.
- 1.HCUPnet. A tool for identifying, tracking, and analyzing national hospital statistics. Rockville, MD. 2013. https://hcupnet.ahrq.gov/#setup. Accessed 10 Sept 2013.
- 3.Xu HF, White RS, Sastow DL, Andreae MH, Gaber-Baylis LK, Turnbull ZA. Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York. J Clin Anesth. 2017;43:24–32. https://doi.org/10.1016/j.jclinane.2017.09.008.CrossRefPubMedGoogle Scholar
- 6.Weiss A, Elixhauser A, Steiner C. Readmissions to US hospitals by procedure, 2010: statistical brief# 154. Rockville: Agency for Health Care Policy and Research (US); 2006.Google Scholar
- 12.Federal Register/Vol. 78, No. 160. Government Publishing Office. 2013. http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf. Accessed 2 June 2017.
- 13.Federal Register/Vol. 76, No. 160. 2011. https://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-19719.pdf. Accessed 2 June 2017.
- 14.Boccuti C, Casillas G. Aiming for fewer hospital U-turns: the Medicare hospital readmission reduction program. Henry J Kaiser Fam Found. 2015:1–10.Google Scholar
- 15.National Quality Measures C. Total hip arthroplasty (THA) and/or total knee arthroplasty (TKA): hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA. Agency for Healthcare Research and Quality (AHRQ), Rockville MD. 2015. https://www.qualitymeasures.ahrq.gov/summaries/summary/49200/total-hip-arthroplasty-tha-andor-total-knee-arthroplasty-tka-hospitallevel-30day-allcause-riskstandardized-readmission-rate-rsrr-following-elective-primary-tha-andor-tka.
- 16.The Patient Protection and Affordable Care Act. Washington, DC.Google Scholar
- 17.Federal Register/Vol. 77, No. 170. 2012. http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011-19719.pdf. Accessed 10 Sept 2013.
- 18.Dummit LA, Kahvecioglu D, Marrufo G, Rajkumar R, Marshall J, Tan E, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodes. JAMA. 2016;316(12):1267–78. https://doi.org/10.1001/jama.2016.12717.CrossRefPubMedGoogle Scholar
- 19.Bundled Payments for Care Improvement (BPCI) Initiative: general information. https://innovation.cms.gov/initiatives/Bundled-Payments/index.html. Accessed 29 Aug 2015.
- 21.Paxton EW, Inacio MC, Singh JA, Love R, Bini SA, Namba RS. Are there modifiable risk factors for hospital readmission after total hip arthroplasty in a US healthcare system? Clin Orthop Relat Res. 2015;473(11):3446–55. https://doi.org/10.1007/s11999-015-4278-x.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Ricciardi BF, Oi KK, Daines SB, Lee YY, Joseph AD, Westrich GH. Patient and perioperative variables affecting 30-day readmission for surgical complications after hip and knee arthroplasties: a matched cohort study. J Arthroplast. 2017;32(4):1074–9. https://doi.org/10.1016/j.arth.2016.10.019.CrossRefGoogle Scholar
- 32.HCUP. Overview of the state inpatient databases. Healthcare cost and utilization project. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed 4 Feb 2017.
- 33.HCUP. HCUP quality control procedures. Agency for Healthcare Research and Quality, Rockville, MD. 2016. https://www.hcup-us.ahrq.gov/db/quality.jsp. Accessed 20 Nov 2017.
- 34.Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130–9. https://doi.org/10.1097/01.mlr.0000182534.19832.83.CrossRefPubMedGoogle Scholar
- 36.Barnett JC, Vornovitsky MS. Health insurance coverage in the United States: 2015. US Census Bureau, Current Population Reports, Report 2016 (P60–257).Google Scholar
- 37.Parker K, Horowitz J, Mahl B. On views of race and inequality, blacks and whites are worlds apart. Pew Research Center. Retrieved from http://www.pewsocialtrends.org/files/2016/06/ST_2016; 2016.
- 40.Zhang W, Lyman S, Boutin-Foster C, Parks ML, Pan TJ, Lan A, et al. Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty. J Bone Joint Surg Am. 2016;98(15):1243–52. https://doi.org/10.2106/jbjs.15.01009.CrossRefPubMedGoogle Scholar
- 41.Ravi P, Sood A, Schmid M, Abdollah F, Sammon JD, Sun M, et al. Racial/ethnic disparities in perioperative outcomes of major procedures: results from the National Surgical Quality Improvement Program. Ann Surg. 2015;262(6):955–64. https://doi.org/10.1097/sla.0000000000001078.CrossRefPubMedGoogle Scholar
- 42.Adelani MA, Keller MR, Barrack RL, Olsen MA. The impact of hospital volume on racial differences in complications, readmissions, and emergency department visits following total joint arthroplasty. J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2017.09.034.
- 44.J. J. Utah is nation’s fastest-growing state, Census Bureau Reports. US Census Bureau. http://www.census.gov2017/. Accessed 8 Feb 2017.
- 53.Fleischut PM, Eskreis-Winkler JM, Gaber-Baylis LK, Giambrone GP, Faggiani SL, Dutton RP, et al. Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute. Am J Med Qual. 2015;30(2):172–9. https://doi.org/10.1177/1062860614525989.CrossRefPubMedGoogle Scholar
- 59.Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296–301. https://doi.org/10.1073/pnas.1516047113.CrossRefPubMedPubMedCentralGoogle Scholar
- 60.Wiznia DH, Zaki T, Maisano J, Kim CY, Halaszynski TM, Leslie MP. Influence of medical insurance under the affordable care act on access to pain management of the trauma patient. Reg Anesth Pain Med. 2017;42(1):39–44. https://doi.org/10.1097/aap.0000000000000502.CrossRefPubMedPubMedCentralGoogle Scholar
- 65.Jordan CJ, Goldstein RY, Michels RF, Hutzler L, Slover JD, Bosco JA 3rd. Comprehensive program reduces hospital readmission rates after total joint arthroplasty. Am J Orthop (Belle Mead NJ). 2012;41(11):E147–51.Google Scholar
- 67.Coughlin TA, Long SK, Clemans-Cope L, Resnick D. What difference does medicaid make? Assessing cost effectiveness, access, and financial protection under Medicaid for low-income adults. Kaiser Commission Medicaid and the Uninsured. 2013.Google Scholar