Patient Risk Factors Do Not Impact 90-Day Readmission and Emergency Department Visitation After Total Ankle Arthroplasty: Implications for the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Plan.

backgroundThe Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital care and care within 90 days following discharge for Medicare beneficiaries undergoing lower-extremity joint replacement involving the hip, knee, or ankle (total hip arthroplasty, total knee arthroplasty, or total ankle arthroplasty [TAA]). The study hypothesis was that patient comorbidities are associated with readmissions, emergency department (ED) utilization, and subspecialist wound-healing consultation, which are examples of costly contributors to postoperative health-care spending.

methodsThe medical records for 1,024 patients undergoing TAAs between June 2007 and December 2016 at a single academic center in the southeastern United States were reviewed for the outcomes of readmissions, ED visitations, and subspecialist wound-healing consultation within the 90-day post-discharge period. All patients undergoing TAA (n = 1,365) were eligible. Of the 1,037 patients who consented to participation in the study and underwent TAA, 1,024 (98.7%) completed the study. Medical comorbidities according to the Elixhauser and Charlson-Deyo comorbidity indices that were present prior to TAA were recorded. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes.

resultsFour hundred and ninety-six (48.4%) of the 1,024 patients were female, and 964 (94.1%) were white/Caucasian, with an average age (and standard deviation) of 63 ± 10.5 years. Hypertension, obesity, solid tumor, depression, rheumatic disease, cardiac arrhythmia, hypothyroidism, diabetes mellitus, and chronic pulmonary disease had a prevalence of >10%. Fifty-three (5.2%) of the 1,024 patients were readmitted for any cause. Thirty-six (3.5%) of the 1,024 returned to the ED but were not admitted to the hospital. Readmission or ED visitation was most commonly for a wound complication, followed by deep venous thrombosis (DVT) and pulmonary embolism (PE) evaluation, while urgent medical evaluations composed the majority of non-TAA-related ED visitations. No patient comorbidities were significantly associated with 90-day readmission, ED visitation, or wound complications in multivariable models.

conclusionsPatient comorbidities were not associated with 90-day hospital readmissions or ED visitation for patients undergoing TAA. Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. These data suggest that there may be considerable differences between TAA and total hip arthroplasty or total knee arthroplasty that cause surgeons to question the inclusion of TAA in CJR bundled payment models. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.