Abstract
Total knee arthroplasty (TKA) is one of the most common elective procedures performed in adults with end-stage arthritis. Racial disparities in TKA outcomes have been described in the literature. To assess the association of race/ethnicity with discharge disposition and hospital readmission after elective primary TKA and to assess the association of nonhome discharge disposition with hospital readmission risk. This retrospective cohort study used data from the Pennsylvania Health Care Cost Containment Council Database, a large regional database that included demographic data from all discharges of patients who underwent elective primary TKA in 170 nongovernmental acute care hospitals in Pennsylvania from April 1, 2012, to September 30, 2015. Data analyses were conducted from September 29, 2017, to November 29, 2017. Patient race/ethnicity and discharge disposition. Discharge disposition and 90-day hospital readmission. Among 107 768 patients, 7287 (6.8%) were African American, 68 372 (63.4%) were women, 46 420 (43.1%) were younger than 65 years, and 60 636 (56.3%) were insured by Medicare. In multivariable logistic regression, among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) (adjusted relative risk ratio [aRRR], 2.49 [95% CI, 1.42-4.36]; P = .001) or a skilled nursing facility (SNF) (aRRR, 3.91 [95% CI, 2.17-7.06]; P < .001) and had higher odds of 90-day hospital readmission (adjusted odds ratio [aOR], 1.30 [95% CI, 1.02-1.67]; P = .04). Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF (aRRR, 3.30 [95% CI, 1.81-6.02]; P < .001). In both age groups, discharge to an IRF (age <65 years: aOR, 3.62 [95% CI, 2.33-5.64]; P < .001; age ≥65 years: aOR, 2.85 [95% CI, 2.25-3.61]; P < .001) or SNF (age <65 years: aOR, 1.91 [95% CI, 1.37-2.65]; P < .001; age ≥65 years: aOR, 1.55 [95% CI, 1.27-1.89]; P < .001) was associated with higher odds of 90-day readmission. This cohort study found that race/ethnicity was associated with higher odds of discharge to an IRF or SNF for postoperative care after primary TKA. Among patients younger than 65 years, African American patients were more likely than white patients to be readmitted to the hospital within 90 days. Discharge to an IRF or SNF for postoperative care and rehabilitation was also associated with a higher risk of readmission to an acute care hospital.
Highlights
Total knee arthroplasty (TKA) is considered one of the most successful elective orthopedic procedures
Among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) or a skilled nursing facility (SNF) and had higher odds of 90-day hospital readmission
Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF
Summary
Total knee arthroplasty (TKA) is considered one of the most successful elective orthopedic procedures. Clinical indications for joint replacement, such as radiographic indications of knee OA-related[7,8,9,10] or arthritis-related activity, work limitations, and severe pain, have been shown to disproportionately affect African American patients compared with white patients,[7,9,10,11,12,13,14] a 2005 study[15] reported marked racial variations in the receipt of elective joint replacement The reasons for this disparity are complex and may involve patient-, clinician-, and system-level factors, including socioeconomic disparities, patient preference, medical comorbidity, depression, education, health literacy, and the patient-physician relationship.[16,17,18,19,20,21,22,23,24] One aspect of the disparity may be whether there are variations in postoperative care and rehabilitation after the surgical procedure. Discharge to an inpatient facility, such as an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF), was associated with increased odds of all-cause 30-day readmission to an acute care hospital.[25]
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