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Background: Total knee arthroplasty (TKA) provides good clinical outcomes for the treatment of end-stage osteoarthritis; however, discharge destination after TKA has major implications on postoperative adverse outcomes and readmissions. With the initiation of Bundled Payments for Care Improvement (BPCI), it is unclear how racial disparities in discharge destination after TKA will be affected by the new bundled payment for TKA. Methods: Bundled Payments for Care Improvement was implemented in July 01, 2014, at the University of Pennsylvania. We compared differences during early implementation (July 1, 2014, to, March 30, 2016) and during late policy implementation (April 1, 2016, to February 28, 2017) in patient characteristics (including race: African American [AA], white, and other race), discharge destination (skilled nursing facility [SNF], inpatient rehabilitation facility, home, home with home health, or other), and outcomes. Results: We identified 2276 patients who underwent TKA (43.8% AA, 48.2% white, and 8.0% other race). African American patients were more likely to be discharged to SNF as opposed to home than white patients both during the early BPCI (AA: 53.0%, n = 320; white: 32.4%, n = 210, P < .05) and late BPCI implementation (AA: 44.4%, n = 169, white: 26.9%, n = 120, P < .05), though all races showed trends to decreasing SNF use during the late BPCI implementation. Discussion: There were no significant differences in readmissions, length of stay, mortality, or intensive care unit days during early and late implementation of BPCI or when AA patients were compared to white patients. Conclusion: We found no significant changes in racial variations in discharge destination and outcomes after elective TKA. Bundled Payments for Care Improvement has encouraged better preoperative preparation of patients and discharge planning; however, payment reforms alone might not be sufficient to address variation in post-op management following elective surgery.

Background: Three-quarters of patients who undergo total hip replacement (THR) receive postsurgical rehabilitation care in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or through a home health agency. The objectives of this study are to examine racial differences where THR recipients receive postsurgical rehabilitation care and determine whether discharge destination is associated with hospital readmission. Methods: Using the Pennsylvania Health Care Cost Containment Council database, we selected African American (AA) or white adults who underwent THR surgery (n = 68,016). We used multinomial logistic regression models to assess the relationship between race and postsurgical discharge destination. We calculated 90-day hospital readmission as function of discharge destination. Results: Among patients

Introduction: To examine racial variations in access to postacute care (PAC) and rehabilitation (Rehab) services following elective total knee arthroplasty and whether where patients go after surgery for PAC/Rehab is associated with 30-day readmission to acute care facility. Materials and Methods: Sample consisted of 129 522 patients discharged from 169 hospitals in the State of Pennsylvania between fiscal years 2008 and 2012. We used multinomial regression models to assess the relationship between patient race and discharge destination after surgery, for patients aged 18 to 64 years and for those aged 65 and older. We used multivariable (MV) regression and propensity score (PS) approaches to examine the relationship between patient discharge destination after surgery for PAC/Rehab and 30-day readmission, controlling for key individual- and facility-level factors. Results: Lower proportions of younger patients compared to those older than 65 were discharged to inpatient rehabilitation facilities (IRFs; 5.8% vs 12.6%, respectively) and skilled nursing facilities (SNFs; 15.2% vs 32.7%, respectively) compared to home-based Rehab (self-care; 23.3% vs 14.2%, respectively). Compared to whites, African American patients had significantly higher odds of discharge to IRF (age < 65, odds ratio = 2.04; age ≥ 65, odds ratio = 1.64) and to SNF (age < 65, odds ratio = 2.86; age ≥ 65, odds ratio = 2.19) and discharge to home care in patients younger than 65 years (odds ratio = 1.31). The odds of 30-day readmission among patients discharged to an IRF (MV odds ratio = 7.76; PS odds ratio = 8.34) and SNF (MV odds ratio = 2.01; PS odds ratio = 1.83) were significantly higher in comparison to patients discharged home with self-care. Conclusion: African American patients with knee replacement are more likely to be discharged to inpatient Rehab settings following surgery. Inpatient Rehab is significantly associated with 30-day readmission to acute care facility.

Background: Administrative data are commonly used to examine orthopedic outcomes including total hip arthroplasty (THA), but little is known about how minor analytic decisions impact results. Our objective was to examine how the rates of 3 adverse outcomes (deep vein thrombosis [DVT], pulmonary embolism [PE], and hemorrhage) varied with subtle adjustments to our analytic method. Methods : W e used Medicare Part A data to identify all beneficiaries who underwent primary or revision THA during 2007 to 2008. We used 2 published algorithms (Katz/Cram and Patient Safety Indicators [PSIs]) to identify cases of DVT, PE, and hemorrhage occurring at 3 different points in time; index admission; 30-day readmission; and index admission plus readmission. We used the kappa statistic to compare the agreement between methods. We examined variation in complication rates across hospitals using regression models that adjusted for differences in patient demographics and comorbidity. Results: Among 202 773 primary and 40 973 revision THA patients, the agreement between the Katz/Cram and PSI methods was excellent for DVT and PE at all time points (kappa 0.95-1.0) but poor for hemorrhage (kappa 0.07-0.29). The incidence of DVT during the index admission among the primary THA cohort was 0.40% using the Katz/Cram method and 0.37% using the PSI method. The incidence of hemorrhage during the index admission among the primary THA cohort was 1.29% using the Katz/Cram method and 0.05% using the PSI method. We found significant variation in hospital rates of all 3 complications (DVT, PE, and hemorrhage). For example, the mean rate of hemorrhage at index admission or readmission for revision THA was 5.7% (standard deviation: 12.8%); we found 137 hospitals with hemorrhage rates of 25% or higher among their revision THA patients. Discussion: We found important differences in the rates of THA complications depending upon the coding algorithms and time frame employed. Our results suggest that administrative data can be used to evaluate THA complications but that methodology should be carefully considered.