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Study Finds Racial Variation in Post-Operative Care Following Knee Replacement Surgery

A large study analyzing 107,000 knee replacement surgeries found that African Americans were significantly more likely than white patients to be discharged to an inpatient rehabilitation or skilled nursing facility rather than home care after the procedure. Researchers also found that African American patients under 65 were more likely to be readmitted to the hospital within 90 days of a knee replacement.

The regional database analysis study was published in JAMA Network Open, an open access journal of the American Medical Association, on October 30. It was a collaborative effort among researchers from Hospital for Special Surgery (HSS) in New York City (Michael L. Parks, MD), the University of Alabama at Birmingham (Jasvinder Singh, MBBS, MPH), the University of Pennsylvania (Yong Chen, PhD) and Weill Cornell Medicine/New York Presbyterian Hospital (Said A. Ibrahim, MD, MPH). The study included patients who had elective knee replacement surgery in the state of Pennsylvania between 2012 and 2015.

“Total knee replacement is one of the most common and successful elective procedures performed in adults with arthritis, and previous studies have described racial disparities in outcomes,” said Dr. Parks, hip and knee surgeon at HSS who was involved in study concept and design and in drafting the manuscript. “For this study, we wanted to determine if there was an association of race/ethnicity with discharge destination and hospital readmission after this procedure.”

Demand for total knee replacement in the United States has been projected to increase by more than 600% between 2005 and 2030. In a 2009 national estimate, the number of total knee replacements performed in the United States exceeded 750,000 surgeries annually.

The study authors noted that postoperative care and rehabilitation after surgery account for a significant portion of the overall cost of care. In 2014, the Centers for Medicare & Medicaid Services, the largest payer of total joint replacement, introduced the Medicare Bundled Payment for Care Improvement initiative, which included payment models to hold hospitals accountable for costs related to joint replacement for 90 days after patients' hospital discharge.

In addition to analyzing the racial/ethnic variation in discharge destination, the researchers also wanted to determine if postoperative discharge to an inpatient rehab facility or skilled nursing facility was associated with higher odds of hospital readmission up to 90 days after surgery. They noted that hospital readmissions are not only costly and associated with an increased morbidity burden; they also represent a major policy initiative for Medicare reimbursement.

For their retrospective study, investigators used data from the Pennsylvania Health Care Cost Containment Council. It included demographic information from all discharges of patients who underwent elective primary total knee replacement in 170 hospitals in Pennsylvania from April 2012 to September 2015. They compiled statistics on how many patients went to an inpatient rehab center, how many went to a skilled nursing facility for rehabilitation and how many received their rehab at home after a knee replacement.

“The analytic sample, which included a total of 107,768 patients, found that African American patients were 2.5- to 5-times more likely than white patients to be discharged to an inpatient rehabilitation facility or skilled nursing facility rather than to their home. In 2015, almost 50 percent of African American patients were discharged to a skilled nursing facility,” said Dr. Parks.

Among patients younger than 65, African American patients also had 1.3-times higher odds of 90-day hospital readmission, although there was no difference in hospital readmission rates in patients who were 65 or older. Discharge destination to an inpatient or skilled nursing facility for rehabilitation was associated with increased odds of hospital readmission.

Noting that their findings are significant, the researchers wrote: “It is possible that the decision on where to discharge patients after a surgical procedure is informed not only by clinical indications but also by social determinants of health, including socioeconomic status, employment, and social support, of which race/ethnicity might be a marker.”

They noted that future studies are needed to evaluate the decision­making process regarding discharge destination and how social determinants of health affect these decisions. They advised that future studies should also examine how Centers for Medicare & Medicaid Services policy reforms, such as Bundled Payment for Care Improvement, affect not only cost and quality of care, but also equity.

“We need to understand that there are people who may not fit into the new complex reimbursement bundles who require specialized care, and we need to make sure we address their needs going forward,” Dr. Parks said.

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a fourth consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnose, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.