Abstract
Introduction
Inpatient rehabilitation services following joint replacement have been estimated to cost over $3 billion/ yr. A shift in reimbursement strategies to bundle payments with the goal of decreasing cost and improving quality has given discharge disposition after joint replacement a front row seat. Our objectives were (1) to establish a correlation between the accuracy of current tools utilized to predict discharge location and (2) compare preoperative and postoperative patient oriented outcomes (POO's) according to discharge disposition.
Methods
188 consecutive total hip arthroplasty (THA) surgeries performed by a single surgeon were prospectively studied. Pre-intervention assessment of the probable and preferred discharge disposition was performed using one of 5 tools (1) experienced surgical coordinator evaluation (2) Risk Assessment and Prediction Tool (RAPT); (3) Charlson Score; (4) ASA Score; and (5) Patient Self-Reported Health Status. Demographic characteristics, Visual Analogue Scale, QWB-7, SF-36, WOMAC, clinical scores were recorded before and after surgery. Correlation between final discharge disposition (home vs rehab) and its predictors was performed. Preoperative and postoperative outcomes were compared, p<0.05 was considered significant.
Results
Most accurate predictor of discharge disposition was determined by our experienced surgical coordinator (OR: 11.05; 95% CI of 2.21 to 55.32; p<0.001), followed by the RAPT (OR: 1.56; 95% CI of 1.29 to 1.90; p=0.01). We found a significant difference in age (Rehab: 72.4 SE 1.2 vs Home: 70.3 SE 1.0; p=0.01) and length of stay (Rehab: 3.6 SE 0.01 vs Home: 3.14 SE 0.07; p<0.001) between those discharged to rehab than those discharged home. Mean follow-up time was 2.22 years (range 1–4 years). There was a significant difference between groups on most outcome measures preoperatively (rehab worse than home; p<0.001). Both groups demonstrated significant improvement in all patient perceived outcome measures after THA, but those discharged to rehab continue to report worse scores for the QWB (Rehab: 0.62 SE 0.02 vs Home: 0.67 SE 0.01; p=0.02) and Hip Harris Score (Rehab: 83.07 SE 1.75 vs Home: 88.65 SE 1.31; p=0.01).
Discussion
Clinical intuition and personal interaction proved to be the best predictor for discharge disposition. Worse outcomes were observed in patients being discharged to rehab.
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