Use of a Mandatory Clinical Decision Unit Reduces Readmission Rates following Total Joint Arthroplasty

Abstract

Readmission penalties have encouraged the implementation of protocols to reduce readmission rates. We hypothesized that by keeping postoperative patients, who return to the emergency department (ED) in a clinical decision unit (CDU) until being evaluated by the orthopaedic team, there would be a reduction in the readmission rate after total joint arthroplasty (TJA) at our institution. Our institution mandated the use of the CDU for all potential orthopaedic TJA readmissions. A retrospective review of prospectively collected data was performed on 365 patients who presented to the ED after either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients presenting in the year prior to the implementation of the CDU program were compared with patients presenting in the year after implementation. Demographics, length of stay, comorbidities, and 30-day readmission rates were recorded. Additionally, a financial analysis was performed. Overall, for THA and TKA, there were a combined 141 ED visits prior to the implementation of the CDU program and 224 afterward; of these, 40 were readmitted before the CDU program and only 13 were readmitted afterward (p < 0.01). The financial analysis found that the overall 90-day cost for patients in the postoperative period was nearly $800 lower on average (p = 0.027) post-CDU implementation.

During the first year of the CDU project at our institution, we significantly reduced the readmission rates following TJA and demonstrated significant cost saving. This is a Level III, prognostic study.

Keywords

clinical decision unit - total knee arthroplasty - total hip arthroplasty - readmission rates - Hospital Readmission Reduction Program

Publication History

Received: 10 July 2019

Accepted: 10 November 2019

Article published online:
06 January 2020

• References

• 1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360 (14) 1418-1428
• 2 Medicare Payment Advisory Commission (U.S.). Report to the Congress: Promoting Greater Efficiency in Medicare. Washington, DC: MedPAC; 2007: xvi , 277 p
• 3 Readmissions Reduction Program (HRRP) - Centers for Medicare & Medicaid Services. 10/20/2018]; Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
• 4 Cooper JG, Smith B, Hassan TB. A retrospective review of sudden onset severe headache and subarachnoid haemorrhage on the clinical decision unit: looking for a needle in a haystack?. Eur J Emerg Med 2016; 23 (05) 356-362
• 5 O'Shea E, Cusack S, O'Sullivan I. A study of the patients admitted to the clinical decision unit over one year. Ir Med J 2016; 109 (06) 424
• 6 Sop J, Gustafson M, Rorrer C, Tager A, Annie FH. Undiagnosed diabetes in patients admitted to a clinical decision unit from the emergency department: a retrospective review. Cureus 2018; 10 (10) e3390
• 7 Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. The future of emergency care in the United States health system. Ann Emerg Med 2006; 48 (02) 115-120
• 8 Aplin KS, Coutinho McAllister S, Kupersmith E, Rachoin JS. Caring for patients in a hospitalist-run clinical decision unit is associated with decreased length of stay without increasing revisit rates. J Hosp Med 2014; 9 (06) 391-395
• 9 McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation 2015; 131 (20) 1796-1803
• 10 Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. Kaiser Health News. Accessed October 28, 2018 at: https://khn.org/news/readmission-penalties-medicare-hospitals-year-two/
• 11 Weber SM, Greenberg CC. Medicare Hospital Readmission Reduction Program: what is the effect on surgery?. Surgery 2014; 156 (05) 1066-1068
• 12 Martsolf GR, Barrett ML, Weiss AJ. et al; Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Hospital Readmission Rates Following Hip and Knee Arthroplasty. Impact of race/ethnicity and socioeconomic status on risk-adjusted hospital readmission rates following hip and knee arthroplasty. J Bone Joint Surg Am 2016; 98 (16) 1385-1391
• 13 Kind AJ, Jensen L, Barczi S. et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff (Millwood) 2012; 31 (12) 2659-2668
• 14 Yakusheva O, Hoffman GJ. Does a reduction in readmissions result in net savings for most hospitals? an examination of Medicare's Hospital Readmissions Reduction Program. Med Care Res Rev 2020; 77 (04) 334-344
• 15 Hoffman GJ, Tilson S, Yakusheva O. The financial impact of an avoided readmission for teaching and safety-net hospitals under Medicare's Hospital Readmission Reduction Program. Med Care Res Rev 2020; 77 (04) 324-333
• 16 Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011; 155 (08) 520-528
• 17 Markley J, Andow V, Sabharwal K, Wang Z, Fennell E, Dusek R. A project to reengineer discharges reduces 30-day readmission rates. Am J Nurs 2013; 113 (07) 55-64
• 18 Kind AJ, Jensen L, Barczi S. et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Aff (Millwood) 2012; 31 (12) 2659-2668
• 19 Hällfors E, Saku SA, Mäkinen TJ, Madanat R. A consultation phone service for patients with total joint arthroplasty may reduce unnecessary emergency department visits. J Arthroplasty 2018; 33 (03) 650-654