The Most Common Reasons Driving Readmissions in TJA


Prem N. Ramkumar, M.D., the author of a recent analysis on readmission rates in TJA, speaks with Rheumatology Network about why readmission rates matter.

In today’s healthcare environment, hospital readmission rates are garnering an increasing amount of attention as the industry moves toward bundled payments, making it harder for providers to recoup reimbursement. This could present significant problems for orthopedic surgeons who perform total joint arthroplasties - one of the most commonly performed orthopedic procedures.

But, until now, there’s been no benchmark for what an acceptable rate should be for these procedures. The general belief, though, is lower readmission rates can improve care standards and lower costs. To answer the question about what acceptable readmission rates are for total joint arthroplasties (TJA), Prem N. Ramkumar, M.D., a resident physician of orthopedic surgery at the Cleveland Clinic, led a systemic review and meta-analysis of existing studies, looking for the average 30-day and 90-day readmission rates. The review was published in the September 2015 issue of the American Journal of Orthopedics.

By analyzing 12 total hip arthroplasty and 10 total knee arthroplasty studies, the team reviewed readmission rates for nearly 4 million patients for both time intervals. According to results, the gold standard for hip readmissions was 5.6 percent of the 30-day population and 7.7 percent of the 90-day group. Of the knee readmissions, the benchmark was 3.3 percent of 30-day readmissions and 9.7 percent of 90-day patients.

The cost of these readmissions is already an issue, Dr. Ramkumar said, but the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) is ramping up and will push more and more providers into merit-based incentive payment systems. To better understand why these readmission rates are important and what you can do to improve your outcomes, Rheumatology Network spoke with Dr. Ramkumar about his study results and what they mean in the MACRA environment.  [[{"type":"media","view_mode":"media_crop","fid":"50561","attributes":{"alt":"Prem N. Ramkumar, M.D.","class":"media-image media-image-right","id":"media_crop_4423053069088","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6182","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Prem N. Ramkumar, M.D.","typeof":"foaf:Image"}}]]

Rheumatology Network:  Why did you decide to look into unplanned readmissions for total joint arthroplasty?

Dr. Ramkumar:  Mainly, it was a timeliness issue. With the way reimbursement is being changed for the orthopedic surgeon, I think outcomes were being held against things we usually didn’t measure in the past. Before, how a physician would say whether an outcome was good was essentially based on what the surgeon said.  Sometimes, the patient may or may not have agreed, but now there are other eyes on patient care. Now, the doctor-patient relationship isn’t just between those two. For me, it’s really being part of a larger team of players in the hospital and the belief that the readmission rates were timely because it’s one of the few metrics surgeons are being evaluated against.

Why Readmission Rates Matter

(See next page)

Why Readmission Rates Matter

RN:  Why does it matter?

Dr. Ramkumar:  Having this data matters because it’s a benchmark for what our current state is. It’s hard to know how to improve when you don’t have anything to compare yourself to. I felt that our study helped established our benchmark for what we can improve upon. The goal of our study was to establish a benchmark for joint replacement – one of the most heavily utilized surgical procedures.

RN:  What are the most important parts of your results? What are their impacts?

Dr. Ramkumar:  The most important part was the readmission rate we found for 30 and 90 days, and the impact was establishing this as the gold standard. I think it’s something that our hospital – or even my personal record as a surgeon – should be able to do. That’s the only way of establishing progress. Secondly, it’s important to know what the actual cases behind the readmissions were for someone who had knee or hip replacement surgery. Perhaps the surgeon will pay even more attention to closures because superficial and deep, soft tissue infections are disasters for the patients. But, it’s not hard for the surgeon to re-evaluate and re-assess how they do their own infection protocols and inter-operative handiwork.

RN:  What challenges were revealed for orthopedic surgeons?

Dr. Ramkumar:  Joint replacement is a tough task. There are increasing pressures to churn out more procedures, and often there’s a temptation to go with what works. Some surgeons try to get everything perfect, but others know the pursuit of perfection may or may not affect the clinical outcomes.

And, the surgeon’s idea of perfection may not be the patient’s idea of it. Surgeons should re-evaluate how patients feel with the joint daily and ensure, mechanically, the joint is stable whether they’re seeing the patient before surgery, doing the procedure or providing post-operative communication. Surgeons aren’t just technicians. They’re involved in every step. It’s a tough burden, but it’s definitely something the study forces us to critically evaluate.

RN:  How does this research fit in with MACRA?

Dr. Ramkumar:  We have to figure out the exact way to evaluate outcomes. A huge problem is, oftentimes, we expect surgeons to be 100 percent in control of outcomes. So many things go into a patient’s success that are completely left out of the equation from the reimbursement standpoint. A host of factors remain. Patients are different – their anatomy, responses to inter-operative trauma, or abilities with rehabilitation and recovery.

Surgery isn’t a question of whether the surgeon can or should be doing 100 percent of work. A lot depends on the patients’ effort and their intrinsic ability to recover. In terms of MACRA, the program is trying extremely hard, with understandable reasons, to try to control the controllable errors or problems. But, there has to be a level of expectation and understanding that readmission rates can’t reach zero percent because there are patients - who are either sick or otherwise healthy  -  who don’t handle surgery well. It’s not always the surgeon’s fault, but the surgeon is getting dinged for bad outcomes.

This all leaves the surgeon thinking about consequences and patient selection at the beginning of the cycle. If cutting reimbursement is based on outcomes, well-meaning physicians who put their personal financial resources and labor into becoming a surgeon now have to turn away needy patients. That’s tough for the surgeon and for the patient. From that perspective, I’m sure we’re going to see more patient selectivity from surgeons.

RN:  How can your work be used to promote better and improved outcomes?

Dr. Ramkumar:  It’s going to end up being a surgeon keeping a score card of their or their department’s readmission rates. That will be compared to the rates we’ve published in the paper. Surgeons looking to control readmission rates can consider patient selection or they can improve post-operative management and instruction for patients. In addition, they can increase their attention toward wound closure - but not that they aren’t paying great attention already because that’s their craft, but they can be on the look-out for the best types of materials and dressings that will allow closures to not ooze or result in possible readmissions.


Prem N. Ramkumar, M.D., is a resident physician in orthopedic surgery at Cleveland Clinic.




Ramkumar PN, Chu CT, Harris JD, Athiviraham A, Harrington MA, White DL, Berger DH, Naik AD, Li LT. “Causes and Rates of Unplanned Readmissions After Elective Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.” American Journal of Orthopedics. (Belle Mead NJ). 2015 Sep;44(9):397-405.


Related Videos
© 2024 MJH Life Sciences

All rights reserved.