Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments

Abstract

Objectives: The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program. Methods: The CMS research identifiable file for the State of Texas for 2011–2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day postdischarge ED claims. The claims associated with live discharge were divided into three cohorts: elective total hip replacement (THR), emergent (THR), and total knee replacement. The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the postdischarge period as well as discharge diagnosis. Visits were correlated with age, sex, joint replaced, and fracture. Results: There were 50,838 TJR surgeries in Texas in 2011–2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-day postdischarge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65–74 years predominated in both elective surgery categories. There were 2,370 ED visits within 90 days of 10,786 elective THRs, of which 55.5% were discharged home, 34.6% were hospitalized or transferred, and 6.9% were admitted to observation. Of the 3,438 ED visits among 8,475 emergent hip replacement cases, 22.4% were discharged home, 50.2% were hospitalized or transferred, and 5.3% were admitted to observation. Of the 6,939 visits among 31,387 knee replacement cases, 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the postdischarge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection. Conclusions: ED services are frequent for Medicare TJR bundle-eligible patients within the postdischarge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing postoperative adverse outcomes.