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Joint replacement? Consider this

By Carol Gentry and David Gulliver
6/4/2009 Health News Florida

Patients who had knee-replacement surgery last year had a much smoother recovery than average if they were at one of 10 hospitals in the state, new data show. But they were much more likely to bounce back into the hospital within two weeks if they had the procedure at one of 10 other hospitals. (See chart) 
The same wide disparities in readmission rates appeared for hip-joint replacement, according to an analysis by Health News Florida of data posted at  The state site, maintained by the Agency for Health Care Administration, is a partnership with the Florida Hospital Association, set up to educate consumers on health care.

Health News Florida chose hip and knee replacement for this second part of a report on “revolving-door syndrome” because the operations are so common in Florida. (Part 1 was published Wednesday.)

The site shows rates of readmission that occur within 15 days of discharge, although no reason for the rebound (infection, bleeding, dislocation, a fall, etc.) is given. But the data are adjusted for the types of patients a hospital gets to avoid penalizing those that tend to attract older, sicker ones. After that adjustment, the hospital is said to have a readmission rate that is “as expected,” “higher than expected,” or “lower than expected.”

Here’s what we found:

--You can’t predict which hospitals will have higher rates of readmission and which will be lower from their size or location. Some of the hospitals that were high on the readmission list are now members of an FHA collaborative to address the problem, but some aren't.

--The state average rate of readmissions within 15 days was one in 16 for hip patients and one in 25 for knees. Hip replacement was the only one of 14 diagnoses for which comparison data were available that saw an improvement in the readmission rate between 2007 and 2008. The improvement in the rate was slight, one-tenth of a percentage point.

--Hospitals with high rates of readmission for hip-replacement surgery didn’t necessarily have high rates for knees, and vice versa. Only one -- Palm Springs General in Hialeah – made both lists as having a “higher-than-expected” rate of potentially preventable readmissions.

--Four hospitals in the state did better than expected for both types of surgery: Gulf Breeze Hospital, near Pensacola; Sarasota Memorial; Tampa General; and West Marion Community Hospital in Ocala.

It’s worth noting that two of those hospitals are huge safety-net centers that get some of the toughest cases around, while two are small community hospitals. The lesson: Any type of hospital can improve coordination of care.

--Patients, employers and taxpayers could have saved a great deal of money last year if none of those potentially preventable readmissions had occurred. It could be as high as $50 million, if several assumptions are correct. One big assumption is that all the hospitals were able to track all the readmissions, based on claims forms. Another is that they correctly reported the readmission rates to the state. Another is that the amount hospitals got paid for the surgeries was about one-third of the charge on the hospital bill. The actual payments aren't listed on the AHCA site because hospitals won't reveal them, citing proprietary information. We used one-third of the charge, a rule of thumb in the industry, to come up with a rough -- very rough -- estimate.  

If all the numbers on the Web site are correct, we can multiply the state's average rate of readmissions – 3.6 percent for knees and 5.7 for hips – times the number of admissions (36,600 for knees, over 26,150 for hips).  We can take a midpoint in the range of charges for the procedure and multiply that by the estimated number of readmissions. That produces a total of $150 million in charges. Take one-third of that, and you get $50 million as an estimate of the cost of potentially preventable readmissions for hip and knee replacements.

Whatever the cost, it's substantial, judging from a New England Journal of Medicine study published in April. That study found that up to one-fifth of all Medicare patients are readmitted within a month of being discharged and a third are rehospitalized within 90 days. 

Dr. Stephen F. Jencks, the author, estimated the cost of all those unplanned readmissions to hospitals as $17 billion in 2004 alone. It's "one of the fruits of an increasingly fragmented health care system,” he told The New York Times.

But hospitals have been warned that the federal government will soon start penalizing those that continue showing above-average rates on preventable readmissions. The members of FHA’s collaborative are learning how to coordinate care – even though hospitals don’t have much control over what doctors say and what patients do once they leave the hospital.

“The state of the art is we can prevent many readmissions if the patient and the provider and the hospital work together,” said Linda Quick, president of the South Florida Hospital and Healthcare Association. “It’s unnecessarily expensive and time-consuming for patients to return.”

Kim Streit, vice president for research at FHA, has been the organization's liaison with AHCA to bring down readmission rates. ”Our hospitals really are committed to looking at ways to improve quality,” she said. “There’s a lot of energy around it.”

Executives at Palm Springs General Hospital, the one that had high readmission rates for both types of joint replacement, could not be reached for comment this week. Sarasota Memorial, which did better than expected, was more forthcoming.

Judy Milne, director of quality improvement and patient safety, said every knee and hip replacement patient attends a class before surgery where a nurse educator and care manager spell out what the operation will be like and what each day of recovery following surgery will entail -- for example, how much standing and walking the patient will do.

It helps the patient commit to rehabilitation, and allows the hospital to assess what level of follow-up care the patient will need, Milne said.

Surgeons are following the latest research and guidelines, said Dr. Daryl L. Miller, chief of orthopedics. For example, it used to be standard practice to give patients antibiotics for three days after surgery. But research has indicated that may make some patients more vulnerable to secondary infections, so surgeons now limit antibiotics use.

One of the greatest risks after hip surgery is deep-vein thrombosis. Miller said Sarasota Memorial requires surgeons to document the reasons any time they do not use standard preventative measures, including blood-thinning drugs and pneumatic devices to stimulate circulation.

Most nurses in the operating rooms and orthopedic unit have specialty certification in orthopedics, Milne said. And the hospital has kept turnover low, which improves outcomes. 

--Carol Gentry can be reached at 727-410-3266 or at this e-mail; David Gulliver can be contacted through e-mail.