Temporal trends and predictors of 30-day readmissions and emergency department visits following total knee arthroplasty in Ontario 2003-2016

Abstract Introduction Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. While rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings , few studies have evaluated trends in length of stay (LOS), hospital readmissions and ED visits following TKA in a universal single-payer system. Methods Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences (IC/ES), we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available ICD-9 and ICD-10 coding information. Results LOS decreased significantly over the study period (p Predictors of 30-day readmission following TKA included: older age, male sex, lower income quartile, not having a post-operative visit with a primary care physician (PCP), increased comorbidities, longer LOS, revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included: older age, male sex, lower income quartile, not having a post-op visit with a PCP, increasing comorbidities, year of surgery, longer LOS, revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Discussion We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male sex, lower income, higher comorbidities and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency and enhancing patient-experience.