Background There are marked racial/ethnic disparities in the utilization of hip joint replacement in the US. Differences in post-surgical rehabilitation care may influence this disparity. There is relatively little research on racial variations in post-hip joint replacement surgery care processes.
Objectives The main objective of this analysis was to examine racial differences in where patients go for post-acute care rehabilitation after elective hip replacement surgery. We also assessed whether or not where patients go for post-surgery rehabilitation care impacts quality of care markers such as 90-day hospital readmission.
Methods A retrospective, large regional dataset analysis using the Pennsylvania Health Care Cost Containment Council database was performed. Patients who underwent elective hip replacement surgery and discharged from Pennsylvania hospitals between fiscal years 2008–2012 were selected. Post-surgery rehabilitation destinations options included: home with self-care, home with home health (HH) care; skilled nursing facility (SNF) and in-patient rehab facility (IRF).
We used multinomial logistic regression models to estimate unadjusted and adjusted relative risk ratios (aRRRs) of being discharged home with HH care, to a SNF or to an IRF (vs. home with self-care) after surgery, comparing African-American (AA) to white patients. Multivariable models adjusted for patient-level and facility-level variables associated (p<0.10) with post-surgical discharge destination based on bivariate analyses. Unadjusted and adjusted odds ratios (aORs) of 90-day hospital readmission were estimated using binary logistic regression models. Multivariable models adjusted for patient-level and facility-level variables associated (p<0.10) with 90-day hospital readmission. In all models, patients were stratified by age group (<65 and ≥65 years) to account for differences in Medicare eligibility.
Results Among all patients analyzed, 4,391 self-identified as AA and 63,625 self-identified as white. Among those <65 years of age, AAs, in comparison to whites, were less likely to have private insurance (52.5% vs. 82.7%) and more likely to rely on Medicare or Medicaid (47.5% vs. 17.3%) (both p<0.001). For those age ≥65, ∼90% of both AAs and whites relied on Medicare. Co-morbidities such as hypertension, diabetes and renal failure were more common among AAs than whites (p<0.001, all comparisons, both age groups).
The Figure summarizes the unadjusted (UN) and adjusted (ADJ) RRRs of referral to an IRF, SNF and HH care (vs. home self-care) in AAs (vs. whites) by age group. Among patients <65 years of age, compared to whites, AAs had higher risk of discharge to an IRF (aRRR 2.56, 95% CI, 1.77–3.71) and a SNF (aRRR 3.37, 95% CI, 2.07–5.49). Among those ≥65 years of age, AA patients also had higher risk of discharge to an IRF (aRRR 1.96, 95% CI, 1.39–2.76) and a SNF (aRRR 3.66, 95% CI, 2.29–5.84). Discharge to either IRF (<65 years: aOR 4.06, 95% CI, 3.49–4.74; ≥65 years: aOR 4.32, 95% CI, 3.67–5.09) or SNF (<65 years: aOR 2.05, 95% CI, 1.70–2.46; aOR 1.74, 95% CI, 1.46–2.07), instead of home with self-care, was significantly associated with higher odds of hospital readmission within 90 days.
Conclusions Compared to whites, AA patients who underwent hip replacement were more likely to be discharged to an IRF or SNF. Furthermore, discharge to either IRF or SNF was associated with higher risk of hospital readmission.
Disclosure of Interest None declared