Study Finds Racial Variation in Postoperative Care Following TKA

    In an analysis of more than 100,000 total knee arthroplasty (TKA) procedures published in JAMA Network Open, African American patients were found to be significantly more likely than white patients to be discharged to an inpatient rehabilitation or skilled nursing facility rather than home care after surgery.

    African American patients under age 65 were also more likely to be readmitted to the hospital within 90 days of TKA.

    “Total knee replacement is one of the most common and successful elective procedures performed in adults with arthritis, and previous studies have described racial disparities in outcomes,” said Michael Parks, MD, an orthopedic surgeon at Hospital for Special Surgery (HSS) who was involved in study concept and design and in drafting the manuscript.

    “For this study, we wanted to determine if there was an association of race/ethnicity with discharge destination and hospital readmission after this procedure.”

    In addition to analyzing the racial/ethnic variation in discharge destination, the researchers also wanted to determine if postoperative discharge to an inpatient rehabilitation facility or skilled nursing facility was associated with higher odds of hospital readmission up to 90 days after surgery.

    For this retrospective study, the researchers used data from the Pennsylvania Health Care Cost Containment Council on patients who had elective TKA in 170 hospitals in Pennsylvania between April 2012 and September 2015. They examined:

    • How many patients went to an inpatient rehab center
    • How many went to a skilled nursing facility for rehabilitation
    • How many received their rehab at home after a TKA

    “The analytic sample, which included a total of 107,768 patients, found that African American patients were 2.5- to 5-times more likely than white patients to be discharged to an inpatient rehabilitation facility or skilled nursing facility rather than to their home,” Dr. Parks said. “In 2015, almost 50% of African American patients were discharged to a skilled nursing facility.”

    Among patients younger than age 65, African American patients also had 1.3-times higher odds of 90-day hospital readmission, although there was no difference in hospital readmission rates in patients who were age 65 or older. Discharge destination to an inpatient or skilled nursing facility for rehabilitation was associated with increased odds of hospital readmission.

    Noting that their findings are significant, the researchers wrote: “It is possible that the decision on where to discharge patients after a surgical procedure is informed not only by clinical indications but also by social determinants of health, including socioeconomic status, employment, and social support, of which race/ethnicity might be a marker.”

    They noted that future studies are needed to evaluate the decision-making process regarding discharge destination and how social determinants of health affect these decisions. They advised that future studies should also examine how Centers for Medicare & Medicaid Services policy reforms, such as Bundled Payment for Care Improvement, affect not only cost and quality of care, but also equity.

    “We need to understand that there are people who may not fit into the new complex reimbursement bundles who require specialized care, and we need to make sure we address their needs going forward,” Dr. Parks said.


    Singh JA, Kallan MJ, Chen Y, Parks ML, Ibrahim SA. Association of race/ethnicity with hospital discharge disposition after elective total knee arthroplasty. JAMA Netw Open. 2019 Oct 2;2(10):e1914259. doi: 10.1001/jamanetworkopen.2019.14259.