Where a Person Lives Influences Postop Care and Rehab after THA, Study Finds

    A new study finds that the community in which a patient lives influences whether they receive postoperative care and rehabilitation after elective total hip arthroplasty (THA) in an inpatient facility or at home, with patients from the least affluent communities more likely to be discharged to an inpatient rehabilitation or skilled nursing facility.

    Bella Mehta, MBBS, MS, a rheumatologist at Hospital for Special Surgery (HSS) in New York City, presented the findings at the 2019 ACR/ARP Annual Meeting.

    “With the aging of the population, elective total hip replacement has become one of the fastest-growing procedures to manage severe osteoarthritis,” Dr. Mehta said. “By 2030, the number of hip replacements is expected to reach 572,000 annually in the US.

    “Medicare, the largest payer of joint replacement surgery, has introduced several payment reform models that target discharge destination and risk of hospital readmission after surgery. Our study examined how the socioeconomic status of the community in which one resides influences discharge destination and the odds of 90-day hospital readmission after hip replacement.”

    Dr. Mehta noted that where a patient receives postoperative care and rehabilitation has a considerable impact on the total cost of THA. Previous studies have demonstrated significant variations in outcomes and costs due to individual factors such as race. There have been far fewer studies on the impact of community-level factors.

    For the analysis, the investigators identified almost 85,000 patients in the Pennsylvania Health Care Cost Containment Council database who had elective THA between 2012 and 2016. The researchers used the Area Deprivation Index (ADI) from the American Census Survey, which reflects a geographic area’s level of socioeconomic deprivation and is associated with health outcomes.

    In addition to discharge destination, the investigators assessed the risk of 90-day readmission for patients sent to an inpatient facility compared with those who received their postoperative care and rehabilitation at home. The researchers also assessed the interaction of race and ADI on outcomes.

    They found that patients from impoverished communities were more likely to be discharged to an institution instead of home after THA. The interaction effect of race and ADI on discharge destination was statistically significant in African American patients 65 years and older, but not in patients under 65 years old. The level of community deprivation did not have an effect on 90-day hospital readmission, nor did the interaction of ADI and race.

    As a possible explanation for the study findings, Dr. Mehta noted that patients from impoverished communities may have less access to community-based services such as social support. Thus, discharge to a facility for postoperative care might be perceived as a safer option in clinical decision-making.

    “Our study is important because it advances our understanding of the relationship between healthcare and social determinants of health,” said Said Ibrahim MD, MPH, MBA, senior investigator and chief of the Division of Healthcare Delivery Science and Innovation at Weill Cornell Medicine.

    “Future studies should determine which specific community factors influence discharge destination and how they could be modified to allow more patients to go home after a hip replacement.”

    Dr. Mehta added, “The ultimate goal of research is to design socially informed health policies to improve quality of care and outcomes.”


    Mehta B, Goodman S, Ho K, Parks M, Ibrahim S. Community-level Deprivation Index: Impact on Discharge Destination After Elective Hip Replacement (Abstract 1852). Presented at the 2019 ACR/ARP Annual Meeting, November 8-13, Atlanta, Georgia.