1. COHP 450 PICO presentation
By Katy Lucas, RN

2. Introduction and Purpose
PICO Question:
In post-operative hip and knee arthroplasty patients, does length of stay increase the risk of readmission?
Purpose:
To determine if there is a correlation between increased length of stay after surgery and being readmitted to the hospital and to evaluate if findings from different studies can be applied to practice to decrease rates of readmissions.

3. Saucedo, J. , Marecek, G. , Wanke, T. , Lee, J. , Stulberg, S
Saucedo, J., Marecek, G., Wanke, T., Lee, J., Stulberg, S., Puri, L. (2014). Understanding readmission after primary total hip and knee arthroplasty: Who’s at risk? The Journal of Arthroplasty , vol 29, doi: /j.arth
Schairer, W., Sing, D., Vail, T., Bozic, K. (2013). Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clinical Orthopaedics and Related Research, vol 472, p doi: /s

4. Results
Search words: joint arthroplasty, readmission, rates, risk factors, predictors
Search Engines: Ferris library: FLITE
Results of search: Many different articles related to different types of admission data

5. Rationale for articles
“Causes and Frequency of Unplanned Hospital Readmission after total hip arthroplasty”
This article was chosen because of its relation to the PICO question and its clear results. Its unbiased results and clear data give clear answers to the question posed.

6. Rationale for articles
“Understanding readmission after primary total hip and knee arthroplasty: Who’s at risk?”
This article was chosen because it too directly addresses the question asked. Its data is clear and the results directly answer the question posed.

7. Article analysis
Theory used: Both of these articles propose that there is an identifiable relationship between certain risk factors and readmission rates. Both studies identify the importance of cost of readmission in today’s changing reimbursement methods
Type of study: Both of these articles are retrospective population based quantitative studies.
Design: Both articles utilize a posttest-only control group design.

8. Article analysis
Methods: Schairer’s article analyzed 1415 hip arthroplasty (primary, revision and antibiotic spacer placement) patients from a single institution that had been readmitted within 90 days of their original surgery. Saucedo analyzed an electronic database from their institution that had undergone a total hip arthroplasty or total knee arthroplasty. Both articles also collected demographic and clinical data on this population.

9. Article Analysis Findings:
Schairer’s article found that general readmission rates were 4% at thirty days postoperatively and 7% at 90 days postoperatively. Primary hips had lower rates than revisions and antibiotic spacers. Medical reasons counted for one quarter of unplanned readmissions with over half of readmissions being surgically related.

10. Article Analysis Findings:
Saucedo’s article found that readmission rates were 4.2% for thirty days and 7.8% for ninety days. Surgical reasons counted for half of readmissions at all times.
Both articles found a relationship between initial length of stay and hospital readmission rates within days.

11. Ethical Considerations
Because these are both highly objective articles and because they are both retrospective analysis of already existing data, there aren’t many ethical considerations to be had. It may be said that some of the patients did not give their consent to be in the study, but in actuality, they probably did when they signed the forms at the hospital regarding release of information. The fact that the study was primarily conducted for financial purposes does pose an ethical question. Why weren’t these studies conducted for the benefit of surgical outcomes for patients?

12. Evaluating articles Strength of Study
The strengths of Saucedo’s article include that it focused on statistically determining significant risk factors instead of just studying complications after surgery. As well, they utilized a 90 day rate to gain a better picture of risk factors. The article also looked at a large patient population instead of just Medicare data thus capturing all types of payers, not just Medicare.
Schairer’s article claimed that its strength was that it did not use an administrative database. Instead, it was able to confirm readmissions with their actual medical record. They claim that cross-referencing these results provides more accurate data.

13. Evaluating Articles Quality
The level of evidence in both articles is a Level III. Both of these articles are highly credible in that they are based on solid evidence and have statistically backed up their claims. The articles can directly be applied to practice in an Evidence based practice way in that they show which patients may need more pre-operative or post-operative training, education and care.

14. Evaluating Articles Credibility of each study
Each article is from a credible journal and is recent. These are peer reviewed journals and are written by authors that are affiliated with the field of study focused on. Because of each large sample size and objective analysis, the results and inferences are sound. There is little to no bias in these studies, although there may be a small amount of systematic error that we cannot account for. Because the data was already in place, it is reliable. Internal valididty was not threatened because the study was based on recent surgeries and therefore has little attrition. The measurement of the studies may have been altered by human recording error. Both studies focused on readmissions in their own hospital which may have limited the generalizability of the study. Because both studies look at single institutions, more readmissions may take place in the larger world. As well, both studies did not stratify between specific types of implants and many other surgical factors.

15. Evaluation of Articles
Contributions to Evidence Based Practice
How would they be communicated? (include at what level, individual level, policy, standard of care level, professional level?)
Contributions could be presented at a conference or a meeting alerting the staff and managers that length of stay does play a statistically significant role in readmission rates. This fact may initiate another study into longer length of stay arthroplasty surgeries. This research would involve members of the healthcare team at all levels: RNs, Managers, Clinical nurse specialists, data specialists, doctors and more.

16. Relevance to Practice
These findings do have the potential to change practice if further studies were implemented. More specificity may be needed to enact interventions in the longer length of stay patient. Reducing readmissions directly affects quality of hospital and patient care. As well, reducing readmissions reduces costs and penalties therefore improving quality. Safety is not an issue here unless you take into account injuries or illnesses related to length of stay. Because both of these different studies came up with very similar results, we may infer that there is some generalizability in the findings. Despite the fact that the studies were done on smaller, localized populations, their common findings speak to the quality and strength of the information.
The Problem with applying the results of these findings is that direct patient intervention is not discussed. More research and further studies would be needed to address why patients with longer lengths of stay or surgical complications are coming back to the hospital. As well, a closer look at medical problems, specifically the ones that have been found to be statistically significant needs to be examined.

17. Relevance to Practice
Potential barriers (policy, resources, values) on utilization of the research findings: Once these research findings have been discussed with the appropriate panels, the larges barrier to implementation of interventions to prevent readmissions would be money, time, staff and dedication. These types of projects require attention to detail and deep statistical analysis. Convincing the hospital to fund further studies may prove to be challenging. As well, the value doing such a thing needs to be justified. This may not be that hard, as the hospital is very interested in reducing readmissions so that they may avoid penalties and fines.

18. Article Analysis PICO Questions
In orthopedic patients whose stay was at least five days long, what is the primary reason for increased length of stay?
In orthopedic patients readmitted for medical reasons, what are the primary reasons for medical readmission?
In post-operative orthopedic patients, are there measures that could be taken to prevent readmissions?
What is the biggest factor contributing to joint arthroplasty longer length of stays?
Can discharge education on co-morbidities decrease readmission rates in the post-operative orthopedic patient?
Does having increased home health care after orthopedic surgery decrease the rate of readmissions?

19. Summary
Length of stay is directly related to readmission rates in orthopedic patients. We have examined two retrospective studies based on patient populations in the orthopedic field that were conducted in single institutions. While many factors are related to readmissions, specifically having a hospital stay of greater than or equal to five days was correlated to have a p value of with a statistical significance being quantified at p< From we can see that there is a strong correlation between length of stay and hospital readmissions in the orthopedic patient. Applying this evidence to our practice will take further study and analysis, but over all will benefit quality of care for patients, quality measures for hospitals and an overall better outcome for all involved.