Author Affiliations: Rothman Institute, Philadelphia, Pennsylvania (parvj@aol.com).
To the Editor: Dr Cram and colleagues reported a decrease in hospital length of stay (LOS) with an increase in readmission for the Medicare population undergoing total hip arthroplasty between 1991 and 2008.1 The authors concluded that modifications in reimbursement should be made to incentivize “the correct LOS, rather than perpetual reductions in LOS that seem to be occurring.” Although such reimbursement modifications may be beneficial, the results reported do not justify these conclusions.
From 1991 to 2000, there was a rapid decrease in LOS (9.1 days to 4.5 days) and decreased rates of 30-day and 90-day all-cause readmission rates (30-day: 5.9% to 4.8%). The later period (2001-2008) saw an increase in readmission rates (30-day: 4.6% to 8.5%) with a slight decrease in LOS (4.4 days to 3.7 days). During this time, the number of comorbidities for patients undergoing total hip arthroplasty increased. If the authors are correct in their assumption that the data set is not biased by changes in diagnostic coding practices, then the reported increase in obesity (1.4% to 4.7%) and renal failure (0.8% to 6.1%) may be a more probable explanation for the increased readmission rate.
The authors missed an opportunity to perform a direct correlation of LOS and readmission rates. With the data set available, a multivariable analysis assessing the independent effects of LOS on readmission would have been interesting.
The literature on the relationship of LOS and readmission rates in the Medicare population is sparse. The available reports provide evidence that current LOS practices do not increase readmission. Bozic et al2 reported that higher annual procedure volume among surgeons was associated with shorter LOS and lower readmission rates following total joint replacement surgery. In a multicenter analysis, Weingarten et al3 provided evidence that implementation of practice guidelines that shortened LOS did not increase 30-day readmission rates for knee or hip replacements.
With a significant increase in total hip arthroplasty projected,4 the study by Cram et al was timely and necessary but not definitive. Because of the potential effect on quality and cost of care, future research is crucial to identify the causes of escalating rates of readmission.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Hozack reported being a consultant for and receiving royalties from Stryker Orthopaedics. Dr Parvizi reported being a consultant for Stryker Orthopaedics and having intellectual property rights for SmarTech. Mr Zmistowski reported no disclosures.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.