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Original Investigation
December 20, 2017

Factors Associated With 30-Day Readmission After Primary Total Hip Arthroplasty: Analysis of 514 455 Procedures in the UK National Health Service

Author Affiliations
  • 1St Mary’s Hospital, London, England
  • 2Imperial College, London, England
  • 3Colchester General Hospital, England
  • 4Dr Foster Unit at Imperial College, London, England
JAMA Surg. 2017;152(12):e173949. doi:10.1001/jamasurg.2017.3949
Key Points

Question  Which patient factors are most strongly associated with 30-day readmission after primary total hip arthroplasty, and is there a difference between predictors of all-cause, surgical, and return-to-theater readmissions?

Findings  In this study of 514 455 patients from the UK National Health Service, we found that key predictors of each type of total hip arthroplasty readmission were different.

Meaning  All-cause readmission is the only metric in widespread use but overlooks important information that enables readmission risk to be understood; focus on surgical and return-to-theater readmission may facilitate risk reduction and cost savings.


Importance  Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood.

Objective  To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant.

Design, Setting, and Participants  Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA.

Main Outcomes and Measures  Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT.

Results  Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population attributable fractions of the comorbidities (3.4%). Return to theater in the index episode was associated with a significantly increased risk of RTT readmission (OR, 5.35; 95% CI, 4.45-6.43; P < .001). Emergency readmission to the hospital in the preceding 12 months increased the risk of readmission significantly, with the association being most pronounced for all-cause readmission (for >2 emergency readmissions, OR, 2.33; 95% CI, 2.11-2.57; P < .001). Hip resurfacing was associated with a lower risk of RTT when compared with cemented implants (OR, 0.69; 95% CI, 0.54-0.88; P = .002) but for other types of readmission, implant type had no significant association with readmission risk. Increasing age and length of stay were strongly associated with all-cause readmission.

Conclusions and Relevance  Many patient-related risk factors for surgical and RTT readmission differ from those for all-cause readmission despite the latter being the only measure in widespread use. Clinicians and policy makers should consider these alternative readmission metrics in strategies for risk reduction and cost savings.