Thursday, August 6, 2015

Shoulder arthroplasty - what factors are associated with the outcome?

Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty. A Population-Based Study

Increased length of hospital stay, hospital readmission, and revision surgery are adverse outcomes that increase the cost of elective orthopaedic procedures, such as shoulder arthroplasty. These authors suggest that awareness of the factors related to these adverse outcomes may help surgeons and medical centers design strategies for minimizing their occurrence and for managing their associated costs.

They analyzed data from the New York Statewide Planning and Research Cooperative System on 17,311 primary shoulder arthroplasties performed from 1998 to 2011 to identify factors associated with extended lengths of hospitalization after surgery, readmission within ninety days, and surgical revision.

They found that the factors associated with each of these three adverse outcomes were different.

Longer lengths of hospital stay were associated with female sex, advanced patient age, Medicaid insurance, comorbidities, fracture as the diagnosis for arthroplasty, higher hospital case volumes, and lower surgeon case volumes. 

Readmission was associated with advanced patient age and medical comorbidities. The most common diagnoses for readmission within ninety days were fluid and electrolyte imbalance (28%), acute pulmonary problems (21%), cardiac arrhythmia (20%), heart failure (15%), acute myocardial infarction (10%), and urinary tract infection (10%). 

Revision was associated with younger patient age and osteoarthritis or traumatic arthritis. The most common diagnoses at the time of revision surgery were unspecified mechanical complications of the implant (60%), shoulder pain (18%), dislocation of the prosthetic joint (12%), component loosening (10%), a broken prosthesis (8%), a cuff tear (7%), and infection (7%).

They concluded that a small number of easily identified characteristics (sex, age, race, insurance type, comorbidities, diagnosis, and provider case volumes) were significantly associated with longer lengths of stay, readmission, and revision surgery. Consideration of these factors and their effects may guide efforts to improve patient safety and to manage the costs associated with these adverse outcomes.

Comment:  The care of patients with risk factors for adverse outcomes may benefit from advanced planning for the prevention, management, and cost of these possible outcomes. Older individuals and those with comorbidities may merit extra attention to their fluid and electrolyte, cardiac, pulmonary, and urinary status prior to discharge. Young individuals with osteoarthritis and traumatic arthritis may need to be cautioned to be conservative in their use of the shoulder arthroplasty in light of their increased rate of revision surgery necessitated by mechanical failure.

On a socioeconomic note, the Affordable Care Act has provided a basic level of medical insurance for patients with a higher prevalence of risk factors for more costly care. As a result, health-care systems caring for a substantial number of these patients may have difficulty funding the care with the resources provided. The Hospital Readmissions Reduction Program creates a penalty risk for medical centers caring for large numbers of patients at increased risk for readmission . If the care of patients with risk factors for increased cost of care is not affordable within the fiscal limits of the reimbursement for the care, providers may be disinclined to care for them. Furthermore, it is evident that patients with increased risk for higher costs of treatment will create a challenge for providers pursuing the bundled payment approach to reimbursement.

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