These authors used the 2011 Nationwide Inpatient Sample to identify an estimated 40,869 patients who underwent elective total shoulder arthroplasty (62.5% anatomic; 37.5% reverse) and separated them into those with normal length of stay (<75th percentile) and prolonged length of stay (>75th percentile). The 75th percentile was 4 days for reverse total shoulders and three days for anatomic total shoulders. Multivariate logistic regression modeling was performed to identify factors associated with prolonged length of stay. With respect to the 4 Ps:
Patient level factors associated with prolonged length of stay included increasing age, female sex, congestive heart failure, renal failure, chronic pulmonary disease, and preoperative anemia. Race, insurance and other factors were influential as well.
Provider-related factors associated with prolonged length of stay included lower hospital case volume and location in the South or Northeast.
Problem related factors associated with length of stay include the diagnosis. Patients with a diagnosis other than osteoarthritis had longer lengths of stay after anatomic arthroplasty.
Procedure related factors: 11% of the patients having reverse total shoulders stayed longer than 4 days. 22% of the patients having anatomic total shoulders stayed longer than 3 days.
Comment: This work again points out that the 4 Ps can be predictive of which patients will be outliers in terms of length of stay. An important related post can be found here. As we have pointed out before the cost of care of these patients may fall outside of those projected in a bundled payment plan. If uncorrected for the 4 Ps, the care of these patients may contribute to a provider scoring less well on quality of care metrics that include length of stay.
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