Friday, April 8, 2016

Shoulder arthroplasty and orthopedic specialty hospitals - effects and causes

Length of stay after shoulder arthroplasty—the effect of an orthopedic specialty hospital

These authors retrospectively identified all primary shoulder arthroplasties performed between January 1, 2013, and July 1, 2015, at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC) and matched cohorts to compare lengths of stay (LOS) and readmission rates.

The average LOS at the OSH was 1.31 ± 0.48 days compared with 1.85 ± 0.57 days at the TRC.

Of the 136 OSH patients, 3 (2.2%) required transfer to a TRC. 
Two of 136 OSH and one of 136 TRC patients required readmission

Comment: In considering the factors that might account for differences between the two groups, one might first consider why a patient might wind up in one hospital or the other. Patients meeting the selection criteria apparently were offered the choice of the OSH or a TRC. While the patients in the two groups were 'matched', it seems likely that more thoughtful patients might anticipate an advantage of a hospital specializing in orthopaedics (even if it is a bit further from their home) as opposed to a tertiary center that does kidney transplants, inpatient psychiatric care, and brain surgery. Next, it seems possible that surgeon ownership of the OSH may provide special motivation to optimize the patient selection and patient experience there. Other factors, such as fast-track rehabilitation and disposition protocols would seem easier to implement at the OSH. Finally, the staff and the physical facility are more likely to be more tuned to orthopaedic care at the OSH.

While it is attractive to focus on the LOS as a metric "The average per day hospital cost for shoulder arthroplasty is already $24,925.15", it is important to recognize that the preponderance of the costs are incurred on the first day (admission, OR, recovery room); an additional half day inpatient stay does not add proportionally to the total cost. Excessive focus on shortening the LOS may lead to an increase in transfers to TRCs or readmissions, both of which are costly.

There is no question that patient safety and patient satisfaction can be optimized when there is sufficient shoulder arthroplasty volume to justify special staff and defined protocols. These benefits can be realized within the context of either a specialty hospital or a referral center that dedicates resources to the shoulder arthroplasty program.


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