Wednesday, October 5, 2016

Readmissions after total shoulder arthroplasty, how to stay out of the penalty box


These authors sought to determine the incidence rate, risk factors, and postoperative conditions associated with 30-day readmission after total shoulder arthroplasty (TSA). They identified 3547 patients who underwent primary TSA from the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program.

The 30-day readmission rate was 2.9%.

The only preoperative predictors of hospital readmission were
(1) American Society of Anesthesiologists classification of 3 or greater (odds ratio, 2.16; 95% confidence interval, 1.30-3.61) and
(2) history of cardiac disease (odds ratio, 2.13; 95% confidence interval, 1.05-4.31).

Of patients with any perioperative complications, 42 (34%) were readmitted, and the presence of any complication increased the risk of readmission (odds ratio, 28.95; 95% confidence interval, 18.44-45.46).

Postoperative periprosthetic joint infection, myocardial infarction, pulmonary embolism, deep venous thrombosis, and pneumonia were significantly associated with hospital readmission after TSA (P<.0001).

The incidence of hospital readmission after TSA peaked within the first 5 days after discharge, and 26%, 32%, and 55% of all hospital readmissions occurred by postoperative days 5, 7, and 14, respectively.

These authors recommend pre-operative medical optimization to reduce the rates of postoperative complications, such as periprosthetic joint infection, myocardial infarction, pulmonary embolism, deep venous thrombosis, pneumonia, and urinary tract infection to decrease the need for subsequent readmission.

They point out that hospital readmissions add as much as $20 billion in costs per year.  The Patient Protection and Affordable Care Act established the Hospital Readmission Reduction Program to curtail costs incurred as a result of unplanned readmissions. Hospital readmission rates have quickly become a metric for evaluating hospital performance by the Centers for Medicare & Medicaid Services and the National Quality Forum. Financial penalties are imposed for rates exceeding normative values.

Comment: Surgeons and medical centers will need to consider the evidence that admitting patients for TSA with ASA classification ≥ 3 or a history of cardiac disease more than doubles the risk of readmission and readmission rate associated penalties.

This article can be considered along with a prior one:

Hospital readmissions after primary shoulder arthroplasty.

Although shoulder arthroplasty procedures are more frequently performed in the United States, there is insufficient information on outcome measures such as hospital readmission rates or factors for readmission after surgery.

The State Inpatient Database from 7 different states was used to identify patients who underwent hemiarthroplasty, total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) from 2005 through 2010. The database was used to determine the 90-day readmission rate, causes of readmission, and risk factors for readmission. Multivariate modeling and a Cox proportional hazards model were used to measure factors and risk for readmission.

Included were 26,218 patients receiving shoulder arthroplasty, with an overall 90-day readmission rate of 7.3%. RTSA had the highest rate (11.2%), followed by hemiarthroplasty (8.2%) and TSA (6.0%; P < .001). Medical complications contributed to 82% of readmissions, and surgical complications contributed to 18%. Osteoarthritis was the most common medical diagnosis (11%), followed by deep venous thrombosis or pulmonary embolism (4.4%) and pneumonia (3.9%). Infection was the most common surgical cause of readmission (4.8%), followed by dislocation (4.6%). There was a stepwise increase in risk of readmission with increasing age. Patients with Medicaid insurance had more than a 50% greater risk of readmission than patients with Medicare. Procedures performed at medium-volume and high-volume hospitals showed lower risk of readmission than low-volume centers.

Patients undergoing RTSA had higher hospital readmission rates than those undergoing hemiarthroplasty or TSA, but most readmissions after shoulder arthroplasty were due to medical causes.
We try to avoid denying access to TSA for patients with risk factors for readmission when preoperative medical management and planning can minimize this risk.