Tuesday, February 21, 2017

Shoulder joint replacement: 17% perioperative complications. Actionable intelligence.

Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty

These authors obtained data from the Nationwide Inpatient Sample on 103,290 patients have shoulder arthroplasty between 2004 and 2011. The overall rate of medical and surgical complications
occurring during the same hospitalization was 17.2% (n = 17,810) and the mortality rate was 0.20% (n = 208).  In descending order, the most common complications were acute cardiac event, urinary tract infection, pneumonia, acute kidney injury, cerebrovascular event, venous/thromboembolic event, and sepsis. Perioperative surgical complications included wound disruption, hematoma formation, included implant failure, fractures, and blood transfusions.

The distribution of insurance coverage for these patients was: 68,578 Medicare, 27,159 private insurance, 3,544 Medicaid/uninsured, and 4009 other.

The complication rates were different for matched patients with different types of insurance as shown below

Other factors, such as sex, race, age, emergency admission, procedure type and cormorbidities also had significant relationships to the complication rates as shown below.

Many important factors are interrelated.  Patients with government-sponsored insurance demonstrated a higher comorbidity index than those with private insurance. Privately insured patients were more likely to receive treatment at hospitals with a higher surgical volume.

Comment: While the insurance and other factors related to in-hospital complications are of interest, it is of greater interest to us that the leading causes of complications seem in large part preventable. Careful preoperative assessment and careful in-hospital care of patients having elective surgery should be able to minimize the risk of acute cardiac events, urinary tract infections, pneumonia, acute kidney injuries, cerebrovascular events, venous/thromboembolic events, and sepsis. Even patients having emergency admission rarely require urgent shoulder joint replacement before the risk of complications is minimized.

In thinking about risks, we ask what is the 'actionable intelligence'? We would not presume to change a patient's age, sex, race or insurance, but we can act to prevent complications that should be preventable. Better patient care would not only benefit the patients, but would improve the safety ratings of the medical center and reduce the cost of care.