Avoiding emergency visits after outpatient rotator cuff repair. Lessons learned

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair:potential for avoidance

These authors reviewed 1306 outpatient RCR procedures in a closed health care system, and all unplanned emergency department (ED) and urgent care (UC) visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction).

Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention.

Of the 729 male and 577 female patients; average age, 60 years, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). 

Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common, whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied.

Comment: What is interesting about this paper is the actions the physicians in the system took to minimize the number of avoidable unplanned visits after cuff repair:

Preoperatively, patients receive counseling on pain management, constipation prevention, and return precautions. They are given prescriptions for postoperative pain to be filled the day before surgery. 

They recommended a single 375-mL glass of a high-carbohydrate clear liquid (eg, apple juice) up to 2 hours before arrival for surgery is used to help prevent constipation, nausea, and vomiting. 

Multimodal analgesia with acetaminophen, gabapentin, and a nonsteroidal antiinflammatory drug is started preoperatively for increased pain control and reduction of constipation, urinary retention risk, nausea, and vomiting. 

Perioperatively, monitored anesthesia care is preferred over general anesthesia whenever possible, and local anesthesia or field blocks are encouraged. 

Intravenous fluid restriction to less than 500 mLis also attempted to decrease the risk of urinary retention. 

Before discharge from the postanesthesia care unit, a concerted effort is made to ensure that a stool softener or laxative is prescribed for the patient.

This is a great example of a robust effort to identify issues with quality of patient care and cost, followed by a plan to address the problems identified.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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

PREDICTORS OF HOSPITAL READMISSION AFTER TOTAL SHOULDER ARTHROPLASTY.

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.


BACKGROUND:
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.

METHODS:
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.

RESULTS:
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.

CONCLUSIONS:
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.
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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.

Readmissions - causes and prevention

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients

These authors point out that readmission penalties have increased interest in improving care transitions. They studied 1000 general medicine patients (median age 55 years) readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013.

They found that 269 (26.9%) of the readmissions were potentially preventable.
The factors most strongly associated with potential preventability included
* emergency department (ED) decision making regarding the readmission
* failure to relay important information to outpatient health care professionals
* discharge of patients too soon
* lack of discussions about care goals among patients with serious illnesses
* inability to keep appointments after discharge
* patient lack of awareness of whom to contact after discharge

They concluded that approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

Comment: While these were 'general medicine' patients, the lessons from this study can surely be applied to the costly problem of orthopaedic  readmissions. The ED may readmit patients that can be otherwise managed, especially if there is a lack of communication with the orthopaedic service. If primary care physicians are not informed about the patient's condition, readmissions may result. Excessive emphasis on shortening the length of stay may result in discharge before the patient and family are prepared. And patients uninformed about expectations, appointments and 'who to call' may cause the patient to return to the medical center.

In that readmissions within 30 days are likely to be unfunded, it is easy to imagine the cost-savings if a quarter of the readmissions could be prevented.

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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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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Risk factors for hospital readmission after shoulder arthroplasty - consequences

Hospital readmissions after primary shoulder arthroplasty.

These authors used State Inpatient Databases from 7 different states  to identify 26,218 patients who underwent hemiarthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty from 2005 through 2010.

These patients had 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 as well as for patients with comorbidities. 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.

Comment: The importance of developing strategies for minimizing readmissions has recently be amplified by the Centers for Medicare and Medicaid Services' Readmission Reduction Program that requires CMS to reduce payments to hospitals with excess readmissions, a program that became effective for discharges beginning on October 1, 2012. It is of note that such a program can create an unintended consequence:  a disincentive to offer shoulder arthroplasty to older individuals on Medicaid insurance who have comorbidities. If such patients are to receive surgical care for shoulder arthritis, steps will be needed to modulate the risk to medical centers.

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Risk of readmission is associated with more comorbidity

Higher Charlson Comorbidity Index Scores are Associated With Readmission After Orthopaedic Surgery.

These authors sought to determine if Charlson Comorbidity Index (CCI) was correlated with the risk of  hospital readmission,  surgical site infection or other adverse events,  transfusion, or  mortality after orthopaedic surgery.

Of a total of 30,129 patients having orthopaedic surgeries performed between 2008 and 2011,

913 patients (3.0%) were readmitted within 30 days after discharge;

393 (1.4%) had adverse events occurred; 

417 (1.4%) had a surgical site infection develop; 

211 (0.7%) needed transfusions, and 

56 (0.2%) died within 30 days after surgery. 

Every point increase in CCI score added an additional 0.45% risk in readmission for patients undergoing arthroplasty. While it was  not associated with surgical site infection or other adverse surgical events, it was associated with the risk of transfusion and mortality. 

Comment: The patient's overall health is one of the major determinants of the outcome of surgery. As interest grows in bundled payment for elective surgery (that includes the risk of 90 day readmission), profiling of the risk of readmission will become increasingly important. We have posted previously on the importance of comorbidity

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Readmission after shoulder arthroplasty

Readmission after shoulder arthroplasty

The authors performed a retrospective view of 680  shoulder arthroplasties they performed from 2005 to 2011. The overall readmission rate was 5.9%. For hemiarthroplasty, total shoulder arthroplasty, and reverse total shoulder arthroplasty, 90-day readmission rates were 8.8%, 4.5%, and 6.6%, respectively.

For hemiarthroplasties and reverse total shoulders, readmissions were most likely to occur within 30 days of admission.

Comment: It is of interest that the reasons for readmission and the initial indications for the arthroplasties requiring readmission were very different for the three different types of arthroplasty (see below).

The authors point out the importance of trying to minimize readmissions. To do that it will be important to learn which of the 4 Ps contribute to these readmissions. Is it the problem (diagnosis/indication for surgery), the patient (tendency to fall, tendency for respiratory, cardiac, gastrointestinal, and genitourinary problems), the physician (surgeon), or the procedure (hemi vs total vs reverse)?

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Complications of Surgery and Readmission - the 4 Ps

The Relationship Between Timing of Surgical Complications and Hospital Readmission

There is an increasing emphasis on safety of surgical care. Commonly used metrics include length of stay, mortality and in-hospital complications. In the future, however, reimbursement will be decreased for excessive readmissions, initially for those readmissions within 30 days for heart problems and pneumonia, but the list is expected to expand in the near future.

These authors sought to determine the timing of postoperative complications with respect to hospital discharge and the frequency of readmission. They examined the records of patients having surgery from January 2005 to August 2009, including arthroplasty, vascular, colorectal, and gynecologic procedures at 112 Department of Veterans Affairs (VA) hospitals.  They were particularly interested in the association between timing of complication with respect to index hospitalization and 30-day readmission.

The study of 59 273 surgical procedures performed found an overall complication rate of 22.6% of which over 25% were discovered after discharge; many of these required readmission. Over half of the surgical site infections were discovered after discharge.

The overall 30-day readmission rate was 11.9%, of which only 56.0% of readmissions were associated with a currently assessed complication. Readmission was predicted by patient comorbid conditions, procedure factors, and the occurrence of postoperative complications.  Readmissions were commonly needed for infections, CNS issues, venous thromboembolism, respiratory issues, cardiac issues and urinary tract issues.

The authors concluded that hospital discharge is an insufficient end point for quality assessment.

Comment: this is a powerful article. Close reading reveals the following risk factors for length of stay, complications and readmission shown in the table below, indicating the importance of factors related to the Patient and the Procedure (see more about the 4 Ps here)

These data suggest that risk stratification and post discharge surveillance for complications and readmissions will be important to the evaluation of health care quality.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, androtator cuff surgery as well as the 'ream and run essentials'

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Readmission after shoulder joint replacement

Readmission after shoulder arthroplasty

These authors conducted a retrospective view of all 680 shoulder arthroplasty procedures (124 hemiathroplasties, 376 total shoulders, and 180 reverse total shoulders) performed at their institution between 2005 and 2011.  The overall 90 day readmission rate was 5.9%, (8.8% for hemiarthroplasty, 4.5% for total shoulder and 6.6% for reverse total shoulder arthroplasty). Most readmissions after hemiarthroplasty and reverse total shoulder occurred within 30 days of discharge. 

Of note is that the number of hemiarthroplasty procedures performed decreased from 28 cases in 2005 to 8 in 2011. Conversely reverse total shoulder procedures increased from 4 cases in 2005 to 62 cases in 2011. The rate of readmission after reverse total shoulders decreased from 1 of 4 in 2005 (25%) to 4 of 62 in 2011 (5.5%). 

Reasons for readmission after hemiarthroplasty included fall, infection, instability, cuff tear, and arthritic pain.

Reasons for readmission after total shoulder were deep infection rotator cuff tear, pulmonary infections, pain, cardiac issues, urinary tract infection, and fracture.

Reasons for readmission after reverse total shoulder were for instability, small bowel obstruction, deep infection, cellulitis, fracture, and instability.

It was evident from the manuscript that patients requiring readmission often had more complex pathology prior to their index arthroplasty. For example, 5 of the 11 hemiarthroplasties requiring revision were for fracture and 2 were for arthritis associated with instability. 

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The importance of the patient in quality of outcome, the second P.

Risk Factors for Readmission of Orthopaedic Surgical Patients

As we've been pointing out in recent posts, the outcome of treatment depends on the 4 Ps: the problem, the patient, the provider and the procedure. This study does an excellent job of emphasizing the importance of the patient in determining one of the often measured and important indicators of quality of care: readmission rate. In any 'pay for performance' system, practices associated with lower rates of readmission are likely to be rewarded. A prior study (Jencks et al. in 2009) showed a national rate of thirty-day readmission among Medicare beneficiaries of 19.6%, with an estimated cost of $17.4 billion.

They addressed two questions: What is the incidence of thirty-day readmission for orthopaedic patients and what are the risk factors for readmission? Their study was based on over 3000 orthopaedic surgical admissions to an academic medical center during a two year interval. 73.9% of the readmissions were classified as surgical; of these, thirty-five readmission events (34.3%) were for infection at the surgical site, 14% were for septic arthroplasty, and another 1% for septic arthritis.

They found an unplanned thirty-day readmission rate of 4.2%. Multivariate analysis indicated readmission rate was associated with :

*marital status of ‘‘widowed’’  (OR, 1.846; 95% confidence interval [CI], 1.070 to 3.184; p = 0.03), *African American race (OR, 2.178; 95% CI, 1.077 to 4.408; p = 0.03),  

*American Indian or Alaskan Native race (OR, 3.550; 95% CI, 1.429 to 8.815; p = 0.006)

*Medicaid insurance (OR 1.547; 95% CI, 0.941 to 2.545; p = 0.09) 

*Any intensive care unit stay (OR, 2.356; 95% CI, 1.361 to 4.079; p = 0.002) 

*Longer length of stay ( 5.9 days in the unplanned readmission group compared with 3.6 days for non-readmitted patients (OR, 1.038; 95% CI, 1.014 to 1.062; p = 0.002)). 

As we've pointed out previously, the problem is that patients with these risk factors may be selected against by providers and medical centers concerned about readmission as a metric for quality of care.
As the authors state: "Without sufficient risk adjustment, a medical center that cares for the sicker population is almost ensured to receive poorer “quality” grades and financial penalties. Patients with socioeconomic risk factors for readmission present similar concerns. Without sufficient risk adjustment in these sicker and/or socioeconomically challenged populations, a potential undesired consequence could be selection against these populations for care. Subsequently, these populations may find new difficulties in accessing providers."

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