High volume shoulder arthroplasty

Cost analysis and complication profile of primary shoulder arthroplasty at a high-volume institution 

These authors analyzed the complications, readmission rates, and costs of primary shoulder arthroplasty in a high volume practice where 2 shoulder surgeons performed 1794 consecutive primary shoulder arthroplasties between 2012 and 2016: 636 anatomic total shoulder arthroplasties (TSAs), 1081 reverse shoulder arthroplasties (RSAs), and 77 hemiarthroplasties.

The 90-day complication, reoperation, and readmission rates were 2.3%, 0.6%, and 1.8%, respectively. The 90-day readmission risk was higher among patients with an American Society of Anesthesiologists score of 3 or greater; a 1-unit increase in the American  Society of Anesthesiologists score was associated with a $429 increase in index cost. 

Of the hospital readmissions, 10 were directly related to the index arthroplasty whereas 21 were not. 

A standardized cost analysis for this study was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively. The period of 60 days prior to surgery was selected because the 2 surgeons participating in this study routinely provide a consultation, refer patients for medical clearance for anesthesia and surgery, and obtain new radiographs and a computed tomography scan of the shoulder to be replaced all within the 2 months preceding surgery.

The median standardized costs were as follows: preoperative evaluation, $481; index surgical hospitalization, $15,758; and postoperative care, $183. The median standardized costs for index surgical hospitalization were different for each procedure: TSA, $14,010; RSA, $16,741; and hemiarthroplasty, $12,709. The median standardized costs inclusive of preoperative workup and 90-day postoperative recovery were $14,675 and $17,407 for TSA and RSA, respectively.

Hospital room cost and length of stay were driven by discharge disposition. The median and mean lengths of stay for the 88.8% of patients discharged home were 1 and 1.2 days, respectively, whereas patients who were not discharged home remained in the hospital for a median of 3 days and mean of 3.3 days.

The 90-day event rates for complications, reoperations, and readmissions were 2.34%, 0.63%, and 1.82%, respectively. The majority of complications identified in this study were medically related; the most frequent complications were respiratory, renal, and cardiac in nature.

Comment: These results demonstrates the value of the systems of care to be found in high volume practices,  systems that derive benefit from highly tuned patient selection, standardization, personnel experienced in all aspects of the preoperative, intraoperative and postoperative care as well as the potential for volume discounts on implant costs. The results include low percentages of complications, reoperations, and readmissions in comparison to two other recently reported studies (see this link and this link). 

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