Do faster shoulder arthroplasty surgeons get better results?

 Is There an Association Between Operative Time and Length-of-Stay after Shoulder Arthroplasty?

These authors reviewed data on 14,449 primary shoulder arthroplasty cases found in the National Surgical Quality Improvement Program (NSQIP) database  between 2008 and 2016.

Overall, the mean length of stay was 2 ± 2 days.  Multivariate analysis showed that after adjusting for patient factors (age, sex, BMI, and ASA, longer operative times were associated with with longer hospital stays. 

They pointed to the importance of operating room efficiency on healthcare quality and economics after shoulder arthroplasty. They state, "Hence, based on the results of this study, it seems that surgeons who wish to perform shoulder arthroplasty procedures should strive to become proficient, and dedicate time and effort into decreasing operative time during their TSA and RTSA".

Comment: There is no question that longer surgical times and longer hospital stays lead to increased costs of care. However, the implication of this study is that longer surgery times cause longer lengths of stay, whereas in fact it only showed that longer surgery was associated with longer lengths of stay. It seems likely that more complex cases had both longer operating times and longer hospital stays - unfortunately the study did not stratify cases by diagnosis; thus cases of arthroplasty for fracture were mixed with cases for primary arthritis. It remains to be seen whether, for example, shorter times for anatomic shoulder arthroplasty for osteoarthritis were indeed associated with shorter lengths of stay. This could be addressed simply by plotting OR time vs length of stay for each diagnosis and each procedure type (TSA and RTSA). 

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

How modifying risk factors may increase the value of shoulder arthroplasty

 Modifiable risk factors increase length of stay and 90-day cost of care after shoulder arthroplasty

These authors queried the electronic medical record (EPIC) for 1317  houlder arthroplasty cases under DRG 483 within a regional 7-hospital system to calculate mean length of stay (LOS), total 90-day charges, related emergency department (ED) visits and charges, and related hospital readmissions after shoulder arthroplasty. 

Data for patients who had 1 or more predefined modifiable risk factors (MRFs), defined as 

anemia (hemoglobin < 10 g/dL), 

malnutrition (albumin < 3.4 g/dL), 

obesity (BMI > 40), 

uncontrolled diabetes

(random glucose > 180 mg/dL or glycated hemoglobin > 8.0%), 

tobacco use (International Classification of Diseases, Tenth Revision, code indicating patient is a smoker), 

and opioid use (opioid prescription within 90 days of surgery), 

were evaluated as potential covariates to assess the relationship between MRFs and total encounter charges, LOS, ED visits, ED charges, and hospital readmissions.

The prevalence of these risk factors is shown below

Multivariable analysis demonstrated that anemia ($19,847), malnutrition ($5850), and obesity ($2762) independently contributed to higher charges after shoulder arthroplasty as shown in the graph below.

Mean LOS was higher in patients with anemia (5.0 days), malnutrition (3.7), and uncontrolled diabetes (2.8). 

Comment: The value of shoulder arthroplasty can be defined as the benefit to the patient divided by the cost of care.  While this study did not assess the numerator (i.e. the benefit of arthroplasty in terms of patient assessed measures of comfort and function) it did demonstrate the increased costs care related to anemia, malnutrition and obesity.

While these three risk factors are - in theory - modifiable, how to most effectively modify them needs further study. For example, while anemia may be amenable to management preoperatively by iron supplementation, treatment with medication such as epoetin alpha, transfusion, and/or identification and correction of the underlying cause, it is uncertain how effective these approaches are in reducing cost: is a transfusion of two units the day prior to surgery likely to result in earlier discharge - might transfusion increase the risk of infection? Malnutrition exists for a reason (malabsorption, poverty, alcoholism) how effective is nutritional supplementation in increasing the serum albumin to the point of reducing cost?  Obesity can be addressed by bariatric surgery which creates a relative starvation: does such a surgery reduce the cost of arthroplasty?

The purpose in asking these questions is a practical one: what should a surgeon tell the patient with painful arthritis who also has anemia, malnutrition, or obesity: "I'm not operating on you until you've corrected your hemoglobin, albumin, or BMI" or "We can do your surgery, but it is likely to cost (someone) more or to be associated with a longer length of stay in the hospital"?

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

 

Minimizing length of hospital stay after shoulder joint replacement

Length of Stay in Total Shoulder Arthroplasty: Does Day of Surgery Matter?

These authors investigated the effect that surgical day of week has on length of hospital stay (LOS) for shoulder arthroplasty patients.

1784 patients had a primary anatomic or reverse total shoulder arthroplasty by a single surgeon on Monday, Wednesday, or Friday over a 10-year period, were retrospectively reviewed. 

The overall average LOS was 2.9±1.8 days and was significantly longer for patients having surgery Friday (3.0±1.9 days) versus Wednesday (2.7±1.7 days, P..002). For those discharged home, the mean LOS was 2.6±1.3 days versus 4.3±3.3 days for those discharged to extended care facilities (ECFs). Patients discharged to ECF with Friday surgery had a significantly longer LOS than Monday (P..028) and Wednesday (P..010) patients, with 30% of patients with Friday surgery being discharged postoperative day 4 versus 14% and 9% on Monday and Wednesday, respectively. 

Comment: We have implemented a system-wide program designed to discharge patients to home on the day after surgery. This program is based on (1) setting the expectation of next day discharge well before the procedure (2) assuring that the patient has a family member or friend as their Care Partner, who will be readily available for the 1st seven days after discharge, (3) reinforcing that shoulder joint replacement does not meet the criteria for admission to an ECF, (4) assuring the patient that after surgery they will have ready access to their surgical team via email and phone, (5) use of preoperative tylenol, celebrex and neurontin, (6) transitioning the patient to oral pain medication on the afternoon of surgery and (7) avoiding the use of brachial plexus blocks. 

At present, the majority of our patients are discharged the day after surgery, avoiding the "day of the week" problem identified in the study.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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

How you can support progress in shoulder surgery

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

Shoulder arthroplasty - factors associated with longer lengths of hospital stay. The 4 Ps

Predictors of extended length of stay after elective shoulder arthroplasty.

These authors used the 2011 Nationwide Inpatient Sample to identify an estimated 40,869 patients who underwent elective total shoulder arthroplasty (62.5% anatomic; 37.5% reverse) and separated them into those with normal length of stay (<75th percentile) and prolonged length of stay (>75th percentile). The 75th percentile was 4 days for reverse total shoulders and three days for anatomic total shoulders.  Multivariate logistic regression modeling was performed to identify factors associated with prolonged length of stay. With respect to the 4 Ps:

Patient level factors associated with prolonged length of stay included increasing age, female sex, congestive heart failure, renal failure, chronic pulmonary disease, and preoperative anemia. Race, insurance and other factors were influential as well.

Provider-related factors associated with prolonged length of stay included lower hospital case volume and location in the South or Northeast. 

Problem related factors associated with length of stay include the diagnosis. Patients with a diagnosis other than osteoarthritis had longer lengths of stay after anatomic arthroplasty. 

Procedure related factors: 11% of the patients having reverse total shoulders stayed longer than 4 days. 22% of the patients having anatomic total shoulders stayed longer than 3 days.

Comment: This work again points out that the 4 Ps can be predictive of which patients will be outliers in terms of length of stay. An important related post can be found here. As we have pointed out before the cost of care of these patients may fall outside of those projected in a bundled payment plan. If uncorrected for the 4 Ps, the care of these patients may contribute to a provider scoring less well on quality of care metrics that include length of stay.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

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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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Total shoulder joint replacement arthroplasty - predictors of length of hospital stay - the 4 Ps

Here we have two articles on the same topic using two different national databases.

The first is
Predictors of extended length of stay after elective shoulder arthroplasty.

These authors used the 2011 Nationwide Inpatient Sample, to identify an estimated 40,869 patients who underwent elective total shoulder arthroplasty (62.5% anatomic total shoulder arthroplasty (ATSA)  37.5% reverse total shoulder arthroplasty (RTSA)  and separated them into those with normal length of stay (<75th percentile) and prolonged length of stay (>75th percentile). 

Patient-level factors associated with prolonged length of stay common to patients undergoing ATSA or RTSA included increasing age, female sex, congestive heart failure, renal failure, chronic pulmonary disease, and preoperative anemia. Provider-related factors were lower volume and location in the South or Northeast. Postoperative complications showed a significant influence as well.
 

The second is
Predictors of length of stay after elective total shoulder arthroplasty in the United States.

These authors isolated 2004 patients undergoing primary unilateral total shoulder arthroplasty (TSA) between 2005 and 2011 from the National Surgical Quality Improvement Program database.

Mean length of stay after TSA was 2.2 days (standard deviation, 1.7), and 91% of cases received hospital discharge in <3 days. Multivariable logistic regression analysis identified renal insufficiency (OR, 11.35; P = .0002), increased age (OR, 2.13; P = .011), longer operative time (OR, 1.94; P = .0041), and American Society of Anesthesiologists class ≥3 (OR, 1.86; P = .0016) as the most significant risk factors for length of stay. Women were more likely to stay ≥4 days (OR, 0.44; P < .0001).

Comment: Once again the importance of the 4 Ps is emphasized. In these papers the Patient-related factors were highly significant: age, comorbidities, female sex, and ASA class. Physician-related factors were lower case volume, location in the South or Northeast and longer operative time.

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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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Predicting length of stay after total shoulder arthroplasty.

Predictors of length of stay after elective total shoulder arthroplasty in the United States

These authors searched the National Surgical Quality Improvement Program database between 2005 and 2011 for patients undergoing primary unilateral total shoulder arthroplasty (TSA) for data related to the length of hospital stay. A total of 2004 patients (average age 68.8 years, 57% women) were identified. Mean length of stay after TSA was 2.2 ± 1.7 days. 91% of cases were discharged in less than 3 days.

Renal insufficiency (OR, 11.35; P = .0002), increased age (OR, 2.13; P = .011), longer operative time (OR, 1.94; P = .0041), and American Society of Anesthesiologists class ≥3 (OR, 1.86; P = .0016) were the most significant risk factors for longer length of stay in a multivariate analysis.

Comment: In this case, length of stay was used as the primary outcome variable. Other important outcome variables would have been perhaps more interesting, such as rate of readmission, rate of revision, and functional outcome. This study shows - again - that the health of the patient is an important determinant of the result. Other factors that often have a profound effect are missing from this study, including the specific procedure performed, the experience of the provider, and the problem or diagnosis for which the procedure is performed. Along with patient factors these four form the 4 Ps that determine the quality of the result.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

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'