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ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
- Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
- Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
- Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994. doi:10.2106/JBJS.J.01994.
- Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
- Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
- Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
- Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
- Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
- Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
- Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
- Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
- Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
- Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
- Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
- Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
- Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
- Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
- Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
- Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
- Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
- American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
- Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
- Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
- Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
- Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
- Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
- Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994. doi:10.2106/JBJS.J.01994.
- Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
- Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
- Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
- Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
- Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
- Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
- Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
- Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
- Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
- Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
- Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
- Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
- Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
- Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
- Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
- Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
- Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
- American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
- Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
- Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
- Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
- Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
- Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
- Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994. doi:10.2106/JBJS.J.01994.
- Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
- Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
- Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
- Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
- Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
- Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
- Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
- Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
- Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
- Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
- Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
- Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
- Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
- Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
- Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
- Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
- Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
- American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
- Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
- Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
- Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
TAKE-HOME POINTS
- Shoulder arthroplasty is an increasingly commonly performed procedure for shoulder arthritis and other conditions.
- Unplanned readmission in the 30 days after shoulder arthroplasty occurred in about 1 of 40 cases.
- Increasing age was associated with readmission, particularly age >80 years.
- Other risk factors for readmission were male sex, anemia, and dependent functional status.
- The most common reasons for readmission were pneumonia, dislocation, pulmonary embolism, and surgical site infection.