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Risk Factors for Early Readmission After Anatomical or Reverse Total Shoulder Arthroplasty
Hospital readmissions are undesirable and expensive.1 The Centers for Medicare & Medicaid Services (CMS) use hospital readmission rates as one measure of healthcare quality and hospital performance.2 In addition, the Patient Protection and Affordable Care Act of 2010 established a provision that decreases payments to hospitals with above-average readmission rates.3 Total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) are among the most common surgical procedures leading to readmission and cost almost $20 billion dollars annually in the Medicare population alone.1 Identifying factors that lead to readmissions after certain popular procedures may be a way to improve healthcare quality and outcomes while decreasing costs.
One such operation is shoulder arthroplasty (SA), which has surged in popularity over the past decade and is projected to increase faster than TKAs and THAs.4-6 SA is used to treat a variety of shoulder conditions, including osteoarthritis, inflammatory arthritis, severe proximal humeral fracture, avascular necrosis, and rotator cuff tear arthropathy.7-12 Much as with knee and hip arthroplasty, good outcomes have been reported with SA: decreased pain, improved range of motion, and high patient satisfaction.10,13 However, there have been few studies of rates of readmission after SA and the associated risk factors.3,14,15 The reported rates of early readmission after SA have ranged from 5.6% to 7.3%.3,14,15 These rates are comparable to rates of readmission after TKA (4.0%-6.6%) and THA (3.5%-8.4%).15-17Recently, CMS introduced legislation to void payments for hospital-acquired conditions (HACs), preventable medical conditions that patients develop during or as a result of their hospital care and that were not present on admission.18 Although many factors contribute to readmission, a recent study regarding all-cause readmission during the first 30 days after discharge found that almost 50% of 30-day readmissions after knee and hip replacements were potentially preventable.19 HACs resulting in readmission after SAs make up 9.3% to 34.5% of all readmissions, after anatomical total shoulder arthroplasties (ATSAs) and reverse total shoulder arthroplasties (RTSAs).3,14 The most common HACs include retained foreign body after surgery, air embolism, falls and trauma, catheter-associated urinary tract infection (CAUTI), surgical-site infection, deep vein thrombosis (DVT), and pulmonary embolism (PE).18 Raines and colleagues16 found that HACs accounted for 41.7% of all complications in knee or hip arthroplasty and that HACs were the greatest predictors of early readmission after both procedures.
We conducted a study to evaluate rates of readmission within 30 days after ATSA and RTSA and to describe the independent risk factors for readmission. We hypothesized that the rate of readmission after SA would be similar to the rate after knee and hip arthroplasty and that readmission risk factors would be similar. Elucidating these rates and associated risk factors may ultimately help to minimize the burden of disability on patients and the burden of financial costs on healthcare institutions.
Materials and Methods
Institutional Review Board approval was not required for this study, and all data used were de-identified to Health Insurance Portability and Accountability Act (HIPAA) standards. We used the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database for this study. The NSQIP was developed in the 1990s to improve surgical quality in the Veterans Health Administration and was later adapted by the ACS.20 NSQIP follows patients for 30 days after operations and provides clinical data and outcome measures that are closely regulated and internally audited.21 The program has continued to expand and now includes more than 400 institutions. The NSQIP database has been validated as a reliable source of surgical outcomes data, including outcomes data for orthopedic procedures, and has been used in other studies of readmissions.17,22
In the present study, the ACS-NSQIP files for the period 2011-2013 were queried for all total shoulder arthroplasties (TSAs) (Current Procedural Terminology [CPT] code 23472, which includes ATSA and RTSA). Descriptive analysis was performed to determine the overall readmission rate as well as the percentages of readmissions for medical and surgical complications. Reasons for readmission were collected from 2012 and 2013 (information from 2011 was absent).
The various patient parameters compiled within the database were examined in a review of ATSAs and RTSAs. Demographics, comorbidities, operative characteristics, and predischarge complications were amassed from these data. Demographics included age, sex, race, body mass index, smoking status, preoperative functional health status, and American Society of Anesthesiologists (ASA) score. Comorbidities included diabetes mellitus, hypertension, chronic corticosteroid use, coagulation disorder, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), cardiac comorbidity (including congestive heart failure, history of myocardial infarction, previous coronary intervention or cardiac surgery, and angina), renal comorbidity (including acute renal failure and preoperative dialysis), neurologic comorbidity (including impaired sensorium, hemiplegia, history of transient ischemic attack, and history of cerebrovascular accident with or without residual deficit), and preoperative blood transfusion. Operative characteristics included resident involvement, operative time more than 1 SD from the mean (>164.4 minutes), intraoperative blood transfusion, and revision surgery. Predischarge complications included pneumonia, CAUTI, DVT, PE, postoperative bleeding that required transfusion, cerebrovascular accident, myocardial infarction, and sepsis. Surgical-site infection, CAUTI, DVT, and PE were selected for analysis because these HACs are common in our cohort.
After the data on these characteristics were collected, univariate analysis was performed to determine association with any readmission. Factors with P < .20 were then entered into multivariate analysis to determine independent risk factors for readmission. This P value was selected to make the model inclusive of any potentially important predictor. Univariate analysis was performed using the Fisher exact test. Multivariate analysis was performed using backward conditional binary logistic regression. Statistical significance was set at P < .05. All analysis was performed with SPSS Version 22.0 (SPSS).
Results
This study included a combined total of 3501 ATSAs and RTSAs performed between 2011 and 2013. The overall readmission rate was 2.7%. The associated diagnosis for readmission was available for 54% of the readmitted patients. Of the known readmission diagnoses, 33% were secondary to HACs. 
Of the 51 readmissions, 34 (67%) were for medical complications, and 17 (33%) were for surgical complications. Pneumonia was the most common medical complication (11.8%), followed by UTI (7.8%), DVT (5.9%), PE (5.9%), and renal insufficiency (3.9%). Surgical-site infection was the most common surgical complication (13.7%), followed by prosthetic joint dislocation (9.8%) and hematoma (3.9%). 
Other risk factors significantly (P < .05) associated with readmission were age over 75 years, dependent functional status, ASA score of 4 or higher, cardiac comorbidity, 2 or more comorbidities, postoperative CAUTI, extended LOS, and revision surgery (Table 3). 
Discussion
Hospital readmissions are important because they represent quality of care and play a role in patient outcomes. Arthroplasty research has focused mainly on readmissions after primary knee and hip replacements.23-25
Historical rates of early readmission after SA14 are comparable to those found in our study. Previously identified risk factors have included increasing age, Medicaid insurance status, low-volume surgical centers, and SA type.3 Mahoney and colleagues14 reported a 90-day readmission rate of 5.9%, but, when they removed hemiarthroplasty replacement from the analysis and shortened the readmission timeline to 30 days, the readmission rate was identical to the 2.7% rate in the present study. In their series from a single high-volume institution, the highest 90-day readmission rate was found for hemiarthroplasty (8.8%), followed by RTSA (6.6%) and ATSA (4.5%). In a study by Schairer and colleagues,3 the readmission rate was also influenced by replacement type, but their results differed from those of Mahoney and colleagues.14 Schairer and colleagues3 analyzed data from 7 state inpatient databases and found that the highest readmission rate was associated with RTSA (11.2%), followed by hemiarthroplasty (8.2%) and ATSA (6.0%). In both series, RTSA readmission rates were higher than ATSA readmission rates—consistent with the complication profiles of these procedures, with RTSA often provided as a surgery of last resort, after failure of other procedures, including ATSA.26 The lower 30-day readmission rate in the present study may be attributable to the fact that some surgical and medical complications may not have developed within this short time. Nonetheless, the majority of readmissions typically present within the first 30 days after SA.14,15 Other factors, including hospital volume, surgeon volume, race, and hospital type, may also influence readmission rates but could not be compared between
The present study found that revision surgery, 3 or more comorbidities, and extended LOS (>4.3 days) more than doubled the risk of readmission. Published SA revision rates range from 5% to 42%, with most revisions performed for instability, dislocation, infection, and component loosening.6,29 Complication rates are higher for revision SA than for primary SA, which may explain why revisions predispose patients to readmission.30 Compared with primary SAs, revision SAs are also more likely to be RTSAs, and these salvage procedures have been found to have high complication rates.31 In the present study, the most common comorbidities were hypertension, diabetes, and COPD; the literature supports these as some of the most common comorbid medical conditions in patients who undergo ATSA or RTSA.5,26,32 Furthermore, all 3 of these comorbidities have been shown to be independent predictors of increased postoperative complications in patients who undergo SA, which ultimately would increase the risk of readmission.3,26,33,34 Last, extended LOS has also been shown to increase the risk of unplanned readmissions after orthopedic procedures.35 Risk factors associated with increased LOS after ATSA or RTSA include female sex, advanced age, multiple comorbidities, and postoperative complications.32Several other factors must be noted with respect to individual risk for readmission. In the present study, age over 75 years, dependent functional status, ASA score of 4 or higher, and cardiac comorbidity were found to have a significant association with readmission. Increased age is a risk factor for increased postoperative complications, more medical comorbidities, and increased LOS.34,36 Older people are at higher risk of developing osteoarthritis and rotator cuff tear arthropathy and are more likely to undergo SA.5,6 Older people also are more likely to be dependent, which itself is a risk factor for readmission.19 An ASA score of 3 or 4 has been found to be associated with increased LOS and complications after SA, and cardiac comorbidities predispose patients to a variety of complications.34,36,37In studies that have combined surgical and medical factors, rates of complications early after ATSA and RTSA have ranged from 3.6% to 17.8%.26,38,39 After SAs, medical complications (80%) are more common than surgical complications (20%).39 In the present cohort, many more readmissions were for medical complications (67%) than for surgical complications (33%). In addition, Schairer and colleagues3 found medical complications associated with more than 80% of readmissions after SA.3 Infection was the most common medical reason (pneumonia) and surgical reason (surgical-site infection) for readmission—consistent with findings of other studies.3,35,40 Infection has accounted for 9.4% to 41.4% of readmissions after ATSA and RTSA.3,14In joint arthroplasty, infection occurs more often in patients with coexisting medical comorbidities, leading to higher mortality and increased LOS.41 Prosthetic joint dislocation was common as well—similar to findings in other studies.3,10In the present study, 33% of known readmission diagnoses were secondary to HACs. Surgical-site infection was the most common, followed by CAUTI, DVT, and PE. In another study, of knee and hip arthroplasties, HACs accounted for more than 40% of all complications and were the strongest predictor of early readmission.16 In SA studies, HACs were responsible for 9.3% to 34.5% of readmissions after ATSA and RTSA.3,14 Our finding (33%) is more in line with Mahoney and colleagues14 (34.5%) than Schairer and colleagues3 (9.3%). One explanation for the large discrepancy with Schairer and colleagues3 is that UTI was not among the medical reasons for readmission in their study, but it was in ours. Another difference is that we used a database that included data from multiple institutions. Last, Schairer and colleagues3 excluded revision SAs from their analysis (complication rates are higher for revision SAs than for primary SAs30). They also excluded cases of SA used for fracture (shown to increase the risk for PE42). The US Department of Health and Human Services estimated that patients experienced 1.3 million fewer HACs during the period 2010-2013, corresponding to a 17% decline over the 3 years.43 This translates to an estimated 50,000 fewer mortalities, and $12 billion saved in healthcare costs, over the same period.43 Preventing HACs helps reduce readmission rates while improving patient outcomes and decreasing healthcare costs.
This study had several limitations. We could not differentiate between ATSA and RTSA readmission rates because, for the study period, these procedures are collectively organized under a common CPT code in the NSQIP database. Readmission and complication rates are higher for RTSAs than for ATSAs.3,14 In addition, our data were limited to hospitals that were participating in NSQIP, which could lead to selection bias. We studied rates of only those readmissions and complications that occurred within 30 days, but many complications develop after 30 days, and these increase the readmission rate. Last, reasons for readmission were not recorded for 2011, so this information was available only for the final 2 years of the study. Despite these limitations, NSQIP still allows for a powerful study, as it includes multiple institutions and a very large cohort.
Conclusion
With medical costs increasing, focus has shifted to quality care and good outcomes with the goal of reducing readmissions and complications after various procedures. SA has recently become more popular because of its multiple indications, and this trend will continue. In the present study, the rate of readmission within 30 days after ATSA or RTSA was 2.7%. Revision surgery, 3 or more comorbidities, and extended LOS were independent risk factors that more than doubled the risk of readmission. Understanding the risk factors for short-term readmission will allow for better patient care and decreased costs, and will benefit the healthcare system as a whole.
Am J Orthop. 2016;45(6):E386-E392. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
1. 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.
2. Axon RN, Williams MV. Hospital readmission as an accountability measure. JAMA. 2011;305(5):504-505.
3. Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355.
4. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120.
5. 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.
6. Jain NB, Yamaguchi K. The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(12):1905-1912.
7. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
8. Chalmers PN, Slikker W 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204.
9. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002;11(2):130-135.
10. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485.
11. Fevang BT, Lygre SH, Bertelsen G, Skredderstuen A, Havelin LI, Furnes O. Good function after shoulder arthroplasty. Acta Orthop. 2012;83(5):467-473.
12. Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007;16(3 suppl):S27-S32.
13. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604-613.
14. Mahoney A, Bosco JA 3rd, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381.
15. Fehringer EV, Mikuls TR, Michaud KD, Henderson WG, O’Dell JR. Shoulder arthroplasties have fewer complications than hip or knee arthroplasties in US veterans. Clin Orthop Relat Res. 2010;468(3):717-722.
16. Raines BT, Ponce BA, Reed RD, Richman JS, Hawn MT. Hospital acquired conditions are the strongest predictor for early readmission: an analysis of 26,710 arthroplasties. J Arthroplasty. 2015;30(8):1299-1307.
17. Pugely AJ, Callaghan JJ, Martin CT, Cram P, Gao Y. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. J Arthroplasty. 2013;28(9):1499-1504.
18. Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Published 2014. Accessed May 21, 2015.
19. Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.
20. Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363-376.
21. American College of Surgeons. About ACS NSQIP. http://www.facs.org/quality-programs/acs-nsqip/about. Published 2015. Accessed June 14, 2015.
22. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16.
23. Bini SA, Fithian DC, Paxton LW, Khatod MX, Inacio MC, Namba RS. Does discharge disposition after primary total joint arthroplasty affect readmission rates? J Arthroplasty. 2010;25(1):114-117.
24. Husted H, Otte KS, Kristensen BB, Orsnes T, Kehlet H. Readmissions after fast-track hip and knee arthroplasty. Arch Orthop Trauma Surg. 2010;130(9):1185-1191.
25. Vorhies JS, Wang Y, Herndon J, Maloney WJ, Huddleston JI. Readmission and length of stay after total hip arthroplasty in a national Medicare sample. J Arthroplasty. 2011;26(6 suppl):119-123.
26. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467.
27. Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010;92(16):2643-2652.
28. Tsai TC, Orav EJ, Joynt KE. Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care. Ann Surg. 2014;259(6):1086-1090.
29. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292.
30. 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.
31. Black EM, Roberts SM, Siegel E, Yannopoulos P, Higgins LD, Warner JJ. Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger. J Shoulder Elbow Surg. 2014;23(7):1036-1042.
32. Menendez ME, Baker DK, Fryberger CT, Ponce BA. Predictors of extended length of stay after elective shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):1527-1533.
33. Jain NB, Guller U, Pietrobon R, Bond TK, Higgins LD. Comorbidities increase complication rates in patients having arthroplasty. Clin Orthop Relat Res. 2005;(435):232-238.
34. 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.
35. Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients. J Bone Joint Surg Am. 2013;95(11):1012-1019.
36. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ Jr. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(5):754-759.
37. Maile MD, Engoren MC, Tremper KK, Jewell E, Kheterpal S. Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg. 2014;119(3):522-532.
38. Farng E, Zingmond D, Krenek L, Soohoo NF. Factors predicting complication rates after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2011;20(4):557-563.
39. Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ Jr. 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.
40. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322-330.
41. Poultsides LA, Ma Y, Della Valle AG, Chiu YL, Sculco TP, Memtsoudis SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty. 2013;28(3):385-389.
42. Young BL, Menendez ME, Baker DK, Ponce BA. Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):e271-e278.
43. US Department of Health and Human Services. Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided [press release]. http://www.hhs.gov/news/press/2014pres/12/20141202a.html. Published December 2, 2014. Accessed May 25, 2015.
Hospital readmissions are undesirable and expensive.1 The Centers for Medicare & Medicaid Services (CMS) use hospital readmission rates as one measure of healthcare quality and hospital performance.2 In addition, the Patient Protection and Affordable Care Act of 2010 established a provision that decreases payments to hospitals with above-average readmission rates.3 Total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) are among the most common surgical procedures leading to readmission and cost almost $20 billion dollars annually in the Medicare population alone.1 Identifying factors that lead to readmissions after certain popular procedures may be a way to improve healthcare quality and outcomes while decreasing costs.
One such operation is shoulder arthroplasty (SA), which has surged in popularity over the past decade and is projected to increase faster than TKAs and THAs.4-6 SA is used to treat a variety of shoulder conditions, including osteoarthritis, inflammatory arthritis, severe proximal humeral fracture, avascular necrosis, and rotator cuff tear arthropathy.7-12 Much as with knee and hip arthroplasty, good outcomes have been reported with SA: decreased pain, improved range of motion, and high patient satisfaction.10,13 However, there have been few studies of rates of readmission after SA and the associated risk factors.3,14,15 The reported rates of early readmission after SA have ranged from 5.6% to 7.3%.3,14,15 These rates are comparable to rates of readmission after TKA (4.0%-6.6%) and THA (3.5%-8.4%).15-17Recently, CMS introduced legislation to void payments for hospital-acquired conditions (HACs), preventable medical conditions that patients develop during or as a result of their hospital care and that were not present on admission.18 Although many factors contribute to readmission, a recent study regarding all-cause readmission during the first 30 days after discharge found that almost 50% of 30-day readmissions after knee and hip replacements were potentially preventable.19 HACs resulting in readmission after SAs make up 9.3% to 34.5% of all readmissions, after anatomical total shoulder arthroplasties (ATSAs) and reverse total shoulder arthroplasties (RTSAs).3,14 The most common HACs include retained foreign body after surgery, air embolism, falls and trauma, catheter-associated urinary tract infection (CAUTI), surgical-site infection, deep vein thrombosis (DVT), and pulmonary embolism (PE).18 Raines and colleagues16 found that HACs accounted for 41.7% of all complications in knee or hip arthroplasty and that HACs were the greatest predictors of early readmission after both procedures.
We conducted a study to evaluate rates of readmission within 30 days after ATSA and RTSA and to describe the independent risk factors for readmission. We hypothesized that the rate of readmission after SA would be similar to the rate after knee and hip arthroplasty and that readmission risk factors would be similar. Elucidating these rates and associated risk factors may ultimately help to minimize the burden of disability on patients and the burden of financial costs on healthcare institutions.
Materials and Methods
Institutional Review Board approval was not required for this study, and all data used were de-identified to Health Insurance Portability and Accountability Act (HIPAA) standards. We used the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database for this study. The NSQIP was developed in the 1990s to improve surgical quality in the Veterans Health Administration and was later adapted by the ACS.20 NSQIP follows patients for 30 days after operations and provides clinical data and outcome measures that are closely regulated and internally audited.21 The program has continued to expand and now includes more than 400 institutions. The NSQIP database has been validated as a reliable source of surgical outcomes data, including outcomes data for orthopedic procedures, and has been used in other studies of readmissions.17,22
In the present study, the ACS-NSQIP files for the period 2011-2013 were queried for all total shoulder arthroplasties (TSAs) (Current Procedural Terminology [CPT] code 23472, which includes ATSA and RTSA). Descriptive analysis was performed to determine the overall readmission rate as well as the percentages of readmissions for medical and surgical complications. Reasons for readmission were collected from 2012 and 2013 (information from 2011 was absent).
The various patient parameters compiled within the database were examined in a review of ATSAs and RTSAs. Demographics, comorbidities, operative characteristics, and predischarge complications were amassed from these data. Demographics included age, sex, race, body mass index, smoking status, preoperative functional health status, and American Society of Anesthesiologists (ASA) score. Comorbidities included diabetes mellitus, hypertension, chronic corticosteroid use, coagulation disorder, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), cardiac comorbidity (including congestive heart failure, history of myocardial infarction, previous coronary intervention or cardiac surgery, and angina), renal comorbidity (including acute renal failure and preoperative dialysis), neurologic comorbidity (including impaired sensorium, hemiplegia, history of transient ischemic attack, and history of cerebrovascular accident with or without residual deficit), and preoperative blood transfusion. Operative characteristics included resident involvement, operative time more than 1 SD from the mean (>164.4 minutes), intraoperative blood transfusion, and revision surgery. Predischarge complications included pneumonia, CAUTI, DVT, PE, postoperative bleeding that required transfusion, cerebrovascular accident, myocardial infarction, and sepsis. Surgical-site infection, CAUTI, DVT, and PE were selected for analysis because these HACs are common in our cohort.
After the data on these characteristics were collected, univariate analysis was performed to determine association with any readmission. Factors with P < .20 were then entered into multivariate analysis to determine independent risk factors for readmission. This P value was selected to make the model inclusive of any potentially important predictor. Univariate analysis was performed using the Fisher exact test. Multivariate analysis was performed using backward conditional binary logistic regression. Statistical significance was set at P < .05. All analysis was performed with SPSS Version 22.0 (SPSS).
Results
This study included a combined total of 3501 ATSAs and RTSAs performed between 2011 and 2013. The overall readmission rate was 2.7%. The associated diagnosis for readmission was available for 54% of the readmitted patients. Of the known readmission diagnoses, 33% were secondary to HACs.
Of the 51 readmissions, 34 (67%) were for medical complications, and 17 (33%) were for surgical complications. Pneumonia was the most common medical complication (11.8%), followed by UTI (7.8%), DVT (5.9%), PE (5.9%), and renal insufficiency (3.9%). Surgical-site infection was the most common surgical complication (13.7%), followed by prosthetic joint dislocation (9.8%) and hematoma (3.9%).
Other risk factors significantly (P < .05) associated with readmission were age over 75 years, dependent functional status, ASA score of 4 or higher, cardiac comorbidity, 2 or more comorbidities, postoperative CAUTI, extended LOS, and revision surgery (Table 3).
Discussion
Hospital readmissions are important because they represent quality of care and play a role in patient outcomes. Arthroplasty research has focused mainly on readmissions after primary knee and hip replacements.23-25
Historical rates of early readmission after SA14 are comparable to those found in our study. Previously identified risk factors have included increasing age, Medicaid insurance status, low-volume surgical centers, and SA type.3 Mahoney and colleagues14 reported a 90-day readmission rate of 5.9%, but, when they removed hemiarthroplasty replacement from the analysis and shortened the readmission timeline to 30 days, the readmission rate was identical to the 2.7% rate in the present study. In their series from a single high-volume institution, the highest 90-day readmission rate was found for hemiarthroplasty (8.8%), followed by RTSA (6.6%) and ATSA (4.5%). In a study by Schairer and colleagues,3 the readmission rate was also influenced by replacement type, but their results differed from those of Mahoney and colleagues.14 Schairer and colleagues3 analyzed data from 7 state inpatient databases and found that the highest readmission rate was associated with RTSA (11.2%), followed by hemiarthroplasty (8.2%) and ATSA (6.0%). In both series, RTSA readmission rates were higher than ATSA readmission rates—consistent with the complication profiles of these procedures, with RTSA often provided as a surgery of last resort, after failure of other procedures, including ATSA.26 The lower 30-day readmission rate in the present study may be attributable to the fact that some surgical and medical complications may not have developed within this short time. Nonetheless, the majority of readmissions typically present within the first 30 days after SA.14,15 Other factors, including hospital volume, surgeon volume, race, and hospital type, may also influence readmission rates but could not be compared between
The present study found that revision surgery, 3 or more comorbidities, and extended LOS (>4.3 days) more than doubled the risk of readmission. Published SA revision rates range from 5% to 42%, with most revisions performed for instability, dislocation, infection, and component loosening.6,29 Complication rates are higher for revision SA than for primary SA, which may explain why revisions predispose patients to readmission.30 Compared with primary SAs, revision SAs are also more likely to be RTSAs, and these salvage procedures have been found to have high complication rates.31 In the present study, the most common comorbidities were hypertension, diabetes, and COPD; the literature supports these as some of the most common comorbid medical conditions in patients who undergo ATSA or RTSA.5,26,32 Furthermore, all 3 of these comorbidities have been shown to be independent predictors of increased postoperative complications in patients who undergo SA, which ultimately would increase the risk of readmission.3,26,33,34 Last, extended LOS has also been shown to increase the risk of unplanned readmissions after orthopedic procedures.35 Risk factors associated with increased LOS after ATSA or RTSA include female sex, advanced age, multiple comorbidities, and postoperative complications.32Several other factors must be noted with respect to individual risk for readmission. In the present study, age over 75 years, dependent functional status, ASA score of 4 or higher, and cardiac comorbidity were found to have a significant association with readmission. Increased age is a risk factor for increased postoperative complications, more medical comorbidities, and increased LOS.34,36 Older people are at higher risk of developing osteoarthritis and rotator cuff tear arthropathy and are more likely to undergo SA.5,6 Older people also are more likely to be dependent, which itself is a risk factor for readmission.19 An ASA score of 3 or 4 has been found to be associated with increased LOS and complications after SA, and cardiac comorbidities predispose patients to a variety of complications.34,36,37In studies that have combined surgical and medical factors, rates of complications early after ATSA and RTSA have ranged from 3.6% to 17.8%.26,38,39 After SAs, medical complications (80%) are more common than surgical complications (20%).39 In the present cohort, many more readmissions were for medical complications (67%) than for surgical complications (33%). In addition, Schairer and colleagues3 found medical complications associated with more than 80% of readmissions after SA.3 Infection was the most common medical reason (pneumonia) and surgical reason (surgical-site infection) for readmission—consistent with findings of other studies.3,35,40 Infection has accounted for 9.4% to 41.4% of readmissions after ATSA and RTSA.3,14In joint arthroplasty, infection occurs more often in patients with coexisting medical comorbidities, leading to higher mortality and increased LOS.41 Prosthetic joint dislocation was common as well—similar to findings in other studies.3,10In the present study, 33% of known readmission diagnoses were secondary to HACs. Surgical-site infection was the most common, followed by CAUTI, DVT, and PE. In another study, of knee and hip arthroplasties, HACs accounted for more than 40% of all complications and were the strongest predictor of early readmission.16 In SA studies, HACs were responsible for 9.3% to 34.5% of readmissions after ATSA and RTSA.3,14 Our finding (33%) is more in line with Mahoney and colleagues14 (34.5%) than Schairer and colleagues3 (9.3%). One explanation for the large discrepancy with Schairer and colleagues3 is that UTI was not among the medical reasons for readmission in their study, but it was in ours. Another difference is that we used a database that included data from multiple institutions. Last, Schairer and colleagues3 excluded revision SAs from their analysis (complication rates are higher for revision SAs than for primary SAs30). They also excluded cases of SA used for fracture (shown to increase the risk for PE42). The US Department of Health and Human Services estimated that patients experienced 1.3 million fewer HACs during the period 2010-2013, corresponding to a 17% decline over the 3 years.43 This translates to an estimated 50,000 fewer mortalities, and $12 billion saved in healthcare costs, over the same period.43 Preventing HACs helps reduce readmission rates while improving patient outcomes and decreasing healthcare costs.
This study had several limitations. We could not differentiate between ATSA and RTSA readmission rates because, for the study period, these procedures are collectively organized under a common CPT code in the NSQIP database. Readmission and complication rates are higher for RTSAs than for ATSAs.3,14 In addition, our data were limited to hospitals that were participating in NSQIP, which could lead to selection bias. We studied rates of only those readmissions and complications that occurred within 30 days, but many complications develop after 30 days, and these increase the readmission rate. Last, reasons for readmission were not recorded for 2011, so this information was available only for the final 2 years of the study. Despite these limitations, NSQIP still allows for a powerful study, as it includes multiple institutions and a very large cohort.
Conclusion
With medical costs increasing, focus has shifted to quality care and good outcomes with the goal of reducing readmissions and complications after various procedures. SA has recently become more popular because of its multiple indications, and this trend will continue. In the present study, the rate of readmission within 30 days after ATSA or RTSA was 2.7%. Revision surgery, 3 or more comorbidities, and extended LOS were independent risk factors that more than doubled the risk of readmission. Understanding the risk factors for short-term readmission will allow for better patient care and decreased costs, and will benefit the healthcare system as a whole.
Am J Orthop. 2016;45(6):E386-E392. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
Hospital readmissions are undesirable and expensive.1 The Centers for Medicare & Medicaid Services (CMS) use hospital readmission rates as one measure of healthcare quality and hospital performance.2 In addition, the Patient Protection and Affordable Care Act of 2010 established a provision that decreases payments to hospitals with above-average readmission rates.3 Total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) are among the most common surgical procedures leading to readmission and cost almost $20 billion dollars annually in the Medicare population alone.1 Identifying factors that lead to readmissions after certain popular procedures may be a way to improve healthcare quality and outcomes while decreasing costs.
One such operation is shoulder arthroplasty (SA), which has surged in popularity over the past decade and is projected to increase faster than TKAs and THAs.4-6 SA is used to treat a variety of shoulder conditions, including osteoarthritis, inflammatory arthritis, severe proximal humeral fracture, avascular necrosis, and rotator cuff tear arthropathy.7-12 Much as with knee and hip arthroplasty, good outcomes have been reported with SA: decreased pain, improved range of motion, and high patient satisfaction.10,13 However, there have been few studies of rates of readmission after SA and the associated risk factors.3,14,15 The reported rates of early readmission after SA have ranged from 5.6% to 7.3%.3,14,15 These rates are comparable to rates of readmission after TKA (4.0%-6.6%) and THA (3.5%-8.4%).15-17Recently, CMS introduced legislation to void payments for hospital-acquired conditions (HACs), preventable medical conditions that patients develop during or as a result of their hospital care and that were not present on admission.18 Although many factors contribute to readmission, a recent study regarding all-cause readmission during the first 30 days after discharge found that almost 50% of 30-day readmissions after knee and hip replacements were potentially preventable.19 HACs resulting in readmission after SAs make up 9.3% to 34.5% of all readmissions, after anatomical total shoulder arthroplasties (ATSAs) and reverse total shoulder arthroplasties (RTSAs).3,14 The most common HACs include retained foreign body after surgery, air embolism, falls and trauma, catheter-associated urinary tract infection (CAUTI), surgical-site infection, deep vein thrombosis (DVT), and pulmonary embolism (PE).18 Raines and colleagues16 found that HACs accounted for 41.7% of all complications in knee or hip arthroplasty and that HACs were the greatest predictors of early readmission after both procedures.
We conducted a study to evaluate rates of readmission within 30 days after ATSA and RTSA and to describe the independent risk factors for readmission. We hypothesized that the rate of readmission after SA would be similar to the rate after knee and hip arthroplasty and that readmission risk factors would be similar. Elucidating these rates and associated risk factors may ultimately help to minimize the burden of disability on patients and the burden of financial costs on healthcare institutions.
Materials and Methods
Institutional Review Board approval was not required for this study, and all data used were de-identified to Health Insurance Portability and Accountability Act (HIPAA) standards. We used the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database for this study. The NSQIP was developed in the 1990s to improve surgical quality in the Veterans Health Administration and was later adapted by the ACS.20 NSQIP follows patients for 30 days after operations and provides clinical data and outcome measures that are closely regulated and internally audited.21 The program has continued to expand and now includes more than 400 institutions. The NSQIP database has been validated as a reliable source of surgical outcomes data, including outcomes data for orthopedic procedures, and has been used in other studies of readmissions.17,22
In the present study, the ACS-NSQIP files for the period 2011-2013 were queried for all total shoulder arthroplasties (TSAs) (Current Procedural Terminology [CPT] code 23472, which includes ATSA and RTSA). Descriptive analysis was performed to determine the overall readmission rate as well as the percentages of readmissions for medical and surgical complications. Reasons for readmission were collected from 2012 and 2013 (information from 2011 was absent).
The various patient parameters compiled within the database were examined in a review of ATSAs and RTSAs. Demographics, comorbidities, operative characteristics, and predischarge complications were amassed from these data. Demographics included age, sex, race, body mass index, smoking status, preoperative functional health status, and American Society of Anesthesiologists (ASA) score. Comorbidities included diabetes mellitus, hypertension, chronic corticosteroid use, coagulation disorder, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), cardiac comorbidity (including congestive heart failure, history of myocardial infarction, previous coronary intervention or cardiac surgery, and angina), renal comorbidity (including acute renal failure and preoperative dialysis), neurologic comorbidity (including impaired sensorium, hemiplegia, history of transient ischemic attack, and history of cerebrovascular accident with or without residual deficit), and preoperative blood transfusion. Operative characteristics included resident involvement, operative time more than 1 SD from the mean (>164.4 minutes), intraoperative blood transfusion, and revision surgery. Predischarge complications included pneumonia, CAUTI, DVT, PE, postoperative bleeding that required transfusion, cerebrovascular accident, myocardial infarction, and sepsis. Surgical-site infection, CAUTI, DVT, and PE were selected for analysis because these HACs are common in our cohort.
After the data on these characteristics were collected, univariate analysis was performed to determine association with any readmission. Factors with P < .20 were then entered into multivariate analysis to determine independent risk factors for readmission. This P value was selected to make the model inclusive of any potentially important predictor. Univariate analysis was performed using the Fisher exact test. Multivariate analysis was performed using backward conditional binary logistic regression. Statistical significance was set at P < .05. All analysis was performed with SPSS Version 22.0 (SPSS).
Results
This study included a combined total of 3501 ATSAs and RTSAs performed between 2011 and 2013. The overall readmission rate was 2.7%. The associated diagnosis for readmission was available for 54% of the readmitted patients. Of the known readmission diagnoses, 33% were secondary to HACs.
Of the 51 readmissions, 34 (67%) were for medical complications, and 17 (33%) were for surgical complications. Pneumonia was the most common medical complication (11.8%), followed by UTI (7.8%), DVT (5.9%), PE (5.9%), and renal insufficiency (3.9%). Surgical-site infection was the most common surgical complication (13.7%), followed by prosthetic joint dislocation (9.8%) and hematoma (3.9%).
Other risk factors significantly (P < .05) associated with readmission were age over 75 years, dependent functional status, ASA score of 4 or higher, cardiac comorbidity, 2 or more comorbidities, postoperative CAUTI, extended LOS, and revision surgery (Table 3).
Discussion
Hospital readmissions are important because they represent quality of care and play a role in patient outcomes. Arthroplasty research has focused mainly on readmissions after primary knee and hip replacements.23-25
Historical rates of early readmission after SA14 are comparable to those found in our study. Previously identified risk factors have included increasing age, Medicaid insurance status, low-volume surgical centers, and SA type.3 Mahoney and colleagues14 reported a 90-day readmission rate of 5.9%, but, when they removed hemiarthroplasty replacement from the analysis and shortened the readmission timeline to 30 days, the readmission rate was identical to the 2.7% rate in the present study. In their series from a single high-volume institution, the highest 90-day readmission rate was found for hemiarthroplasty (8.8%), followed by RTSA (6.6%) and ATSA (4.5%). In a study by Schairer and colleagues,3 the readmission rate was also influenced by replacement type, but their results differed from those of Mahoney and colleagues.14 Schairer and colleagues3 analyzed data from 7 state inpatient databases and found that the highest readmission rate was associated with RTSA (11.2%), followed by hemiarthroplasty (8.2%) and ATSA (6.0%). In both series, RTSA readmission rates were higher than ATSA readmission rates—consistent with the complication profiles of these procedures, with RTSA often provided as a surgery of last resort, after failure of other procedures, including ATSA.26 The lower 30-day readmission rate in the present study may be attributable to the fact that some surgical and medical complications may not have developed within this short time. Nonetheless, the majority of readmissions typically present within the first 30 days after SA.14,15 Other factors, including hospital volume, surgeon volume, race, and hospital type, may also influence readmission rates but could not be compared between
The present study found that revision surgery, 3 or more comorbidities, and extended LOS (>4.3 days) more than doubled the risk of readmission. Published SA revision rates range from 5% to 42%, with most revisions performed for instability, dislocation, infection, and component loosening.6,29 Complication rates are higher for revision SA than for primary SA, which may explain why revisions predispose patients to readmission.30 Compared with primary SAs, revision SAs are also more likely to be RTSAs, and these salvage procedures have been found to have high complication rates.31 In the present study, the most common comorbidities were hypertension, diabetes, and COPD; the literature supports these as some of the most common comorbid medical conditions in patients who undergo ATSA or RTSA.5,26,32 Furthermore, all 3 of these comorbidities have been shown to be independent predictors of increased postoperative complications in patients who undergo SA, which ultimately would increase the risk of readmission.3,26,33,34 Last, extended LOS has also been shown to increase the risk of unplanned readmissions after orthopedic procedures.35 Risk factors associated with increased LOS after ATSA or RTSA include female sex, advanced age, multiple comorbidities, and postoperative complications.32Several other factors must be noted with respect to individual risk for readmission. In the present study, age over 75 years, dependent functional status, ASA score of 4 or higher, and cardiac comorbidity were found to have a significant association with readmission. Increased age is a risk factor for increased postoperative complications, more medical comorbidities, and increased LOS.34,36 Older people are at higher risk of developing osteoarthritis and rotator cuff tear arthropathy and are more likely to undergo SA.5,6 Older people also are more likely to be dependent, which itself is a risk factor for readmission.19 An ASA score of 3 or 4 has been found to be associated with increased LOS and complications after SA, and cardiac comorbidities predispose patients to a variety of complications.34,36,37In studies that have combined surgical and medical factors, rates of complications early after ATSA and RTSA have ranged from 3.6% to 17.8%.26,38,39 After SAs, medical complications (80%) are more common than surgical complications (20%).39 In the present cohort, many more readmissions were for medical complications (67%) than for surgical complications (33%). In addition, Schairer and colleagues3 found medical complications associated with more than 80% of readmissions after SA.3 Infection was the most common medical reason (pneumonia) and surgical reason (surgical-site infection) for readmission—consistent with findings of other studies.3,35,40 Infection has accounted for 9.4% to 41.4% of readmissions after ATSA and RTSA.3,14In joint arthroplasty, infection occurs more often in patients with coexisting medical comorbidities, leading to higher mortality and increased LOS.41 Prosthetic joint dislocation was common as well—similar to findings in other studies.3,10In the present study, 33% of known readmission diagnoses were secondary to HACs. Surgical-site infection was the most common, followed by CAUTI, DVT, and PE. In another study, of knee and hip arthroplasties, HACs accounted for more than 40% of all complications and were the strongest predictor of early readmission.16 In SA studies, HACs were responsible for 9.3% to 34.5% of readmissions after ATSA and RTSA.3,14 Our finding (33%) is more in line with Mahoney and colleagues14 (34.5%) than Schairer and colleagues3 (9.3%). One explanation for the large discrepancy with Schairer and colleagues3 is that UTI was not among the medical reasons for readmission in their study, but it was in ours. Another difference is that we used a database that included data from multiple institutions. Last, Schairer and colleagues3 excluded revision SAs from their analysis (complication rates are higher for revision SAs than for primary SAs30). They also excluded cases of SA used for fracture (shown to increase the risk for PE42). The US Department of Health and Human Services estimated that patients experienced 1.3 million fewer HACs during the period 2010-2013, corresponding to a 17% decline over the 3 years.43 This translates to an estimated 50,000 fewer mortalities, and $12 billion saved in healthcare costs, over the same period.43 Preventing HACs helps reduce readmission rates while improving patient outcomes and decreasing healthcare costs.
This study had several limitations. We could not differentiate between ATSA and RTSA readmission rates because, for the study period, these procedures are collectively organized under a common CPT code in the NSQIP database. Readmission and complication rates are higher for RTSAs than for ATSAs.3,14 In addition, our data were limited to hospitals that were participating in NSQIP, which could lead to selection bias. We studied rates of only those readmissions and complications that occurred within 30 days, but many complications develop after 30 days, and these increase the readmission rate. Last, reasons for readmission were not recorded for 2011, so this information was available only for the final 2 years of the study. Despite these limitations, NSQIP still allows for a powerful study, as it includes multiple institutions and a very large cohort.
Conclusion
With medical costs increasing, focus has shifted to quality care and good outcomes with the goal of reducing readmissions and complications after various procedures. SA has recently become more popular because of its multiple indications, and this trend will continue. In the present study, the rate of readmission within 30 days after ATSA or RTSA was 2.7%. Revision surgery, 3 or more comorbidities, and extended LOS were independent risk factors that more than doubled the risk of readmission. Understanding the risk factors for short-term readmission will allow for better patient care and decreased costs, and will benefit the healthcare system as a whole.
Am J Orthop. 2016;45(6):E386-E392. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
1. 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.
2. Axon RN, Williams MV. Hospital readmission as an accountability measure. JAMA. 2011;305(5):504-505.
3. Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355.
4. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120.
5. 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.
6. Jain NB, Yamaguchi K. The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(12):1905-1912.
7. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
8. Chalmers PN, Slikker W 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204.
9. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002;11(2):130-135.
10. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485.
11. Fevang BT, Lygre SH, Bertelsen G, Skredderstuen A, Havelin LI, Furnes O. Good function after shoulder arthroplasty. Acta Orthop. 2012;83(5):467-473.
12. Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007;16(3 suppl):S27-S32.
13. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604-613.
14. Mahoney A, Bosco JA 3rd, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381.
15. Fehringer EV, Mikuls TR, Michaud KD, Henderson WG, O’Dell JR. Shoulder arthroplasties have fewer complications than hip or knee arthroplasties in US veterans. Clin Orthop Relat Res. 2010;468(3):717-722.
16. Raines BT, Ponce BA, Reed RD, Richman JS, Hawn MT. Hospital acquired conditions are the strongest predictor for early readmission: an analysis of 26,710 arthroplasties. J Arthroplasty. 2015;30(8):1299-1307.
17. Pugely AJ, Callaghan JJ, Martin CT, Cram P, Gao Y. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. J Arthroplasty. 2013;28(9):1499-1504.
18. Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Published 2014. Accessed May 21, 2015.
19. Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.
20. Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363-376.
21. American College of Surgeons. About ACS NSQIP. http://www.facs.org/quality-programs/acs-nsqip/about. Published 2015. Accessed June 14, 2015.
22. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6-16.
23. Bini SA, Fithian DC, Paxton LW, Khatod MX, Inacio MC, Namba RS. Does discharge disposition after primary total joint arthroplasty affect readmission rates? J Arthroplasty. 2010;25(1):114-117.
24. Husted H, Otte KS, Kristensen BB, Orsnes T, Kehlet H. Readmissions after fast-track hip and knee arthroplasty. Arch Orthop Trauma Surg. 2010;130(9):1185-1191.
25. Vorhies JS, Wang Y, Herndon J, Maloney WJ, Huddleston JI. Readmission and length of stay after total hip arthroplasty in a national Medicare sample. J Arthroplasty. 2011;26(6 suppl):119-123.
26. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467.
27. Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010;92(16):2643-2652.
28. Tsai TC, Orav EJ, Joynt KE. Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care. Ann Surg. 2014;259(6):1086-1090.
29. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292.
30. 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.
31. Black EM, Roberts SM, Siegel E, Yannopoulos P, Higgins LD, Warner JJ. Reverse shoulder arthroplasty as salvage for failed prior arthroplasty in patients 65 years of age or younger. J Shoulder Elbow Surg. 2014;23(7):1036-1042.
32. Menendez ME, Baker DK, Fryberger CT, Ponce BA. Predictors of extended length of stay after elective shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):1527-1533.
33. Jain NB, Guller U, Pietrobon R, Bond TK, Higgins LD. Comorbidities increase complication rates in patients having arthroplasty. Clin Orthop Relat Res. 2005;(435):232-238.
34. 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.
35. Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients. J Bone Joint Surg Am. 2013;95(11):1012-1019.
36. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ Jr. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(5):754-759.
37. Maile MD, Engoren MC, Tremper KK, Jewell E, Kheterpal S. Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg. 2014;119(3):522-532.
38. Farng E, Zingmond D, Krenek L, Soohoo NF. Factors predicting complication rates after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2011;20(4):557-563.
39. Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ Jr. 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.
40. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. 2012;215(3):322-330.
41. Poultsides LA, Ma Y, Della Valle AG, Chiu YL, Sculco TP, Memtsoudis SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty. 2013;28(3):385-389.
42. Young BL, Menendez ME, Baker DK, Ponce BA. Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):e271-e278.
43. US Department of Health and Human Services. Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided [press release]. http://www.hhs.gov/news/press/2014pres/12/20141202a.html. Published December 2, 2014. Accessed May 25, 2015.
1. 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.
2. Axon RN, Williams MV. Hospital readmission as an accountability measure. JAMA. 2011;305(5):504-505.
3. Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355.
4. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120.
5. 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.
6. Jain NB, Yamaguchi K. The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(12):1905-1912.
7. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
8. Chalmers PN, Slikker W 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204.
9. Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002;11(2):130-135.
10. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485.
11. Fevang BT, Lygre SH, Bertelsen G, Skredderstuen A, Havelin LI, Furnes O. Good function after shoulder arthroplasty. Acta Orthop. 2012;83(5):467-473.
12. Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007;16(3 suppl):S27-S32.
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