Length of Stay and Readmission After Total Shoulder Arthroplasty: An Analysis of 1505 Cases
We conducted a study to characterize the risk factors for extended length of stay (LOS) and readmission after primary total shoulder arthroplasty (TSA). Patients who were 60 years or older and underwent TSA between 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were used to test patient characteristics for association with extended LOS and readmission within 30 days. Extended LOS was defined as LOS of more than 3 days (90th percentile LOS).
Of the 1505 TSA patients identified, 49 (3.3%) were readmitted. Multivariate analysis revealed that extended LOS was independently associated with age 70 years or older and history of diabetes. Readmission was independently associated with history of heart disease and history of hypertension. The identified risk factors may be useful for preoperative discussions, surgical decision-making, and postoperative planning for THA patients.
Waterman and colleagues11 very recently identified (in the ACS-NSQIP database) a patient population that underwent TSA between 2006 and 2011 to describe risk factors for postoperative complications within 30 days. They found that comorbid cardiac disease and older age were independently associated with mortality. Interestingly, the present study identified older age as associated with extended LOS, and cardiac disease as associated with readmission. Together with the results from the previous study, age and cardiac disease seem to be important patient factors to consider when planning TSA, as they are associated with a significantly worse postoperative course.
This study had several limitations. First, given the nature of the ACS-NSQIP database, readmissions are recorded only up to 30 days after surgery, including after discharge. Second, though the ACS-NSQIP tries to collect as many patient variables as possible, some information is not captured. Additional variables that could potentially affect LOS and readmission (eg, insurance status, hospital volume) were not available for analysis. However, we think the high-quality data collection process used by the ACS-NSQIP outweighs the lack of certain variables. Third, original operative notes are not available in the ACS-NSQIP database, and the only way to identify operative procedures is to check CPT codes. Unfortunately, CPT code 23472 is used for both TSA and reverse TSA, so these procedures could not be separated for analysis, and the results of this study can be used to comment only on the risks of both procedures. Another limitation is that there were not enough patients to further analyze the data by each indication.
Conclusion
With the increasing popularity of TSA for an expanding set of indications, it is important to understand the factors that can affect the postoperative course. In this study, we found several patient-related risk factors for extended LOS and readmission. Although the identified factors are generally not modifiable, this information can be used to better define the expectations of patients, providers, and organizations for this increasingly common procedure.
