Shoulder
Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty

https://doi.org/10.1016/j.jse.2015.07.028Get rights and content

Background

Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty.

Methods

The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates.

Results

In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001).

Conclusion

The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Section snippets

Materials and methods

A retrospective review of the Nationwide Inpatient Sample (NIS) discharge records was conducted for the years 2011 and 2012. The search was limited to these 2 years because 2011 is the first year a unique billing code was created for reverse total shoulder arthroplasty (RTSA) and 2012 is the final year of data currently available through this database. The NIS is the largest inpatient database in the U.S., representing a sample of discharges from all hospitals participating in the Healthcare

Patient characteristics

In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 had TSA, and 44,893 had a RTSA. The top 3 indications for both procedures were osteoarthritis, rotator cuff arthropathy, and humeral fractures, accounting for 60.3%, 25.1%, and 11.7% of shoulder arthroplasties, respectively. In addition, 1.76% (1827 patients) were revision arthroplasties.

Of all shoulder arthroplasties, 63.5% (65,958 patients) had a routine discharge, and 14.4% (14,908 patients) were discharged

Discussion

Inpatient discharges after surgical procedures often require a multidisciplinary team to optimize patient care. Most patients are discharged home after shoulder arthroplasty, but a minority of patients is transferred to PAC facilities from the inpatient setting. Hip and knee arthroplasty literature has previously identified patients with a high likelihood of requiring a PAC facility; however, no studies have identified patients with a similar risk after shoulder arthroplasty.2, 4, 8, 11, 14

Conclusion

Increasing age, initial presentation with a fracture, female sex, CHF, diabetes, number of comorbidities, and procedure type were identified as risk factors for discharge to a PAC facility. Interestingly, patients undergoing revision surgeries were less likely to be discharged to a PAC facility. These results could be used to preoperatively counsel patients as well as for early discharge planning. Future studies should investigate whether managing preoperative patient expectations regarding

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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    In our study, discharge to a PAC facility was found to increase by 11% per year with increasing age, females were 3-times more likely than male counterparts to be discharged to a PAC facility, and patients with a dependent functional status were 8-times more likely to be discharged to a PAC facility. For patients with a dependent functional status, PAC facilities maximize access to care.1,40 Although nonmodifiable, these findings may allow physicians to plan for discharge and guide patient expectations more appropriately.

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    Several patient factors were associated with increased risk of nonhome discharge including female sex, age older than 70 years, ASA classification 3 or greater, and history of diabetes, hypertension, wound infection, steroid use, or a bleeding disorder. Similar associations have been reported in previous studies of TSA and total knee arthroplasty, including a systematic review by Berman et al in which female sex, older age, obesity, and reverse TSA were associated with nonhome discharge.39,40 Hospital discharge after any surgical procedure is a complex process that depends on coordination between numerous parties including the patient, the surgeon, the social worker, the care coordinator, the physical therapist, the nurse, and the hospital administrator.

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This study was exempt from Investigational Review Board review at our institution because it used a publicly disseminated database.

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