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Abstract

Background

The number of shoulder arthroplasty procedures performed has greatly increased in recent years and this trend is expected to continue. However, accelerated recoveries by way of reduced postoperative hospital stays have not been studied for this patient population as extensively as in the hip and knee arthroplasty literature. The average length of stay for shoulder arthroplasty patients has consistently been found to be between 2 and 2.5 days. We conducted a study to determine whether postoperative day 1 (POD1) discharge would put patients at increased risk for complications and readmission following elective shoulder arthroplasty.

Methods

A retrospective review of patients who underwent shoulder arthroplasty (reverse or anatomic total shoulder arthroplasty) performed by one surgeon at one institution from 2008 to 2015 was conducted. All elective primary shoulder arthroplasty patients were included. Exclusion criteria included revision arthroplasty, humeral head replacement, humeral head resurfacing, and arthroplasty for fracture. Patient demographics, medical comorbidities, postoperative length of stay, hospital readmission within 30 days of discharge, and reason for readmission were collected. The 30-day readmission rate was the primary outcome used in determination of the safety of this practice.

Results

A total of 353 patients were found to meet our criteria, of which 205 (58.1%) were discharged on POD1. A total of 83 patients were discharged on postoperative day 2 or 3 (POD2-3) from 2008 to 2011. Of those discharged on POD1, 8 were found to have been readmitted to the hospital within 30 days of original discharge to give an overall readmission rate of 3.90%. The most common reason for readmission was dyspnea (3/8, 37.5%). No risk factors were found to be associated with increased likelihood of readmission in this patient group. There were 4 readmissions in the POD2-3 discharge group to give an overall readmission rate of 4.82% (4/83). No statistically significant difference was found between 30-day readmission rates of POD1 and POD2-3 discharge elective shoulder arthroplasty patients in this study or shoulder arthroplasty patients in general from other studies (P > .100).

Conclusion

POD1 discharge following elective shoulder arthroplasty does not increase the risk for postoperative complications requiring hospital readmission. With shorter hospital stays, POD1 discharge following elective shoulder arthroplasty could provide a method to reduce healthcare expenditures.

Keywords

Accelerated discharge early discharge postoperative day 1 discharge readmission rate reverse total shoulder safe shoulder arthroplasty total shoulder

Introduction

The number of shoulder arthroplasty procedures performed has greatly increased in recent years. From 1993 to 2007, the number of total shoulder arthroplasty procedures increased by 369% and this trend is expected to continue.¹ Currently, there is an average increase of 9.4% annually.¹ As prevalence of total shoulder arthroplasty continues to rise, it will have a greater impact on healthcare expenditure as a whole. As the healthcare environment continues to focus on quality metrics and cost-effectiveness, one method to reduce expenses is through accelerated recoveries and shorter postoperative hospital stays. Outpatient arthroplasty procedures have been studied in both the hip and knee patient populations, and have been found to be safe and cost-effective.^2–8

Previous studies on shoulder arthroplasty have examined various topics such as readmission rates, complications, cost, and length of stay as well as the risk factors that impact them. The average postoperative length of stay for shoulder arthroplasty has consistently been found to be between 2 and 2.5 days.^1,9–16 Factors such as obesity, diabetes, renal, pulmonary, and heart disease have been associated with increased lengths of stay. However, accelerated recoveries by way of reduced postoperative hospital stays have not been extensively studied for this patient population.

The purpose of this study is to assess the readmission rate for postoperative day 1 (POD1) discharge patients following elective shoulder arthroplasty. This was performed by retrospectively examining 30-day hospital readmission rates and perioperative complications. We hypothesize that POD1 does not place patients at an increased risk for perioperative complications and hospital readmission.

Methods

We performed a retrospective review of postoperative complications and hospital readmissions of patients who underwent elective primary reverse or anatomic total shoulder arthroplasty performed by one surgeon at one institution from 2008 to 2015. Although the senior author operated at multiple institutions prior to 2012, we chose a single institution with the highest volume in order to limit variables in anesthesia and discharge protocols. All surgeries were performed in the beach chair position, under general anesthesia with an interscalene catheter placed preoperatively. The catheter was maintained throughout the hospital admission. The continuous infusion consisted of ropivicaine 0.5% 30 mL loading dose, followed by a rate of 6 mL per hour. Originally, patients were sent home with an indwelling catheter and ON-Q pump that was removed by the patient on postoperative day 3. Due to a high rate of subjective complaints of dyspnea following discharge, which was thought to be related to phrenic nerve involvement, we changed the indwelling catheter protocol. In 2010, the new protocol involved placement of a continuous interscalene catheter with the same loading dose and rate followed by a bolus (20 mL of 0.5% ropivicaine) the next morning prior to catheter removal. The patients were monitored for 2 hours, following catheter removal for oxygen desaturation and subjective complaints of dyspnea prior to being discharged. This change in management of the interscalene catheter was used in all patients after 2010 and resulted in fewer subjective complaints of dyspnea following discharge.

All elective primary reverse and anatomic shoulder arthroplasties performed at one institution by the senior author (RI) were included in the study. Exclusion criteria included revision arthroplasty, humeral head replacement, humeral head resurfacing, and arthroplasty for fracture. The operative reports, perioperative inpatient records, and postoperative outpatient records were reviewed for each patient. Patient demographics including age, sex, and race were collected. Comorbidities including obesity (BMI ≥ 30), diabetes, cancer history, cardiovascular disease, chronic obstructive pulmonary disease, smoking history, and rheumatoid arthritis were collected for all patients. Preoperative diagnosis, postoperative length of stay, and readmission or emergency room (ER) visit within 30 days of discharge were also collected. The 30-day readmission rate served as the primary outcome measure for the purposes of this study.

Chi-square analysis was used to compare the 30-day readmission rate of POD1 discharge elective shoulder arthroplasty patients to those discharged on postoperative days 2 or 3 (POD2-3) for elective shoulder arthroplasty patients. The POD1 discharge patient’s readmission rates were also compared to those of shoulder arthroplasty patients in a study done by Mahoney et al.,¹⁷ which investigated the 30 -, 60-, and 90-day readmission rates of all shoulder arthroplasty patients regardless of length of stay at a single institution from 2005 to 2011. Further analysis was performed to look for any association between comorbidities, demographics, and hospital readmissions.

Results

From 2008 to 2015, a total of 353 patients met our criteria, of which 205 (58.1%) were discharged on POD1. Additionally, a total of 83 patients were discharged on POD2-3 from 2008 to 2011. These patients served as the control group for this study. Following 2011, POD1 discharges became the preferred practice of the senior author. All patients were prepared for POD1 discharge at their preoperative consultation. All patients who stayed beyond POD1 after 2011 for both social reasons and medical comorbidities were excluded from the data analysis. The length of stay for patients by year can be found in Figure 1 and further demonstrates this change in practice. No statistically significant difference in age, sex, obesity, diabetes mellitus, history of myocardial infarction, coronary artery disease, or chronic obstructive pulmonary disease (COPD) was found between the POD1 and POD2-3 discharge patient groups. Summary of the demographics and comorbidities of the two groups can be found in Table 1. The POD1 discharge group included 109 anatomic total shoulder arthroplasties and 96 reverse total shoulder arthroplasties. Of the POD1 discharge patients, 11/205 (5.37%) went to the emergency department within 30 days of original discharge and of those 8/11 (72.7%) were readmitted to the hospital. The overall readmission rate for this group was 8/205 (3.90%). The most common reason for readmission was dyspnea (3/8, 37.5%). Other reasons for readmission included deep vein thrombosis (1/8, 12.5%), syncope (1/8, 12.5%), pneumonia, (1/8, 12.5%), atrial fibrillation (1/8, 12.5%), and cerebrovascular accident (1/8, 12.5%). Additionally, 3 patients in this group were readmitted within 30 days of discharge for reasons unrelated to the procedure including acute cholecystitis, anxiety with suicidal ideations, and a concussion. Three patients in this group were seen in the ER without admission within 30 days of discharge. Reasons for these visits included nondisplaced incomplete humerus fracture following a fall, intractable pain, and interscalene catheter malfunction. We reviewed hypertension, obesity, diabetes mellitus, history of myocardial infarction, coronary artery disease, and COPD, and none was found to be associated with an increased likelihood of readmission within 30 days of original discharge in either the control group (POD 2-3) or the POD1 group.

Figure 1.

Patient postoperative length of stay by year. Change in the senior author's preferred practice to POD1 discharge following 2011 is demonstrated.

Table 1.

Patient Baseline Characteristics.

	POD1 Discharge	POD2-3 Discharge	P
Total	205	83
Age	69 (45–89)	69 (49–86)
Sex	51% Male (105)	41% Male (34)	.09
Obesity (BMI > 30)	49% (101)	41% (34)	.20
Diabetes mellitus	23% (47)	20% (17)	.65
Hypertension	69% (141)	66% (55)	.68
History of myocardial infarction	8% (16)	8% (7)	.86
Coronary artery disease	13% (26)	8% (7)	.31
Chronic obstructive pulmonary disease	7% (14)	6% (5)	.80

Note. BMI, body mass index; POD, postoperative day.

The POD2-3 discharge group included 63 anatomic total shoulder arthroplasty and 20 reverse total shoulder arthroplasty patients. In this group of patients, 6/83 (7.23%) went to the emergency department within 30 days of original discharge, and of those 4/6 (66.7%) were readmitted to the hospital to give the overall readmission rate of 4/83 (4.82%). Reasons for readmission included influenza, anemia with atrial fibrillation, swelling, and a hematoma. The reasons for ER visit without readmission included intractable pain and interscalene catheter malfunction.

Chi-square analysis showed no significant difference between the 30-day readmission rate of POD1 discharge patients versus those discharged on POD2-3 (P = .62). In a study by Mahoney et al.,¹⁷ a total of 15 of 556 (2.70%) shoulder arthroplasty patients were readmitted to the hospital within 30 days of original discharge. No significant difference was found when comparing the readmission rate of our study group (8/205, 3.90%) to Mahoney’s cohort (15/556, 2.70%) (P = .39). A summary of the readmission rates among the length of stay groupings in our study and Mahoney’s cohort can be found in Figure 2.

Figure 2.

Patient 30-day readmission rates by postoperative length of stay. POD, postoperative day.

Discussion

The purpose of this study was to determine if POD1 discharge following elective shoulder arthroplasty increases the risk of 30-day hospital readmission when compared to longer hospital stays. We compared the readmission rate of POD1 discharge elective shoulder arthroplasty patients, of one surgeon at a single institution from 2008 to 2015 to POD2-3 patients from 2008 to 2011 and to the cohort of patients in a study by Mahoney et al.¹⁷ Patients discharged on POD2-3 were only included through 2011 because POD1 discharge became the senior author’s (RI) primary practice at this time. Starting in 2011, patients discharged on POD2 or later were identified preoperatively as medically or socially unfit to be discharged on POD1. These patients were not included in calculations because they would unjustly bias the POD2-3 discharge patient group.

Readmission rate is a commonly used outcome measure in assessing the efficacy and safety of a treatment algorithm. The overall 30-day readmission rate across all orthopedic procedures has been found to be 5.4%.¹⁸ Our study supports the results of Brolin et al.,¹⁹ who had a 0% readmission rate for 30 patients following POD1 discharge for total shoulder arthroplasty. The average age of their patients was 54 and all of the patients underwent anatomic total shoulder arthroplasties. We present a substantially larger group of both anatomic and reverse total shoulder arthroplasties with an average patient age of 69. Our higher patient age and the use of interscalene catheters may explain the slightly higher readmission rate.

We identified 205 shoulder arthroplasty patients who were discharged on POD1. The 30-day readmission rate for this patient group was 3.90% (8/205). No statistically significant difference was found between readmission rates of our study cohort (POD1 discharge, 3.90%), our control group (POD2-3 discharge, 4.82%), or the cohort by Mahoney et al. (2.70%). A retrospective review of State Inpatient Databases found 90-day readmission rates of 6.0% for total shoulder arthroplasty and 11.2% for reverse total shoulder arthroplasty.²⁰ Other studies have found a 60-day readmission rate of 6.7% and a 30-day readmission rate of 3.3% for total shoulder arthroplasty.^9,14

We believe that POD1 discharge of shoulder arthroplasty patients could reduce overall healthcare costs without compromising patient safety. The average cost per day of hospital stay in the United States has been found to be $4000.²¹ Cost reduction by way of reducing postoperative length of stay has previously been demonstrated in both hip and knee arthroplasty literature.^2,4,7,8 The specific financial data for our patient population was unavailable for use in this study. However, further research on this topic may be warranted.

The most common cause for readmission in our POD1 group was dyspnea (3/8, 37.5%). After investigation, the cause of dyspnea was felt to be phrenic nerve involvement caused by the local anesthetic from the interscalene catheter. We changed the anesthesia protocol because of this issue and this lead to a decrease in the number of subjective complaints of dyspnea. Our perioperative anesthesia differed from that used by Brolin et al.¹⁹ in a study on outpatient shoulder arthroplasty. Their patients received an intraoperative periarticular injection of liposomal bupivacaine, bupivacaine with epinephrine, and ketorolac into the deltoid, pectoralis major, and soft tissue around the incision. For our cohort, the patients were given an interscalene nerve block consisting of ropivicaine 0.5% 30 mL loading dose, followed by a rate of 6 mL per hour through the catheter. They received a 20 mL bolus of 0.5% ropivicaine the morning after surgery prior to catheter removal. Brolin et al.¹⁹ reported no complications of dyspnea with their protocol. The remainder of complications found in this study have been previously described in the literature.^9,14,20,22

There are several limitations to our study. First, data was only collected from a single institution and patients could have sought treatment for a complication at a different institution during data collection. We believe it is unlikely that this situation affected the data given that postoperative office notes would have documented these events. Furthermore, the single surgeon, single institution nature of the study introduces bias. However, the same single surgeon, single institution study design allowed for reduced variability in both surgical and anesthesia techniques. Potential selection bias is another limitation given that after 2011, patients discharged on POD2 or later were preoperatively determined to be medically or socially unfit for POD1 discharge. Lack of available financial data in order to determine the exact impact on overall costs was a limitation of the study but provides an area for future investigation.

Conclusions

To our knowledge, this is the first study to investigate the safety of POD1 discharge following elective anatomic and reverse shoulder arthroplasty. We report an overall readmission rate of 3.90% for this patient group, which is lower than the rate for all orthopedic procedures and comparable to that of longer hospital stays following shoulder arthroplasty. POD1 discharge following elective shoulder arthroplasty patients is safe. Cost reduction through reducing postoperative length of stay has been reported in both hip and knee arthroplasty literature. We believe this to be true for shoulder arthroplasty as well.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Postoperative Day 1 Discharge Following Elective Shoulder Arthroplasty

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Results

Discussion

Conclusions

Footnotes

Declaration of conflicting interests

Funding

References