J Shoulder Elbow Surg (2014) 23, 377-381
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Readmission after shoulder arthroplasty Andrew Mahoney, MD, Joseph A. Bosco III, MD, Joseph D. Zuckerman, MD* Division of Shoulder and Elbow Surgery at the Hospital for Joint Diseases of NYU Langone Medical Center, New York, NY, USA Background: Health care payers, including the federal government, increasingly base reimbursement on quality. Payers consider readmission rates after total joint arthroplasty an indicator of quality. The Patient Protection and Affordable Care Act contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. This study evaluates the readmission rates and the incidence of ‘‘never events’’ after inpatient shoulder arthroplasty procedures. Methods: A retrospective view of all shoulder arthroplasty was performed from 2005 to 2011, with specific emphasis on the readmission rate 30, 60, and 90 days after the procedure. The incidence of never events as defined by the Centers for Medicare and Medicaid Services was also analyzed. Results: During the study period, 680 shoulder arthroplasty procedures were performed. Overall readmission rate was 5.9%. For hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (RTSA), 90-day readmission rates were 8.8%, 4.5%, and 6.6%, respectively. Readmission rates within 30 days of admission were significantly more common for HA and RTSA compared with readmission rates after 30 days. There was a 1.0% incidence of never events, and the incidence associated with each of the 3 arthroplastic procedures did not differ significantly. Conclusion: Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients. There was a 1% incidence of never events. In addition, most readmissions after HA and RTSA occurred within 30 days of discharge. As health care expenditures become more closely scrutinized, readmission rates after shoulder arthroplasty will become increasingly important. Level of evidence: Level III, Retrospective Cohort, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Retrospective case; controlled study; treatment study
Shoulder arthroplasty is an effective approach for the treatment of a variety of clinical conditions affecting the shoulder, including osteoarthritis, inflammatory arthritis, osteonecrosis, rotator cuff arthropathy, and fractures.7,11,13,14,16 The number of shoulder arthroplasty procedures performed each year is increasing, and this trend IRB-approved study performed at the Hospital for Joint Diseases of NYU Langone Medical Center, New York, NY, 10003, USA. *Reprint requests: Joseph D. Zuckerman, MD, Professor and Chairman, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, 14th Floor, New York, NY 10003, USA. E-mail address: [email protected] (J.D. Zuckerman).
is projected to continue.9 The introduction of the reverse total shoulder arthroplasty has improved outcomes in patients with rotator cuff arthropathy and other conditions.2-4,8,10,12,15,17,18 However, early reports of reverse total shoulder arthroplasty outcomes reported high complication rates ranging from relatively minor complications, such as hematoma, to more serious complications, such as dislocation requiring reoperation.4 Readmission rates after shoulder arthroplasty have not been well documented in the literature. Fehringer et al6 performed a study of the Veterans Administration population that looked at outcomes of arthroplasty, which
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.08.007
378 included postoperative complications, 14-day readmission rates, and 30-day mortality in total shoulder arthroplasty, and found that the incidence compared favorably with knee and hip arthroplasty. Farmer et al5 reported that patients experienced less morbidity and mortality after total shoulder arthroplasties than after hip and total knee arthroplasties. Led by the federal government, payers of health care are changing the way they reimburse health care providers. Increasingly, reimbursement is based on quality. The payers consider readmission rates after total joint arthroplasty, including shoulder replacements, an indicator of quality. The Patient Protection and Affordable Care Act of 2010 contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. The Centers for Medicare and Medicaid Services (CMS) continues to introduce mechanisms to eliminate payments for avoidable complications of treatment. The introduction of ‘‘never events’’ is one such method. Complications such as urinary tract infection after Foley catheter placement, deep venous thrombosis, and sacral decubitus ulcers are thought to reflect poor-quality care and are considered to be avoidable when proper guidelines and techniques are followed. Therefore, they have been deemed never events because if quality, evidence-based care is provided, they should never occur.1 In cases in which patients suffer from one of these complications, CMS will not reimburse hospitals for the treatment of the complication, thus eliminating a ‘‘financial reward’’ for poor-quality care. An increasing emphasis on quality care measures and outcomes is expected not only by CMS but by all payers. Therefore, it is important to show the value of any surgical procedure and to demonstrate the quality of care provided. The goal of the present study was to determine the readmission rate after shoulder arthroplasty procedures and the prevalence of never events associated with these procedures.
Materials and methods A retrospective review of hospital records from 2005 to 2011 at NYU Langone Medical Center (which includes The Hospital for Joint Diseases and Tisch Hospital) was performed to determine the 30-, 60-, and 90-day readmission rates after shoulder arthroplasty procedures. We also identified the incidence of never events that occurred during the hospital stay and within 30 days of discharge. Shoulder arthroplasty procedures were defined as total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), and hemiarthroplasty (HA), and the readmission rates were determined for each procedure. We used c2 tests to compare the readmission rates after each procedure. This study used billing records and ICD-9 codes 81.80 (other shoulder replacement), 81.81 (partial shoulder replacement), and 81.88 (introduced in 2010 for RTSA) to identify shoulder arthroplasty procedures during the study period. Once the patients were identified, demographic data including age and sex,
A. Mahoney et al. diagnosis and readmission diagnosis, and revision procedures were recorded. The patient’s medical record number was used to identify readmission within 30, 60, and 90 days after discharge. The readmission diagnosis was used to identify never events.
Results From 2005 to 2011, 680 shoulder arthroplasty procedures were performed, including 124 HA, 376 TSA, and 180 RTSA. During the 6-year period of the study, 40 readmissions occurring within 90 days of discharge were identified (5.9%); 90-day readmission rates were 8.8% (11/ 124) after HA, 4.5% (17/376) after TSA, and 6.6% (12/180) after RTSA (Table I). There was no significant difference in readmission rates (P ¼ .18) among these procedures. Revision surgery within 90 days of discharge was required in 8.1% (10/124) after HA, 2.9% (11/376) after TSA, and 3.3% (6/180) after RTSA. There was a significant difference in revision rates (P ¼ .03) within the first 90 days, with revision more likely after HA. The number of HA procedures performed decreased from 28 cases in 2005 to 8 in 2011. RTSA procedures increased from 4 cases in 2005 to 62 cases in 2011. At the same time, the rate of readmission after RTSA decreased from 1 of 4 in 2005 (25%) to 4 of 62 in 2011 (5.5%). Eight never events occurred after shoulder arthroplasty for an overall incidence of 1.2%.
Hemiarthroplasty There were 11 readmissions after HA; 8 occurred within 30 days of discharge and 3 between 60 and 90 days after discharge. The primary indication for HA requiring readmission was proximal humerus fracture in 5 patients, glenohumeral arthritis with associated instability in 2 patients, osteoarthritis in 2 patients, rheumatoid arthritis in 1 patient, and osteosarcoma in 1 patient. Of the 5 patients treated with HA for fracture, 2 required readmission for falls (1 sustaining a humeral shaft fracture requiring revision), 2 for postoperative infections requiring revision surgery, and 1 for a gastrointestinal bleed. The 2 patients who underwent HA for glenohumeral arthritis associated with instability were both readmitted for recurrent instability and required revision surgery. Of the 2 patients treated for osteoarthritis, 1 patient sustained a subscapularis tear and required repair; the other required revision for insertion of a glenoid component combined with a bone graft. The patient treated for rheumatoid arthritis required revision for treatment of posterior instability. The patient treated for osteosarcoma was readmitted for atelectasis. Of the 11 patients who were readmitted, 10 required revision surgery. The 2 patients with infections were readmitted within 30 days of discharge and would both be classified as never events under CMS. The incidence of never events after HA was 1.2%.
Readmission after shoulder arthroplasty Table I
379
Diagnoses requiring readmission
Arthroplasty procedure
Total number of cases
Total readmission rate
Reasons for readmission
Never events
Hemiarthroplasty
124
8.8% (11)
Infection (2)
Total shoulder arthroplasty
376
4.5% (17)
Reverse total shoulder arthroplasty
180
6.6% (12)
Falls (2) Infection (2) Gastrointestinal bleed (1) Instability (3) Rotator cuff tear (1) Insertion of glenoid component (1) Atelectasis (1) Infection (6) Rotator cuff tear (4) Pneumonia (2) Pain management (1) Myocardial infarction (1) Urinary tract infection (1) Periprosthetic fracture (1) Overanticoagulation (1) Instability (5) Periprosthetic fracture (1) Anemia (1) Infection (3) Bowel obstruction (1) Ascites (1)
Total shoulder arthroplasty In the TSA group there were 17 readmissions; 7 patients were readmitted within 30 days, 6 patients between 30 and 60 days, and 4 patients between 60 and 90 days. Sixteen of the patients were treated for glenohumeral osteoarthritis, and 1 patient was treated for osteonecrosis of the humeral head. Six patients were treated for deep infection requiring irrigation and debridement and revision surgery (3 within 30 days); 4 patients sustained rotator cuff tears requiring revision surgery; 2 patients were readmitted for upper respiratory infections; 1 patient was readmitted for pain control; 1 patient was readmitted for myocardial infarction requiring 3-vessel coronary artery bypass surgery more than 2 months after surgery; 1 patient had a urinary tract infection within 30 days of discharge (a morbidly obese patient who required urinary catheter placement during hospitalization); 1 patient sustained a perioperative fracture requiring open reduction and internal fixation; and 1 patient was readmitted for stabilization of anticoagulation because of an international normalized ratio higher than 7.0 after TSA. There were 4 never events after TSA, 3 infections and 1 urinary tract infection, for an incidence of 1.0%. Of the 17 readmissions, 11 required revision surgery.
Reverse total shoulder arthroplasty There were 12 readmissions after RTSA. The index procedure was performed for cuff tear arthroplasty in 8 patients, proximal humerus fractures in 2 patients, revision
Infection (3) Urinary tract infection (1)
Infection (2)
of failed anatomic shoulder arthroplasty in 1 patient, and proximal humeral nonunion in 1 patient. Eight readmissions occurred within 30 days and 4 between 30 and 60 days; there were no readmissions between 60 and 90 days. Of the 8 patients readmitted after RTSA for cuff tear arthroplasty, 2 were readmitted for instability events (1 requiring revision surgery and 1 a closed reduction), 1 for a small bowel obstruction, 1 for deep infection requiring revision surgery, 2 for cellulitis requiring intravenous antibiotics, 1 for periprosthetic fracture as a result of a fall, and 1 for a blood transfusion for symptomatic postoperative anemia. The 2 patients who were initially treated with RTSA for a proximal humerus fracture were readmitted for instability, and both required revision surgery. The patient treated for proximal humerus nonunion required readmission for management of ascites secondary to cirrhosis. The patient treated for revision of a failed primary TSA required revision for postoperative instability of the RTSA. Two readmissions would be considered never events by CMS (both infections) for an incidence of 1.1%. Of the 12 patients readmitted after RTSA, 6 required revision shoulder surgery. During the 6-year period studied, readmission rates did not differ significantly among the 3 specific arthroplasty procedures. However, readmissions occurred more commonly within the first 30 days (5.9%) than after 30 days (2.5%) for the entire group of arthroplasty procedures as well as for each specific procedure (Table II). The incidence of never events did not differ significantly among the 3 arthroplasty groups.
380 Table II
A. Mahoney et al. Readmission rates and never events based on procedure performed
Arthroplasty procedure
Total number of cases
Total readmission rate
Readmission
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Readmission after shoulder arthroplasty Andrew Mahoney, MD, Joseph A. Bosco III, MD, Joseph D. Zuckerman, MD* Division of Shoulder and Elbow Surgery at the Hospital for Joint Diseases of NYU Langone Medical Center, New York, NY, USA Background: Health care payers, including the federal government, increasingly base reimbursement on quality. Payers consider readmission rates after total joint arthroplasty an indicator of quality. The Patient Protection and Affordable Care Act contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. This study evaluates the readmission rates and the incidence of ‘‘never events’’ after inpatient shoulder arthroplasty procedures. Methods: A retrospective view of all shoulder arthroplasty was performed from 2005 to 2011, with specific emphasis on the readmission rate 30, 60, and 90 days after the procedure. The incidence of never events as defined by the Centers for Medicare and Medicaid Services was also analyzed. Results: During the study period, 680 shoulder arthroplasty procedures were performed. Overall readmission rate was 5.9%. For hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (RTSA), 90-day readmission rates were 8.8%, 4.5%, and 6.6%, respectively. Readmission rates within 30 days of admission were significantly more common for HA and RTSA compared with readmission rates after 30 days. There was a 1.0% incidence of never events, and the incidence associated with each of the 3 arthroplastic procedures did not differ significantly. Conclusion: Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients. There was a 1% incidence of never events. In addition, most readmissions after HA and RTSA occurred within 30 days of discharge. As health care expenditures become more closely scrutinized, readmission rates after shoulder arthroplasty will become increasingly important. Level of evidence: Level III, Retrospective Cohort, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Retrospective case; controlled study; treatment study
Shoulder arthroplasty is an effective approach for the treatment of a variety of clinical conditions affecting the shoulder, including osteoarthritis, inflammatory arthritis, osteonecrosis, rotator cuff arthropathy, and fractures.7,11,13,14,16 The number of shoulder arthroplasty procedures performed each year is increasing, and this trend IRB-approved study performed at the Hospital for Joint Diseases of NYU Langone Medical Center, New York, NY, 10003, USA. *Reprint requests: Joseph D. Zuckerman, MD, Professor and Chairman, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, 14th Floor, New York, NY 10003, USA. E-mail address: [email protected] (J.D. Zuckerman).
is projected to continue.9 The introduction of the reverse total shoulder arthroplasty has improved outcomes in patients with rotator cuff arthropathy and other conditions.2-4,8,10,12,15,17,18 However, early reports of reverse total shoulder arthroplasty outcomes reported high complication rates ranging from relatively minor complications, such as hematoma, to more serious complications, such as dislocation requiring reoperation.4 Readmission rates after shoulder arthroplasty have not been well documented in the literature. Fehringer et al6 performed a study of the Veterans Administration population that looked at outcomes of arthroplasty, which
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.08.007
378 included postoperative complications, 14-day readmission rates, and 30-day mortality in total shoulder arthroplasty, and found that the incidence compared favorably with knee and hip arthroplasty. Farmer et al5 reported that patients experienced less morbidity and mortality after total shoulder arthroplasties than after hip and total knee arthroplasties. Led by the federal government, payers of health care are changing the way they reimburse health care providers. Increasingly, reimbursement is based on quality. The payers consider readmission rates after total joint arthroplasty, including shoulder replacements, an indicator of quality. The Patient Protection and Affordable Care Act of 2010 contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. The Centers for Medicare and Medicaid Services (CMS) continues to introduce mechanisms to eliminate payments for avoidable complications of treatment. The introduction of ‘‘never events’’ is one such method. Complications such as urinary tract infection after Foley catheter placement, deep venous thrombosis, and sacral decubitus ulcers are thought to reflect poor-quality care and are considered to be avoidable when proper guidelines and techniques are followed. Therefore, they have been deemed never events because if quality, evidence-based care is provided, they should never occur.1 In cases in which patients suffer from one of these complications, CMS will not reimburse hospitals for the treatment of the complication, thus eliminating a ‘‘financial reward’’ for poor-quality care. An increasing emphasis on quality care measures and outcomes is expected not only by CMS but by all payers. Therefore, it is important to show the value of any surgical procedure and to demonstrate the quality of care provided. The goal of the present study was to determine the readmission rate after shoulder arthroplasty procedures and the prevalence of never events associated with these procedures.
Materials and methods A retrospective review of hospital records from 2005 to 2011 at NYU Langone Medical Center (which includes The Hospital for Joint Diseases and Tisch Hospital) was performed to determine the 30-, 60-, and 90-day readmission rates after shoulder arthroplasty procedures. We also identified the incidence of never events that occurred during the hospital stay and within 30 days of discharge. Shoulder arthroplasty procedures were defined as total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), and hemiarthroplasty (HA), and the readmission rates were determined for each procedure. We used c2 tests to compare the readmission rates after each procedure. This study used billing records and ICD-9 codes 81.80 (other shoulder replacement), 81.81 (partial shoulder replacement), and 81.88 (introduced in 2010 for RTSA) to identify shoulder arthroplasty procedures during the study period. Once the patients were identified, demographic data including age and sex,
A. Mahoney et al. diagnosis and readmission diagnosis, and revision procedures were recorded. The patient’s medical record number was used to identify readmission within 30, 60, and 90 days after discharge. The readmission diagnosis was used to identify never events.
Results From 2005 to 2011, 680 shoulder arthroplasty procedures were performed, including 124 HA, 376 TSA, and 180 RTSA. During the 6-year period of the study, 40 readmissions occurring within 90 days of discharge were identified (5.9%); 90-day readmission rates were 8.8% (11/ 124) after HA, 4.5% (17/376) after TSA, and 6.6% (12/180) after RTSA (Table I). There was no significant difference in readmission rates (P ¼ .18) among these procedures. Revision surgery within 90 days of discharge was required in 8.1% (10/124) after HA, 2.9% (11/376) after TSA, and 3.3% (6/180) after RTSA. There was a significant difference in revision rates (P ¼ .03) within the first 90 days, with revision more likely after HA. The number of HA procedures performed decreased from 28 cases in 2005 to 8 in 2011. RTSA procedures increased from 4 cases in 2005 to 62 cases in 2011. At the same time, the rate of readmission after RTSA decreased from 1 of 4 in 2005 (25%) to 4 of 62 in 2011 (5.5%). Eight never events occurred after shoulder arthroplasty for an overall incidence of 1.2%.
Hemiarthroplasty There were 11 readmissions after HA; 8 occurred within 30 days of discharge and 3 between 60 and 90 days after discharge. The primary indication for HA requiring readmission was proximal humerus fracture in 5 patients, glenohumeral arthritis with associated instability in 2 patients, osteoarthritis in 2 patients, rheumatoid arthritis in 1 patient, and osteosarcoma in 1 patient. Of the 5 patients treated with HA for fracture, 2 required readmission for falls (1 sustaining a humeral shaft fracture requiring revision), 2 for postoperative infections requiring revision surgery, and 1 for a gastrointestinal bleed. The 2 patients who underwent HA for glenohumeral arthritis associated with instability were both readmitted for recurrent instability and required revision surgery. Of the 2 patients treated for osteoarthritis, 1 patient sustained a subscapularis tear and required repair; the other required revision for insertion of a glenoid component combined with a bone graft. The patient treated for rheumatoid arthritis required revision for treatment of posterior instability. The patient treated for osteosarcoma was readmitted for atelectasis. Of the 11 patients who were readmitted, 10 required revision surgery. The 2 patients with infections were readmitted within 30 days of discharge and would both be classified as never events under CMS. The incidence of never events after HA was 1.2%.
Readmission after shoulder arthroplasty Table I
379
Diagnoses requiring readmission
Arthroplasty procedure
Total number of cases
Total readmission rate
Reasons for readmission
Never events
Hemiarthroplasty
124
8.8% (11)
Infection (2)
Total shoulder arthroplasty
376
4.5% (17)
Reverse total shoulder arthroplasty
180
6.6% (12)
Falls (2) Infection (2) Gastrointestinal bleed (1) Instability (3) Rotator cuff tear (1) Insertion of glenoid component (1) Atelectasis (1) Infection (6) Rotator cuff tear (4) Pneumonia (2) Pain management (1) Myocardial infarction (1) Urinary tract infection (1) Periprosthetic fracture (1) Overanticoagulation (1) Instability (5) Periprosthetic fracture (1) Anemia (1) Infection (3) Bowel obstruction (1) Ascites (1)
Total shoulder arthroplasty In the TSA group there were 17 readmissions; 7 patients were readmitted within 30 days, 6 patients between 30 and 60 days, and 4 patients between 60 and 90 days. Sixteen of the patients were treated for glenohumeral osteoarthritis, and 1 patient was treated for osteonecrosis of the humeral head. Six patients were treated for deep infection requiring irrigation and debridement and revision surgery (3 within 30 days); 4 patients sustained rotator cuff tears requiring revision surgery; 2 patients were readmitted for upper respiratory infections; 1 patient was readmitted for pain control; 1 patient was readmitted for myocardial infarction requiring 3-vessel coronary artery bypass surgery more than 2 months after surgery; 1 patient had a urinary tract infection within 30 days of discharge (a morbidly obese patient who required urinary catheter placement during hospitalization); 1 patient sustained a perioperative fracture requiring open reduction and internal fixation; and 1 patient was readmitted for stabilization of anticoagulation because of an international normalized ratio higher than 7.0 after TSA. There were 4 never events after TSA, 3 infections and 1 urinary tract infection, for an incidence of 1.0%. Of the 17 readmissions, 11 required revision surgery.
Reverse total shoulder arthroplasty There were 12 readmissions after RTSA. The index procedure was performed for cuff tear arthroplasty in 8 patients, proximal humerus fractures in 2 patients, revision
Infection (3) Urinary tract infection (1)
Infection (2)
of failed anatomic shoulder arthroplasty in 1 patient, and proximal humeral nonunion in 1 patient. Eight readmissions occurred within 30 days and 4 between 30 and 60 days; there were no readmissions between 60 and 90 days. Of the 8 patients readmitted after RTSA for cuff tear arthroplasty, 2 were readmitted for instability events (1 requiring revision surgery and 1 a closed reduction), 1 for a small bowel obstruction, 1 for deep infection requiring revision surgery, 2 for cellulitis requiring intravenous antibiotics, 1 for periprosthetic fracture as a result of a fall, and 1 for a blood transfusion for symptomatic postoperative anemia. The 2 patients who were initially treated with RTSA for a proximal humerus fracture were readmitted for instability, and both required revision surgery. The patient treated for proximal humerus nonunion required readmission for management of ascites secondary to cirrhosis. The patient treated for revision of a failed primary TSA required revision for postoperative instability of the RTSA. Two readmissions would be considered never events by CMS (both infections) for an incidence of 1.1%. Of the 12 patients readmitted after RTSA, 6 required revision shoulder surgery. During the 6-year period studied, readmission rates did not differ significantly among the 3 specific arthroplasty procedures. However, readmissions occurred more commonly within the first 30 days (5.9%) than after 30 days (2.5%) for the entire group of arthroplasty procedures as well as for each specific procedure (Table II). The incidence of never events did not differ significantly among the 3 arthroplasty groups.
380 Table II
A. Mahoney et al. Readmission rates and never events based on procedure performed
Arthroplasty procedure
Total number of cases
Total readmission rate
Readmission
