Predictors of Return to Emergency Department and Readmission Following Primary Elective Total Shoulder Arthroplasty

Document Type : RESEARCH PAPER

Authors

1 Albert Einstein College of Medicine, Bronx, New York, United States

2 Albert Einstein College of Medicine - Department of Epidemiology & Population Health, Bronx, New York, United States

3 Montefiore Medical Center - Department of Orthopaedic Surgery, Bronx, New York, United States

Abstract

Objectives: Returns to the Emergency Department (ED) and unplanned readmissions within 90 days of 
shoulder arthroplasty represent a significant financial burden to healthcare systems. Identifying the 
reasons and risk factors could potentially reduce their prevalence. 
Methods: A retrospective review of primary anatomic (aTSA) and reverse shoulder arthroplasty (rTSA) cases from 
January 2016 through August 2023 was performed. Demographic patient and surgical data, including age, diagnosis 
of anxiety or depression, body mass index (BMI), smoking status, age-adjusted Charlson Comorbidity Index (ACCI), 
modified 5-item fragility index (mFI-5), and hospital length of stay (LOS) was collected. Patient visits to the ED within 
12 months prior to surgery were recorded. Predictors for return to the ED within 90 days postoperatively and any 
readmissions were determined. 
Results: There were 338 cases (167 aTSA and 171 rTSA), of which 225 (67%) were women. Patients with anxiety 
(OR=2.44, 95% CI 1.11–5.33; P=0.026), surgical postoperative complications (OR=3.22, 95% CI 1.36–7.58; 
P=0.008), ED visit within 3 months prior to surgery (OR=3.80, 95% CI 1.71–8.45; P=0.001), ED visit 3 to 6 months 
prior to surgery (OR=2.60, 95% CI 1.12–6.05; P=0.027), and ED visit 6 to 12 months prior to surgery (OR=2.12, 
95% CI 1.02–4.41; P=0.045) were more likely to have ED visit within 90 days postoperatively. Patients with prior 
ipsilateral shoulder surgery (OR=3.32, 95% CI 1.21–9.09; P=0.02), surgical postoperative complications (OR=13.92, 
95% CI 5.04–38.42; P<0.001), an ED visit within 3 to 6 months preoperatively (OR=8.47, 95% CI 2.84–25.27; 
P<0.001), and an mFI-5 ≥2 (OR=3.66, 95% CI 1.35–9.91; P=0.011) were more likely to be readmitted within 90 
days. 
Conclusion: Patients who present to the ED within 12 months prior to shoulder arthroplasty, those with anxiety, 
those with surgical complications and those with higher fragility should be monitored closely during the early 
postoperative period to minimize returns to the ED and/or unplanned readmissions. 
 Level of evidence: III

Keywords

Main Subjects


  1. Wagner ER, Farley KX, Higgins I, Wilson JM, Daly CA, Gottschalk MB. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg. 2020; 29(12):2601-2609. doi: 10.1016/j.jse.2020.03.049.
  2. Dillon MT, Chan PH, Inacio MCS, Singh A, Yian EH, Navarro RA. Yearly trends in elective shoulder arthroplasty, 2005-2013. Arthritis Care Res (Hoboken). 2017; 69(10):1574-1581. doi: 10.1002/acr.23167.
  3. Best MJ, Aziz KT, Wilckens JH, McFarland EG, Srikumaran U. Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2021; 30(5):1159-1166. doi: 10.1016/j.jse.2020.08.010.
  4. Gowd AK, Agarwalla A, Beck EC, Rosas S, Waterman BR, Romeo AA, Liu JN. Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning. J Shoulder Elbow Surg. 2022; 31(12):2449-2456. doi: 10.1016/j.jse.2022.07.013.
  5. Werner BC, Bustos FP, Gean RP, Deasey MJ. Emergency department visits in the year prior to total shoulder arthroplasty as a risk factor for postoperative emergency department visits. HSS J. 2021; 17(2):200-206. doi: 10.1177/1556331621995775.
  6. Walters JD, Walsh RN, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Bundled payment plans are associated with notable cost savings for ambulatory outpatient total shoulder arthroplasty. J Am Acad Orthop Surg. 2020; 28(19):795-801. doi: 10.5435/JAAOS-D-19-00441.
  7. Pezzulo JD, Farronato DM, Rondon AJ, Sherman MB, Getz CL, Davis DE. Predicting hospital readmissions after total shoulder arthroplasty within a bundled payment cohort. J Am Acad Orthop Surg. 2023; 31(4):199-204. doi: 10.5435/JAAOS-D-22-00449.
  8. Bosco JA, Harty JH, Iorio R. Bundled Payment Arrangements:

 

Keys to Success. J Am Acad Orthop Surg. 2018; 26(23):817-822. doi: 10.5435/JAAOS-D-17-00022.

  1. Cvetanovich GL, Bohl DD, Frank RM, Verma NN, Cole BJ, Nicholson GP, Romeo AA. Reasons for readmission following primary total shoulder arthroplasty. Am J Orthop (Belle Mead NJ). 2018; 47(7). doi: 10.12788/ajo.2018.0053.
  2. Chung AS, Makovicka JL, Hydrick T, Scott KL, Arvind V, Hattrup SJ. Analysis of 90-day readmissions after total shoulder arthroplasty. Orthop J Sports Med. 2019; 7(9):2325967119868964. doi: 10.1177/2325967119868964.
  3. Scott KL, Chung AS, Makovicka JL, Pena AJ, Arvind V, Hattrup SJ. Ninety-day readmissions following reverse total shoulder arthroplasty. JSES Open Access. 2019; 3(1):54-58. doi: 10.1016/j.jses.2018.11.002.
  4. Holzgrefe RE, Wilson JM, Staley CA, Anderson TL, Wagner ER, Gottschalk MB. Modified frailty index is an effective risk-stratification tool for patients undergoing total shoulder arthroplasty. J Shoulder Elbow Surg. 2019; 28(7):1232-1240. doi: 10.1016/j.jse.2018.12.004.
  5. Traven SA, McGurk KM, Reeves RA, Walton ZJ, Woolf SK, Slone HS. Modified frailty index predicts medical complications, length of stay, readmission, and mortality following total shoulder arthroplasty. J Shoulder Elbow Surg. 2019; 28(10):1854-1860. doi: 10.1016/j.jse.2019.03.009.
  6. Xu S, Baker DK, Woods JC, Brabston EW 3rd, Ponce BA. Risk factors for early readmission after anatomical or reverse total shoulder arthroplasty. Am J Orthop (Belle Mead NJ). 2016; 45(6):E386-E392. PMID: 27737300.
  7. Kind AJH, Buckingham W. Making neighborhood disadvantage metrics accessible: the neighborhood atlas. N Engl J Med. 2018:378:2456-2458. doi: 10.1056/NEJMp1802313.
  8. About the Neighborhood Atlas®.University of Wisconsin School of Medicine Public Health. Area Deprivation Index Datasets. Available at: https://www.neighborhoodatlas.medicine.wisc.edu/. Accessed December 15, 2023.
  9. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol .1994; 47(11):1245-1251.
  10. Chowdhury MZI, Turin TC. Variable selection strategies and its importance in clinical prediction modelling. FAM Med Community Health. 2020; 8(1):e000262. doi: 10.1136/fmch-2019-000262.
  11. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group. JAMA. 1996; 276(6):460-465. doi: 10.1001/jama.276.6.460.
  12. Vinton DT, Capp R, Rooks SP, Abbott JT, Ginde AA. Frequent users of US emergency departments: characteristics and opportunities for intervention. Emerg Med J. 2014; 31(7):526-532. doi: 10.1136/emermed-2013-202407.
  13. Kuhlmann NA, Franovic S, Burdick GB, et al. Shoulder arthroplasty outcomes in patients with major depressive disorder or generalized anxiety disorder. Seminars in Arthroplasty: JSES. 2023; 33(4):722-726. doi: 10.1053/j.sart.2023.07.005.
  14. Lu Y, Oeding JF, Parkes C, Patel H, Berlinberg E, Forsythe B, Camp CL, Sanchez-Sotelo J. Incidence and 30- and 90-day readmission rates after primary shoulder arthroplasty in the United States: an analysis using the National Readmissions Database. J Shoulder Elbow Surg. 2023; 32(6):1174-1184. doi: 10.1016/j.jse.2022.12.003.
  15. Malik AT, Morris J, Bishop JY, Neviaser AS, Khan SN, Cvetanovich GL. Undergoing an arthroscopic procedure prior to shoulder arthroplasty is associated with greater risk of prosthetic joint infection. Arthroscopy. 2021; 37(6):1748-1754.e1. doi: 10.1016/j.arthro.2021.01.013.