Lovy Andrew J, Keswani Aakash, Beck Christina, Dowdell James E, Parsons Bradford O
Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA.
Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA.
J Shoulder Elbow Surg. 2017 Jun;26(6):1003-1010. doi: 10.1016/j.jse.2016.10.019. Epub 2017 Jan 19.
Total shoulder arthroplasty (TSA) is a likely target for future bundled payment initiatives, necessitating accurate preoperative risk stratification. The purpose of this study was to identify risk factors for unplanned readmission and severe adverse events, to risk stratify TSA patients based on these risk factors, and to assess timing of complications after TSA.
Data were collected from patients undergoing TSA from 2009 to 2014 in the American College of Surgeons National Surgical Quality Improvement Program. Bivariate and multivariate analyses of risk factors for severe adverse events or readmission were assessed. Patients were risk stratified, and timing of severe adverse events and cause of readmission were evaluated.
The analysis included 5801 TSA patients; 146 (2.5%) suffered severe adverse events, and 158 (2.7%) had a 30-day unplanned readmission. The most common severe adverse events were reoperation (40%), thrombolic event (deep venous thrombosis or pulmonary embolism; 14%), cardiac event (10%), and death (8.2%). Pneumonia (8.9%) and thrombolic event (7.6%) were the most common medically related causes, whereas dislocation (7.6%) and postoperative infection or wound complication (5.1%) were the most common surgical causes for readmission. Multivariate analysis identified inflammatory arthritis (P = .026), male gender (P = .019), age (P < .001), functional status (P = .024), and American Society of Anesthesiologists class 3/4 (P = .01) as independent predictors for unplanned 30-day readmission and all but inflammatory arthritis for severe adverse events (P ≤ .05 for all). Patients with ≥3 risk factors had an 11.56 (P = .002) and 3.43 (P = .013) times increased odds of unplanned readmission and severe adverse events occurring within 2 weeks after surgery, respectively, compared with patients with 0 risk factors.
Patients at high risk of TSA complications and readmission should be identified preoperatively to improve outcomes and to lower costs. Bundled payment initiatives must account for both patient- and procedure-related risk factors.
全肩关节置换术（TSA）可能是未来捆绑支付计划的目标，因此需要准确的术前风险分层。本研究的目的是确定计划外再入院和严重不良事件的风险因素，根据这些风险因素对TSA患者进行风险分层，并评估TSA术后并发症的发生时间。
收集2009年至2014年在美国外科医师学会国家外科质量改进计划中接受TSA的患者的数据。对严重不良事件或再入院的风险因素进行双变量和多变量分析。对患者进行风险分层，并评估严重不良事件的发生时间和再入院原因。
分析纳入5801例TSA患者；146例（2.5%）发生严重不良事件，158例（2.7%）有30天内计划外再入院。最常见的严重不良事件是再次手术（40%）、血栓形成事件（深静脉血栓形成或肺栓塞；14%）、心脏事件（10%）和死亡（8.2%）。肺炎（8.9%）和血栓形成事件（7.6%）是最常见的医学相关原因，而脱位（7.6%）和术后感染或伤口并发症（5.1%）是再入院最常见的手术原因。多变量分析确定炎症性关节炎（P = 0.026）、男性（P = 0.019）、年龄（P < 0.001）、功能状态（P = 0.024）和美国麻醉医师协会3/4级（P = 0.01）是计划外30天再入院的独立预测因素，除炎症性关节炎外，所有因素均为严重不良事件的独立预测因素（所有P≤0.05）。与无风险因素的患者相比，有≥3个风险因素的患者计划外再入院和术后2周内发生严重不良事件的几率分别增加11.56倍（P = 0.002）和3.43倍（P = 0.013）。
应在术前识别TSA并发症和再入院风险高的患者，以改善预后并降低成本。捆绑支付计划必须考虑患者和手术相关的风险因素。
