From the Midwest Orthopaedics at Rush, Rush University, Chicago, IL.
J Am Acad Orthop Surg. 2021 Oct 1;29(19):e969-e978. doi: 10.5435/JAAOS-D-20-00294.
Rates of shoulder arthroplasty continue to increase. Factors influencing disposition and the effect discharge destination may have on perioperative outcomes are currently unknown. This study (1) investigates patients undergoing total shoulder arthroplasty subsequently discharged to home, skilled nursing facilities, and or independent rehabilitation facilities; (2) identifies differences in perioperative outcomes; and (3) investigates the risk of adverse events and readmission after nonhome disposition.
The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing total shoulder arthroplasty from 2013 to 2018. Bivariate and multivariate analyses were conducted to determine the relationship between patient characteristics and risks of discharge to a non-home destination, discharge to an independent rehabilitation facility as opposed to a skilled nursing facility, severe postdischarge adverse events, and unplanned readmission.
Factors associated with discharge to a non-home facility included those older than 85 years of age (odds ratio [OR], 14.38), dialysis requirement (OR, 4.16), transfer from a non-home facility (OR, 3.69), dependent functional status (OR, 3.17), female sex (OR, 2.78), history of congestive heart failure (2.05), American Society of Anesthesiologists class >2 (OR, 1.97), longer length of stay (OR, 1.47), and body mass index >35 (OR, 1.29) (P < 0.05). Patients discharged to a non-home facility had an approximately quadrupled rate of both major adverse events (8.6% vs 2.4%, P < 0.001) and minor adverse events (6.1% vs 1.4%, P < 0.001). Discharge to a non-home facility had a higher likelihood of a severe adverse event (OR, 1.82, P = 0.029) or unplanned readmission (OR, 1.60, P = 0.001).
Non-home discharge destination demonstrated a notable negative impact on postoperative outcomes independent of medical complexity. Preoperative management of modifiable risk factors may decrease length of inpatient stay, rates of disposition to non-home facilities, and total cost of care. The benefit of more intense postoperative management at a non-home discharge destination must be carefully weighed against the independent risk of postoperative adverse events and readmissions.
肩关节置换术的比例不断增加。影响患者处置方式的因素以及出院目的地对围手术期结果的影响目前尚不清楚。本研究：(1) 调查行全肩关节置换术患者随后出院至家庭、熟练护理机构和/或独立康复机构的情况；(2) 确定围手术期结果的差异；(3) 调查非家庭处置后不良事件和再入院的风险。
使用美国外科医师学院国家手术质量改进计划数据库，检索 2013 年至 2018 年期间行全肩关节置换术的患者。进行了双变量和多变量分析，以确定患者特征与非家庭出院目的地、出院至独立康复机构而不是熟练护理机构、严重出院后不良事件和计划外再入院之间的关系。
与非家庭机构出院相关的因素包括 85 岁以上的患者（优势比[OR]，14.38）、透析需求（OR，4.16）、从非家庭机构转移（OR，3.69）、功能依赖（OR，3.17）、女性（OR，2.78）、充血性心力衰竭史（2.05）、美国麻醉师协会分类>2（OR，1.97）、住院时间延长（OR，1.47）和体重指数>35（OR，1.29）（P < 0.05）。出院至非家庭机构的患者发生主要不良事件（8.6% vs 2.4%，P < 0.001）和轻微不良事件（6.1% vs 1.4%，P < 0.001）的几率大约增加了四倍。出院至非家庭机构的患者发生严重不良事件（OR，1.82，P = 0.029）或计划外再入院（OR，1.60，P = 0.001）的可能性更高。
非家庭出院目的地对术后结果产生了显著的负面影响，而与医疗复杂性无关。术前管理可改变的风险因素可能会减少住院时间、非家庭机构的处置率和总医疗费用。在非家庭出院目的地进行更强化的术后管理的益处必须与术后不良事件和再入院的独立风险仔细权衡。
