Elizabeth Hofheinz, M.P.H., M.Ed.
Noting that shoulder arthroplasty is increasing at a rate faster than hip and knee arthroplasty, a team of researchers set out to refine our understanding of postoperative care after this procedure. Their work, “Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model,” appears in the October 1, 2020 edition of the Journal of the American Academy of Orthopaedic Surgeons.
The research team included Daniel E. Davis, M.D., M.S., an Assistant Professor of Shoulder and Elbow Surgery at the Rothman Orthopaedic Institute and The Sidney Kimmel Medical College at Thomas Jefferson University.
Dr. Davis told OSN: “In our practice, we initiated a method of not only quantifying the patients’ health risk to undergo a surgical procedure, but also their social risks i.e., what factors at home outside of their medical health may cause problems or difficulties for the patient as they recovered from their operation. In addition to calculating these scores, we employ a group of nurses who are designated as navigators. These nurse navigators will review the scores and also talk with the patient to identify exactly what their challenges may be at home. If it is determined that a patient will need more advanced home care or inpatient rehabilitation, our nurse navigators help to establish this before the operation so as to help shorten the patient’s hospital stay. This program was initially developed in our practice for hip and knee arthroplasty patients. On the shoulder service, we wanted to evaluate if focusing on these scores and having patients navigated would make a difference in shoulder arthroplasty as well. This study sought to begin to answer this question.”
All 453 procedures studied were performed by four fellowship-trained shoulder and elbow surgeons who all followed a uniform postoperative protocol. All surgeons had practiced between 5 and 25 years, with 100 and 200 arthroplasties per year per surgeon. The team collected the following outcome measures: hospital length of stay, discharge destination (home, homecare, and inpatient rehabilitation unit), and need for hospital readmission.
“Analysis found elevated Medical (7.3 versus 3.9) and Social (7.1 versus 3.4) Survey Scores in those patients requiring home care or inpatient rehabilitation stay,” wrote the authors. “Significantly higher Medical (9.1 versus 3.9) and Social (8.7 versus 3.4) Survey Scores were found for home care compared with those who required no postoperative care. There was a weak correlation between hospital length of stay and the social component. No variable could predict readmission to the hospital. Multivariable analysis confirmed the Medical Survey as an independent predictor of the need for Inpatient Rehabilitation or Home Care in multivariate analysis. The Social Survey was confirmed as an independent predictor of Inpatient Rehabilitation or Home Care requirements and length of stay. Other predictors for the need of Rehabilitation or Home Care were increasing age and the ECI [Elixhauser Comorbidity Index]. Other predictors for increased length of stay were female sex and ECI.”
“Our most important findings,” said Dr. Davis to OSN, “were that there were clear cut off points in the medical and social scores which helped to predict post-operative destination after undergoing shoulder arthroplasty. A social score of 8 or higher and a medical score of 9 or higher was predictive of a patient requiring home care or inpatient rehabilitation after a total shoulder.”
Asked about the most important implication for postop care, Dr. Davis told OSN, “We found that those patients who had higher medical or social risks require more advanced evaluation to find the best and safest location for their post-operative discharge. While many patients are safe to return home after total shoulder, there are a certain cohort who need to be closely evaluated. While many physicians may be able to instinctively predict who those patients are, this study helps to quantify that more objectively.”
“It is important for orthopaedic surgeons to focus not only on their surgical procedure, but also the post-operative destination and care of the patient. Historically, patients may spend multiple nights in the hospital working with inpatient hospital therapy and then eventually be recommended for inpatient rehabilitation. While this may be appropriate for some patients, it also may portend a slower recovery for others. Therefore, it is important for the physician and their team to take an active role in the post-operative care and destination of the patient.”