Causes and Predictors of 30-Day Readmission After

Shoulder and Knee Arthroscopy: An Analysis of
15,167 Cases
Robert W. Westermann, M.D., Andrew J. Pugely, M.D., Zachary Ries, M.D.,
Annunziato Amendola, M.D., Christopher T. Martin, M.D., Yubo Gao, Ph.D.,
and Brian R. Wolf, M.D.

Purpose: To evaluate the incidence, causes, and risk factors for unplanned 30-day readmission after shoulder and knee
arthroscopy. Methods: A multicenter, prospective clinic registry, the American College of Surgeons National Surgical
Quality Improvement Program, was queried for Current Procedural Terminology codes representing the most common
shoulder and knee arthroscopic procedures. Unplanned readmissions within 30 days were evaluated dichotomously, and
causes of readmission were identified. Univariate and multivariate logistic regression analyses were used to identify
variables predictive of readmission. Results: In total, we identified 15,167 patients who underwent shoulder and knee
arthroscopic procedures in 2012. Overall, 136 (0.90%) were readmitted within 30 days, and the rates were similar after
shoulder (0.86%) and knee (0.92%) procedures. Readmissions were most common after arthroscopic debridement of the
knee (1.56%) and lowest after rotator cuff and labral repairs (0.68%) and cruciate reconstructions (0.78%). The most
common causes of readmission were surgical-site infections (37.1%), deep venous thrombosis and pulmonary embolism
(17.1%), and postoperative pain (7.1%). Multivariate analysis identified age older than 80 years (odds ratio [OR], 3.5;
95% confidence interval [CI], 1.5 to 8.1), chronic steroid use (OR, 3.3; 95% CI, 1.5 to 7.2), and elevated American Society
of Anesthesiologists class (OR, 4.2; 95% CI, 1.4 to 12.0) as independent risk factors for readmission. Conclusions: The
rate of unplanned readmissions within 30 days of shoulder and knee arthroscopic procedures is low, at 0.92%, with
wound-related complications being the most common cause. In patients with advanced age, with chronic steroid use, and
with chronic systemic disease, the risk of readmission may be higher. These findings may aid in the informed-consent
process, patient optimization, and the quality-reporting risk-adjustment process. Level of Evidence: Level III,
prognostic study.

W

ith the passage and affirmation of the Affordable
Care Act, the Centers for Medicare & Medicaid
Services (CMS) has been empowered to initiate several
cost-containment measures. Among these is the
From the Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.
The American College of Surgeons National Surgical Quality Improvement
Program and the hospitals participating in this program are the source of the
data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
The authors report the following potential conflict of interest or source
of funding: A.A. receives support from Arthrex, Arthrosurface, and MTP
Solutions.
Received November 14, 2014; accepted March 18, 2015.
Address correspondence to Robert W. Westermann, M.D., Department of
Orthopaedic Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins
Dr, 01008 JPP Iowa City, IA 52242, U.S.A. E-mail: robert-westermann@
uiowa.edu
Ó 2015 by the Arthroscopy Association of North America
0749-8063/14960/$36.00
http://dx.doi.org/10.1016/j.arthro.2015.03.029

Readmissions Reduction Program, which places particular emphasis on unplanned readmissions within 30
days postoperatively, and hospitals with particularly
high rates will be financially penalized. Furthermore,
the CMS’s Hospital Quality Initiative identified 30-day
readmission rates after surgical procedures as an
important quality metric,1 and the ability to compare
and rank hospitals according to outlined quality measures is becoming publicly available.2
Against this background of increasing emphasis on
unplanned readmission rates, multiple prior studies
have investigated unplanned readmissions in spine
surgery and joint arthroplasty, with reported rates
ranging from 2% to 7%.3-6 These studies have served to
better inform health policy and perioperative management. In contrast, although shoulder arthroscopy and
knee arthroscopy are among the most common orthopaedic procedures performed in the United States,7-9
comparatively little has been published on unplanned
readmissions.10-13 Some studies have reported

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 6 (June), 2015: pp 1035-1040

1035

and risk factors for unplanned 30-day readmission after shoulder and knee arthroscopy. Thus NSQIP-specific variables and International Classification of Diseases. The National Surgical Quality Improvement Program (NSQIP) is a well-established clinical registry developed by the American College of Surgeons with widespread use in orthopaedics. the case would be classified according to the code representing the highest level of intervention or repair.3 (SAS Institute. Cary.16 NSQIP began prospectively collecting readmissions data starting in 2011. unplanned readmission rates ranging from 0. NC). case.14. 29884).64% to 1.15 The CMS’s National Quality Forum has recognized NSQIP’s important role in addressing health care quality. and patients with a hospital stay exceeding 30 days because we believed that these were unlikely to be elective cases. In total.36%. Results Incidence In total. extensive debridement/decompression (29826. meniscal procedures (29880. version 9.15 A complete description of the procedures associated with each Current Procedural Terminology code is provided in Appendix Table 1. 29889). Specific patient factors are collected on all patients and are clearly defined in the NSQIP database. similar methods have been used previously. 29887).05. 29820. This study was deemed exempt from institutional review board review by the University of Iowa.6. and synovectomy/debridement (29873. We then used a univariate analysis to identify patient factors associated with readmission. 29866. We included any variable from the univariate model with P < . 29825). The purpose of this study was to evaluate the incidence.17 Patients are prospectively followed up for 30 days postoperatively. and no external funding was used. thus ensuring that complications that may have presented to outside hospitals are also captured.90%) who underwent shoulder or knee arthroscopic procedures had an unplanned readmission within 30 days postoperatively. The Student t test was used for continuous variables and the c2 test for categorical variables. 136 of 15. 29867. Statistical significance in the multivariate model was defined as P < . W.1 and variable completion of greater than 80%. we constructed a multivariate logistic regression model. to identify variables independently associated with readmissions. 29806.15. and repair: rotator cuff/labrum or other (29827. patients with pneumonia. patients requiring blood pressure support preoperatively. 29821.18-21 Patient. causes. patients in a coma. Comprehensive details regarding data collection methods and variable definition can be found within the NSQIP user guide. Ninth Revision (ICD-9) were used to exclude cases of patients with evidence of preoperative sepsis.10-13 but the causes and risk factors remain poorly defined. 29822. 29881. and the reason for readmission was identified through ICD-9 codes. they are directly contacted by phone. All data and statistical analyses were performed with SAS software. and the database does not include cases performed for acute trauma. All patients were aged at least 18 years. Patient Description Patients were identified using Current Procedural Terminology codes for shoulder and knee procedures (Appendix Table 1).17 and its use has been well established in the general surgery and orthopaedic surgery literature.8%. 29823). 29885. WESTERMANN ET AL.14. and regular auditing of the NSQIP data has shown disagreement rates of less than 1. If patients have not undergone a follow-up visit within 30 days. 29828). 29875. Knee procedure categories were constructed and comprised cruciate reconstruction (29888. patients with a contaminated wound. When multiple codes were used. Statistical Analysis First.17 Patient information in the American College of Surgeons NSQIP database is de-identified and Health Insurance Portability and Accountability Act compliant. We hypothesized that readmission rates after arthroscopic procedures would be low and that advanced age and comorbidity burden would be associated with higher readmission rates.10. 29886. cartilage procedures (29877. and outcome variables are strictly defined to ensure high data fidelity. Shoulder procedure categories were constructed and comprised diagnostic/limited debridement procedures (29805.167 patients (0. 29882. Both overall and procedure-specific readmission rates were calculated. 29824. and trained data reviewers use prospective chart review and direct communication with the surgical team to identify readmissions and complications postoperatively.10. Model performance was assessed for discrimination using the C-index and calibration using HosmerLemeshow c2 statistics. 29826-51. 29876.167 patients. Readmission rates were similar between . 29819. patients were divided into cohorts of those with an unplanned 30-day readmission and those without such a readmission. 29868). 29883. these criteria produced an initial cohort of 15. Our goal was to include only patients undergoing a primary elective procedure. 29807. Methods Overview NSQIP prospectively collects data from nearly 500 US hospitals. 29874. Second. nearly half of which are private and half academic.1036 R.6. 29879.

11 assessed readmission rates after knee arthroscopy from the English National Health Service.1).5 to 8.28%). and pneumonia (3 patients. 1. Medical reasons for readmission were less common than procedurally related reasons and included myocardial infarction (3 patients.0) as compared with ASA class 1 or 2.36%. 3. including older patient age and increasing comorbidity burden (P < . Causes of Readmission The most common causes of unplanned readmission were surgical-site infections (SSIs) and wound complications (26 patients.64%.14%) and postoperative pain (5 patients. 0. chronic steroid use. The second aim of the study was to identify common causes of unplanned readmissions. and postoperative pain (7. were each independently associated with unplanned readmission risk (Table 2).77%.2.11). 4.78% of patients were readmitted after cruciate reconstruction (P ¼ . age older than 80 years (odds ratio [OR]. were also statistically significant (Table 1). 4. 1. 3.05 for each) (Table 1). 17. 95% CI. Our study further expands on their results by providing data from a prospective clinical registry. even small numbers of readmitted patients could substantially affect quality-reporting metrics. the 30-day unplanned readmission rate after primary elective shoulder or knee arthroscopic procedures was low.8) or ASA class 4 (OR. Medical reasons for readmission were less common. 1. did not reach significance in the statistical models. The first aim of the study was to identify the incidence of 30-day unplanned readmissions after primary elective shoulder and knee arthroscopic procedures. The most common complications prompting readmission were wound issues and the treatment of venous thromboembolism.11.2 to 2.1%). at 0. the type of surgery performed did not predict readmission. In the shoulder cohort. and wound hematomas (3 patients.16% after extensive debridement/decompression procedures (P ¼ .3. Other common causes were treatments for deep venous thrombosis (DVT) and/or pulmonary embolism (12 patients.8.90%.2).56% after synovectomy/debridement (P ¼ . we determined that readmission rates were similar after shoulder and knee procedures. 95% CI. outpatient discharge. .48% after cartilage procedures. These numbers compare favorably with those from prior studies citing wound complications and venous thromboembolism as common causes of readmissions. 95% CI. These risk factors may help guide surgeons. hospitals.01). Discussion 1037 According to our findings.81% after meniscus procedures (P ¼ . with a large number of patients enrolled from around the United States. with ASA class 3 (OR.5 95% confidence interval [CI]. chronic steroid use (OR. The delivery of health care is rapidly evolving in the United States.92%). procedure type was not predictive of readmission because no significant differences were detected between groups.1%).4 to 12. superficial incisional SSIs (4 patients. with the most common causes being DVT and knee effusion or synovitis. Procedural factors.14%).READMISSION AFTER SHOULDER/KNEE ARTHROSCOPY shoulder procedures (45 of 5. This is the first study to critically and comprehensively evaluate unplanned readmission after knee and shoulder arthroscopy. Furthermore. Although the absolute differences were small.247 patients. 4. These rates are consistent with previous reports of readmission rates after shoulder and knee arthroscopic procedures ranging between 0. Risk Factors The univariate analysis identified multiple patient factors associated with readmission. 0.68% after repair procedures (rotator cuff or labrum) (P ¼ . including operative time. DVT/pulmonary embolism (17. 0. In the knee cohort. with an incidence of 0. 5.79). 1.14%).28%). and governing bodies in the optimization of patient safety and service value. Readmission risk was significantly associated with patient factors. Changes in surgeon and hospital evaluation are driving orthopaedic surgeons to consider the implications of procedure costs and patient outcomes.1%).12 performed a retrospective review of knee arthroscopies in the Victorian Admitted Episodes Dataset and reported a readmission rate of 0.12 may have underestimated the number of wound complications necessitating readmission because only Staphylococcus aureusepositive wound infections were considered. specifically increased patient age. Jameson et al.71%). as well as lower hematocrit levels. Separately. 0. Notably. and elevated American Society of Anesthesiologists (ASA) status.10-13 Bohensky et al. and 1.86%) and knee procedures (91 of 9.920 patients.5 to 7. This comprised deep incisional or deep space SSIs (19 patients. 4. Reasons for readmission were documented in 70 cases by either NSQIP criteria or an ICD-9 code.28%). and 0.98% after diagnostic/limited debridement procedures. 1. preoperative laboratory values of increased white blood cell counts and creatinine levels. 4.68). 1. 27. 7. Because unplanned readmissions are uncommon after arthroscopy. was also significantly more common in patients who were readmitted (P < . Thus surgeons interested in minimizing readmission rates should be aware of the common causes outlined.” defined as active/chronic steroid use. In the subsequent multivariate analysis. After adjustment for patient factors. The most common reasons identified were wound complications (37.64% and 1.29). the readmission rate was 0. blood loss.13 Bohensky et al.28%) sepsis (3 patients. 37. and procedure type.14%). the NSQIP variable “steroid use.87). 1. and elevated ASA class.

American Society of Anesthesiologists Physical Status Classification.29 66.99 .34 (15. particular attention to wound management.0001 . ASA.46 55.09 (14. vascular.1387 . and steroid use.34 (7.0592 < . BMI. hypertension.92 (2.74 5. % Race.35) 0.0003 .00 47.1472 > . BUN. International Normalized Ratio. Laboratory values that differed in readmitted patients included increased WBC count. white blood cell.59 22.22 We observed over a 3-fold increase in the readmission rate in patients with chronic steroid use before knee or shoulder arthroscopy.62 0.0001 .04 1.00 > .0003 .74 0.25) 41. Furthermore.01) 7.85 21.23 We found steroid use to be an independent risk factor for unplanned readmission after shoulder and knee arthroscopy.85 0. cancer.67 0.to 5-fold increase in wound complication rates in previous studies.99 . W. Because wound-related complications were the most common cause of unplanned 30-day readmissions.0001 . mean (SD). The final aim was to report risk factors for readmissions. COPD.24 evaluated over 230.0001 > .05 (0.62 6.10 (2.90) 43.10 0.90 0.37) 138.9146 2.21 0. WBC.2909 .44 16.5 (3.0123 < .5813 NOTE. mean (SD) Preoperative sodium level Preoperative BUN level Preoperative WBC count Preoperative hematocrit level Preoperative INR Preoperative PRCREAT level ASA class 1 or 2: no or mild disturbance 3: severe disturbance 4: life-threatening disturbance Not Readmitted (n ¼ 15.05 (0. congestive heart failure.23 found that intraoperative steroid injections were associated with postoperative superficial and deep infections in elbow arthroscopy. and patient age older than 80 years. The overall unplanned 30-day readmission rate was 7. Nelson et al.0001 79.09 38.19 1. and independent risk factors . and increased creatinine level. % Comorbidities.85 1. this risk factor merits further discussion. INR.2103 .52 0. peripheral vascular disease. and thoracic surgery.78) 7.53 58.00 6.95 26. venous thromboembolism prophylaxis.07 32. The association between chronic steroid use and derangements in all phases of wound healing has been well established. Lucas et al. PVD.62 70. body mass index.67) . elevated ASA class of 3 or 4.50 (9.00 1. yr Female gender.36 (4. preoperative creatinine.99) 39.1264 > .30 0. Increased patient age and ASA class have also received substantial attention as risk factors for readmissions in prior studies.0026 < . CHF.02 0.24 3.91 (0. PRCREAT.99 .10 .67 (4.88 2. diabetes. Chronic steroid use may be an important issue to address preoperatively regarding medical optimization and informed consent.031) Readmitted (n ¼ 136) 50.99 .85 0.54) 16. Table 1.33 9.94 0.32 0.06 19.7 (2. Our multivariate analysis identified chronic steroid use.8010 .26 0.16) 44.1038 R.04) 1.11 (0.76 79. % Black White Other BMI 35 kg/m2.0185 > .95 19. Patients who were readmitted were significantly older and more commonly carried diagnoses of dyspnea. Patient Demographic and Procedure Characteristics Between Non-Readmitted and Readmitted Patients: Univariate Analysis Characteristic Demographic data Age. decreased hematocrit level.52 1.8%. blood urea nitrogen.99 139. chronic obstructive pulmonary disease.48 6.35) 1. WESTERMANN ET AL.000 patients undergoing general. and pain management is warranted.38 6.79 79.56) 1.09 0.22.0044 .74) 17.0611 < . COPD. Chronic steroid use has been associated with a 2. % Current alcohol abuse Current smoker Recent weight loss Dyspnea COPD CHF Hypertension Diabetes PVD Disseminated cancer Steroid use Bleeding disorder Dialysis Chemotherapy within 30 d Radiation therapy within 90 d Prior operation within 30 d Laboratory results.68 P Value .17 1.2621 .09 2.

References 1. 2.20:606-616. Available at http://www. 7. Martin CT. Centers for Medicare & Medicaid Services. and the quality-reporting riskadjustment process. but we believe that the overall categories are likely representative. or national code-based data sources.90%. Within orthopaedics. Furthermore.14) 1.239 . were determined to be both ASA class and length of stay. Winemaker M. Kim BD.23-2. odds ratio. Gao Y. ASA.887 .18) 1. at 0. and pain management to reduce readmission rates.84-2.84) 1.35 (0. Kim JY.15) 1.004 .86) 4. patients with an increased comorbidity burden.medicare. large numbers.70 (0. Because of this. Risk Factors for 30-Day Unplanned Readmission After Shoulder and Knee Arthroscopy Using Multivariate Logistic Regression Age 60-70 yr Age 71-80 yr Age >80 yr Diagnosis of dyspnea History of COPD History of cancer History of diabetes ASA class 3 v 1 and 2 ASA class 4 v 1 and 2 Steroid use Adjusted OR (95% CI) 1. Mendoza-Lattes S. and with chronic systemic disease. it should be recognized that CMS’s Hospital Quality Initiative has identified this 30-day readmission period as a quality metric.3 Specifically within arthroscopy.19) P Value . OR. Avram V. patient optimization. Irrgang JJ. The database is generalizable.008 . 2012. Practice patterns for subacromial decompression and rotator cuff repair: An analysis of the American Board of Orthopaedic Surgery database. especially those older than 80 years.33 (1. It is possible that inclusion of the remainder of the patients would have altered the relative percentages for causes of readmissions that we have reported in this article. J Neurosurg Spine 2014. In an era of quality reporting in health care. representing both private and academic orthopaedic practices. 4. causes.169 . We have outlined the incidence. ASA class and patient age were both associated with short-term complication rates after both arthroscopic knee surgery15 and arthroscopic shoulder surgery.222 .S. de Beer J. and steroid use. Woodlawn. and surgeons should consider medical and discharge optimization in these high-risk groups. Harner CD.html. 1039 Limitations The NSQIP follow-up data are limited to a 30-day window. Medicare. both ASA class and patient age were previously reported as risk factors for readmissions after joint arthroplasty6 and spine surgery.56-93. These findings may aid in the informed-consent process. J Arthroplasty 2014. Callaghan JJ.10 Thus patients of an increased age.77-2. Spine 2014.gov/ hospitalcompare/search.002 NOTE. elevated ASA class. CMS dry run hospital-specific report for hospital-wide all-cause unplanned readmission (HWR) measure. Smith TR.50 (1. data regarding the exact causes of readmission were not available in all cases. In addition. certain preoperative laboratory studies were not always available and therefore were left out of the multivariate model. Gao Y. This study has several strengths.44-11. J Arthroplasty 2013. and risk factors for unplanned readmissions after some of the most common procedures in orthopaedics. 3. Pugely AJ. Jordan SS. Independent risk factors for readmission after knee and shoulder arthroscopy were determined to be age older than 80 years. Total joint arthroplasty readmission rates and reasons for 30day hospital readmission.READMISSION AFTER SHOULDER/KNEE ARTHROSCOPY Table 2.28: 1499-1504. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: Analysis from the ACS-NSQIP. venous thromboembolism prophylaxis.62) 7. The Official U. and patients with a significant comorbidity burden should be selected to undergo surgery with caution.94: 1492-1499. Lim S. there could be other patient-related factors that contribute to readmission that are not collected in the NSQIP database.66) 1. and comprehensive 30-day follow-up. 2014. CI. .23 (0.98) 3. trained persons performing data extraction.39:761-768. Predictors of unplanned readmission in patients undergoing lumbar decompression: Multi-institutional analysis of 7016 patients. the risk of readmission may be higher.004 .88) 3.15 (1. Cybulski GR. surgeons and hospitals should understand these risk factors and explore measures to minimize unplanned readmissions. COPD. it is likely better structured to evaluate a complex issue such as readmission rates compared with singleinstitution.87 (1.575 . 6.59-1. Pugely AJ. Mauro CS.04 (0. In patients with advanced age. The NSQIP database is a robust data source that uses strict definitions.80-3. with wound-related complications being the most common cause. or patients receiving chronic steroid therapy is warranted. Lastly. J Bone Joint Surg Am 2012. However. MD: Centers for Medicare & Medicaid Services.58-2. An unplanned readmission after shoulder or knee arthroscopy is a rare event. Last accessed June 1.55-7.49 (0. 5. confidence interval. American Society of Anesthesiologists Physical Status Classification.29:465-468.24 (0. Cram P. with chronic steroid use. chronic obstructive pulmonary disease.129 .50-8. Government Site for Medicare. Causes and risk factors for 30-day unplanned readmissions after lumbar spine surgery. and patients may be readmitted for postsurgical complications outside of this time frame. Martin CT. Surgeons should pay particular attention to perioperative wound management. Appropriate preoperative optimization of patients with advanced age. Petruccelli D. Conclusions The rate of unplanned readmissions within 30 days of shoulder and knee arthroscopic procedures is low. Hospital compare.

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29820. 29884) 29873: lateral release 29874: loose body removal 29875: limited synovectomy 29876: major synovectomy 29884: lysis of adhesions ACL. rotator cuff tear. 29868) 29880: medial and lateral meniscectomy 29881: medial or lateral meniscectomy 29882: medial or lateral meniscal repair 29883: medial and lateral meniscal repair 29868: meniscal transplant Cartilage (29877. Procedures Associated With Current Procedural Terminology Codes Shoulder Diagnostic procedures/limited debridement (29805. 29882. RTC. 29876. 29886. 29874. shoulder. 29806. 29822. 29828) 29827: rotator cuff repair 29826-51: SAD with RTC repair 29807: SLAP 29806: capsulorrhaphy/stabilization/Bankart 29828: biceps tenodesis Knee Cruciate reconstruction (29888. 29889) 29888: ACL reconstruction 29889: PCL reconstruction Meniscus (29880. surgical. 29819. 29824. SAD. 29879. PCL. 29883. 1040. 29823) 29826: SAD/acromioplasty 29824: distal clavicle resection 29823: arthroscopy. 29885. 29825) 29805: diagnostic/biopsy 29819: loose body removal 29820: partial synovectomy 29821: complete synovectomy 29822: limited debridement (cuff or labrum) 29825: lysis of adhesions Extensive debridement/decompression (29826. 29821. 29875. posterior cruciate ligament. anterior cruciate ligament.READMISSION AFTER SHOULDER/KNEE ARTHROSCOPY Appendix Table 1. 29887) 29877: chondroplasty 29866: osteochondral autograft 29867: osteochondral allograft 29885: osteochondral drilling with bone graft 29879: abrasion arthroplasty 29886: osteochondral drilling without bone graft 29887: osteochondral drilling with fixation Synovectomy/minor debridement (29873. extensive Repair: RTC/labrum or stabilization (29827. 29826-51. subacromial decompression.e1 . 29881. debridement. 29867. 29866. 29807.