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. 2023 Feb 21;15:38653. doi: 10.52965/001c.38653

Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty

Suleiman Sudah 1,✉, Mariano Menendez 2, Andrew Jawa 3, Jonathan Levy 4, Patrick Denard 5
PMCID: PMC9946799  PMID: 36843859

Abstract

Background

There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts.

Objective

The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States.

Methods

The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as “substantial” variation. Geographic maps were created for visual representation of the data.

Results

There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West).

Conclusions

There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.

Keywords: length of stay, hospital discharge, shoulder arthroplasty, regional variation

Introduction

The incidence of total shoulder arthroplasty (TSA) has risen dramatically in recent decades.1 Currently, over 100,000 cases of TSA are performed annually with a projected increase in volume of 235% by 2025.2 Costs associated with TSA are high and constitute a rising proportion of overall healthcare spending.3–5 In today’s economic climate, there is growing national interest in optimizing cost and resource utilization after musculoskeletal procedures.6 However, little data is present to guide improvement efforts after TSA.

Previous studies have shown that 63% of inpatient costs associated with TSA are related to facility utilization.7 As a result, many have attempted to increase the rate of outpatient TSA procedures,8 which has been shown to reduce costs8 without subjecting patients to increased risk of complications.9 However, most patients undergoing TSA are insured by Medicare.10 Most Current Procedural Terminology (CPT) codes for shoulder arthroplasty are not approved for ambulatory surgery centers (ASC) under Medicare and must be performed at a hospital.5 Thus, current focus has shifted towards safely reducing inpatient length of stay [LOS] after TSA to reduce costs.5

Discharge disposition is an additional post-surgical driver of cost following TSA.11 Recently, it has been shown that disposition to an inpatient rehabilitation facility following TSA increases 90-day reimbursements by 194% when compared to home discharge.11 In addition, non-home discharge has been shown to increase the rate of adverse events and hospital readmission after TSA, independent of a patient’s medical complexity.12

While several studies have identified patient and hospital-related factors associated with LOS and discharge disposition after TSA,4,12–16 little is known about the geographic variability of these markers of resource utilization across the United States. Herein, we used the Centers for Medicare and Medicaid Services (CMS) database to identify Medicare discharges associated with shoulder arthroplasty. We hypothesized that there would be wide geographic variation in LOS and home discharge disposition rates after this procedure. Improved understanding of these differences may yield important patterns that can be used to redirect resources toward higher-value, cost-conscious care.

Materials and Methods

Data for this retrospective analysis were obtained from the CMS Limited Data Set from April 2019 to March 2020. This de-identified database consists of a collection of billing and diagnostic codes with the goal of quality control, population monitoring and tracking procedures. The use of this database does not require institutional review board approval.

We identified Medicare discharges with the Diagnosis-Related Group (DRG) code 483 which includes both elective joint arthroplasty and arthroplasty for acute fracture.17 The data for this study was retrieved with the technical assistance from the Dexur Research and Analytics (Miami, Florida, USA), a research organization specializing in the analysis of large datasets. The technical design involved loading the pre-selected DRG code and identifying outcomes in the claims data. Our outcomes of interest included surgeon-specific LOS (in days) and home discharge rates. This query included physicians performing at least 18 procedures annually.

Standard descriptive statistics such as the mean, standard deviation (SD), and range were used to evaluate national, regional, and state-level variation in LOS and home discharge disposition rates. Geographical regions are classified as Northeast, Midwest, South, and West as previously described.18

The degree of variation was assessed using the coefficient of variation (CV; ratio of the SD to the mean), with a value greater than 0.15 being considered as “substantial” variation.19 Geographic maps were created for visual representation of the data.

Results

State Variation

With regards to LOS, there was a 1.84-fold variation among U.S states: the shortest LOS was observed in Delaware (1.01 ± 0.49 days) and West Virginia (1.06 ± 0.13), and the longest in Florida (1.68 ± 0.54 days) and Kansas (1.86 ± 0.49; Table 1; Figure 1). The largest CVs were observed in Delaware (0.49), Oregon (0.46), and Georgia (0.40) (Table 1).

Table 1. National and State-Level Variation in Length of Stay and Home Discharge Disposition after Shoulder Arthroplasty.

U.S. State Surgeons Length of Stay (days) Home Discharge Rate (%)
Mean SD Coefficient of Range P Mean SD Coefficient of Range P
Variation Min Max Variation Min Max
AK 3 1.47 0.53 0.36 0.95 2.00 <0.001 92 5 0.05 89 98 <0.001
AL 12 1.45 0.45 0.31 0.76 2.20 78 13 0.17 50 95
AR 14 1.33 0.32 0.24 1.06 2.00 80 12 0.14 54 94
AZ 26 1.21 0.24 0.20 0.96 1.92 90 10 0.11 60 100
CA 48 1.53 0.53 0.34 0.64 3.53 83 14 0.17 42 100
CO 25 1.42 0.28 0.20 1.00 2.16 76 18 0.24 35 97
CT 10 1.52 0.38 0.25 1.04 2.38 64 11 0.18 46 75
DC 3 1.56 0.29 0.19 1.30 1.87 77 16 0.21 67 96
DE 5 1.01 0.49 0.49 0.16 1.43 90 9 0.10 74 96
FL 64 1.68 0.54 0.32 0.33 3.12 75 19 0.25 33 100
GA 22 1.36 0.55 0.40 0.53 3.33 87 8 0.09 70 100
HI 1 1.39 1.39 1.39 79 79 79
IA 18 1.48 0.43 0.29 1.05 2.66 84 9 0.11 61 100
ID 12 1.29 0.25 0.19 1.00 1.81 85 12 0.14 58 100
IL 37 1.48 0.34 0.23 0.96 2.39 77 13 0.18 47 98
IN 22 1.36 0.52 0.38 0.50 2.77 83 13 0.16 38 97
KS 18 1.86 0.49 0.26 1.19 2.77 83 11 0.13 59 100
KY 17 1.44 0.22 0.15 1.14 1.79 81 11 0.14 57 95
LA 14 1.38 0.37 0.27 1.00 2.11 69 28 0.41 20 100
MA 19 1.63 0.61 0.38 0.07 2.83 69 16 0.23 50 100
MD 20 1.32 0.37 0.28 0.96 2.56 85 8 0.10 67 95
ME 4 1.14 0.20 0.17 0.86 1.33 73 7 0.10 67 81
MI 37 1.43 0.30 0.21 0.81 2.05 83 9 0.11 65 100
MN 27 1.55 0.33 0.21 1.08 2.52 84 9 0.10 68 100
MO 29 1.49 0.38 0.26 0.52 2.40 83 10 0.12 57 96
MS 10 1.49 0.44 0.30 1.00 2.39 74 19 0.25 38 100
MT 9 1.27 0.24 0.19 1.00 1.66 92 6 0.06 82 100
NC 44 1.55 0.42 0.27 0.52 2.62 80 13 0.16 41 100
ND 6 1.24 0.17 0.14 1.00 1.40 89 9 0.10 78 100
NE 15 1.45 0.48 0.33 1.00 2.55 83 10 0.13 65 100
NH 6 1.47 0.47 0.32 0.86 2.00 70 24 0.34 39 95
NJ 9 1.58 0.48 0.30 0.84 2.32 80 13 0.17 63 100
NM 5 1.22 0.16 0.13 1.05 1.42 88 14 0.16 64 100
NV 11 1.27 0.37 0.29 0.57 1.76 86 24 0.28 28 100
NY 36 1.54 0.39 0.25 0.57 2.30 75 15 0.20 33 100
OH 41 1.36 0.36 0.27 0.45 2.37 81 9 0.11 47 95
OK 16 1.59 0.46 0.29 1.00 2.57 72 24 0.33 28 100
OR 15 1.27 0.58 0.46 0.50 2.74 89 7 0.08 77 100
PA 42 1.43 0.36 0.25 0.85 2.36 74 15 0.21 38 100
RI 3 1.56 0.50 0.32 1.21 2.13 75 25 0.33 46 90
SC 29 1.48 0.52 0.35 0.31 2.80 83 10 0.12 60 100
SD 10 1.34 0.31 0.23 1.00 1.85 86 6 0.07 78 96
TN 26 1.34 0.33 0.25 0.86 2.47 86 11 0.13 52 99
TX 46 1.48 0.44 0.30 0.19 2.35 78 18 0.23 20 100
UT 13 1.41 0.28 0.20 1.08 2.05 66 24 0.36 25 100
VA 31 1.32 0.23 0.17 0.55 1.75 81 14 0.18 49 100
VT 3 1.41 0.51 0.36 1.06 2.00 80 6 0.08 74 86
WA 36 1.27 0.32 0.25 0.09 1.79 90 11 0.12 52 100
WI 19 1.48 0.45 0.30 0.92 2.52 83 9 0.11 61 96
WV 5 1.06 0.13 0.13 0.85 1.20 96 3 0.03 91 100
WY 3 1.21 0.25 0.21 1.00 1.49 85 5 0.06 80 90
 
National 996 1.45 0.42 0.29 0.07 3.53 81 14 0.18 20 100
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Figure 1. Length of Stay (days) after Shoulder Arthroplasty Across US States.

Figure 1.

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With regards to home discharge rates, there was a 1.5-fold variation among U.S states: the lowest home discharge rates were observed in Connecticut (64% ± 11) and Utah (66% ± 24), and the largest in Arkansas (92% ± 5), Minnesota (92% ± 6), and West Virginia (96% ± 3; Table 1; Figure 2). The largest CVs were observed in Louisiana (0.41), Utah (0.36), and New Hampshire (0.34) (Table 1).

Figure 2. Home Discharge Rate after Shoulder Arthroplasty Across US States.

Figure 2.

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Regional and National Variation

With regards to LOS, the shortest LOS was observed in the West (1.35 ± 0.39 days), and the longest in the Northeast (1.5 ± 0.42 days; Table 2).

Table 2. Regional Variation in Length of Stay and Home Discharge Disposition after Shoulder Arthroplasty.

U.S. Region Length of Stay (days) Home Discharge Rate (%)
Mean SD Coefficient of Range P Mean SD Coefficient of Range P
Variation Min Max Variation Min Max
Northeast 1.50 0.42 0.28 0.07 2.83 0.003 73 15 0.20 33 100 <0.001
Midwest 1.47 0.40 0.27 0.45 2.77 82 10 0.13 38 100
South 1.46 0.45 0.31 0.16 3.33 80 15 0.19 20 100
West 1.35 0.39 0.29 0.09 3.53 85 15 0.18 25 100
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With regards to home discharge rates, the lowest home discharge rate was observed in the Northeast (73% ± 15), and the largest in the West (85% ± 15; Table 2).

At the national level, the mean LOS was 1.45 ± 0.42 days, and the mean home discharge rate was 81% ± 14 (Table 1).

Discussion

We found wide geographic variability in LOS and home discharge disposition rates among Medicare-insured patients undergoing shoulder arthroplasty. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates, whereas the West has the shortest hospital stays with the greatest home discharge rates. As healthcare spending continues to increase in the United States,20 the optimization of resource utilization associated with shoulder arthroplasty gains importance. Improved understanding of these differences may lead to the implementation of targeted strategies to lower costs and effectively reduce geographic variation.

Substantial state-level (range, 64% in Connecticut to 96% in West Virginia) and regional variation (range, 73% in the Northeast to 85% in the West) in home discharge disposition rates after TSA were present. Soley-Bori et al21 found similar results in privately insured patients who underwent TKA and THA, as patients in the Northeast were more than twice as likely to be discharged to an extended care facility (ECF) compared to those in the South. Comparable findings were reported in those after traumatic brain injury and burns.22,23 The direction of geographic variability in health services is influenced by the prevalence of disease, price markup differences, community wealth, poverty, access to ECFs, and differences in uniform discharge patterns.21 Within the hip and knee literature, income and residential area significantly influenced discharge disposition.21 Patients in urban areas were 74% more likely to use an ECF, which may reflect limited access to ECF facilities or greater financial burden for those in rural areas. Furthermore, onsite inpatient rehabilitation facilities are more often implemented at high-volume hospitals,21 which may contribute to differences observed in LOS.

Over the past 20 years, LOS following shoulder arthroplasty has declined significantly from 5.8 days in 1993 to 2.4 days in 2007.24,25 In our study, the average LOS following TSA in Medicare patients was 1.45 days nationally. This suggests that LOS following TSA is continuing to decline. Despite this decline, wide regional variation was present and found to be greatest in the Northeast (1.5 days) and lowest in the West (1.35 days). Casp et al5 evaluated regional variation of hospital charges and reimbursements compared with surgeon charges and reimbursements for shoulder arthroplasty in a Medicare population. Interestingly, the ratio of hospital charges to surgeon charges was greatest in the West and lowest in the Northeast. These findings are unexpected as one would expect greater hospital charges in regions with increased LOS. Furthermore, it was found that the ratio of hospital relative to surgeon charges and payments continually increased at the national level throughout the study period, despite stable patient complexity (as evidenced by the Charleston Comorbidity Index). These findings indicate that regional variation exists despite similar overall health status. Perhaps surgeon and hospital-related factors may account for the findings of our study and represent modifiable areas of improvement efforts.

Surgeon and hospital volume has been shown to effect LOS after TSA.26,27 Hammond et al26 showed that surgeons who performed greater than 20 TSA cases per year were three times more likely than low-volume surgeons to have patients with a hospital stay of less than six days. Jain et al27 showed that patients undergoing shoulder arthroplasty by surgeons performing between 2 and 5 cases per year had an average LOS that was 0.3 days longer when compared with surgeons who performed 5 or more cases per year. These findings indicate that LOS may incrementally decrease with greater surgeon experience. The data presented by our study represents cases performed by surgeons who perform more than 18 TSAs annually. Therefore, our data may underestimate LOS after TSA amongst the general population. In addition, a recent study found that more than 75% and 95% of the entire population lives within 50 km and 200 km of a shoulder surgeon with high volume TSA caseloads.28 Despite improving patient access to high volume TSA surgeons,28 regional variation in LOS and discharge disposition still exists. Thus, it may be prudent to examine other surgical factors that may contribute to our findings.

In addition to surgeon volume, anesthesia type and the choice of postoperative pain control after TSA have been shown to affect LOS.29–33 Specifically, general anesthesia was associated with shorter LOS when compared to regional anesthesia (2.0 and 2.3 days; p < 0.001).33 With respect to postoperative pain control, peripheral nerve blocks30 and local injection of liposomal bupivacaine combined with intravenous dexamethasone29 significantly reduced LOS, while continuous interscalene brachial plexus blockades yield mixed results.31,32 While surgeon treatment preferences are highly indivualized and difficult to study on a macro scale, they may represent important areas of further study.

Patient-characteristics are well-studied predictors of healthcare resource utilization after TSA4,12–16 and may be more generalizable to region-specific study. In a recent systematic review of 22 studies, it was determined that age greater than 65 years, female sex, diabetes, and obesity were patient-related factors that contributed to increased LOS and discharge to an ECF after shoulder arthroplasty.34 In a separate retrospective review including 40,869 patients, congestive heart failure, renal failure, chronic pulmonary disease, and preoperative anemia served as additional comorbid factors.15 Racial and demographic discrepancies (including age, sex, income, and comorbidity index) exist regionally within the United States amongst TSA patients and may serve as important areas of further study to reduce variability in healthcare resource utilization.18

Our study is not without limitations. The use of administrative data like Medicare claims may be limited by inaccurate coding, potential missing data, and discrepancies between administrative data and medical records.35,36 Furthermore, the use of only the Centers for Medicare and Medicaid Services database data limited our findings to an older, Medicare population. While TSA is commonly performed in this age-group, there has been a trend in utilization amongst younger patients.37 In addition, lifestyles and practice styles may vary across states, which may cause patients to seek and receive treatment before the age of 65.38 Perhaps our results may differ if data on a wider range of patient age-groups was included. Our study also lacked a measure of social support, functional status, and data on readmission rates, which may influence patient discharge preferences.21 Moreover, patient and hospital characteristics were not accounted for.

Conclusion

There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. Inquiring into the patient, hospital, and surgeon factors influencing this variability may help define best practices for improved standardization of higher-value, cost-conscious care associated with shoulder arthroplasty.

Author Contributions

  • SYS – lead writer

  • MEM – lead writer

  • AJ – investigation, data curation and formal analysis, editing

  • JL – investigation, data curation and formal analysis, editing

  • PJD – supervision, validation, project administration, editing

Disclosures

  • SYS certifies that he had nothing of value related to this study.

  • MEM is a consultant for and receives royalties from Arthrex, Inc.

  • Andrew Jawa is a paid speaker and consultant for DJO Global, a paid consultant for Ignite orthopedics, receives royalties from Depuy Synthesis, and has equity in Boston Outpatient Surgical Suites.

  • Jonathan Levy is a paid consultant for DJO Orthopaedics and Globus Medical. He receives royalties from DJO Orthopaedics and Innomed.

  • Patrick Denard is a consultant for and receives royalties from Arthrex, Inc.

Conference Presentation

This work has been previously presented as a podium presentation at the American Academy of Orthopedic Surgeons Annual Meeting 2022 in Chicago, Illinois.

Acknowledgments

Acknowledgements

None.

Funding Statement

No funding was obtained for this study.

References

  1. The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty. Jain Nitin B., Yamaguchi Ken. Dec;2014 Journal of Shoulder and Elbow Surgery. 23(12):1905–1912. doi: 10.1016/j.jse.2014.06.055. doi: 10.1016/j.jse.2014.06.055. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. Wagner Eric R., Farley Kevin X., Higgins Ixavier, Wilson Jacob M., Daly Charles A., Gottschalk Michael B. Dec;2020 Journal of Shoulder and Elbow Surgery. 29(12):2601–2609. doi: 10.1016/j.jse.2020.03.049. doi: 10.1016/j.jse.2020.03.049. [DOI] [PubMed] [Google Scholar]
  3. An analysis of costs associated with shoulder arthroplasty. Chalmers Peter N., Kahn Timothy, Broschinsky Kortnie, Ross Hunter, Stertz Irene, Nelson Richard, Yoo Minkyoung, Tashjian Robert Z. Jul;2019 Journal of Shoulder and Elbow Surgery. 28(7):1334–1340. doi: 10.1016/j.jse.2018.11.065. doi: 10.1016/j.jse.2018.11.065. [DOI] [PubMed] [Google Scholar]
  4. Factors affecting hospital charges after total shoulder arthroplasty: an evaluation of the National Inpatient Sample database. Davis Daniel E., Paxton E. Scott, Maltenfort Mitchell, Abboud Joseph. Dec;2014 Journal of Shoulder and Elbow Surgery. 23(12):1860–1866. doi: 10.1016/j.jse.2014.04.002. doi: 10.1016/j.jse.2014.04.002. [DOI] [PubMed] [Google Scholar]
  5. Surgeon charges and reimbursements are declining compared with hospital payments for shoulder arthroplasty. Casp Aaron J., Smith J. Michael, Brockmeier Stephen F., Werner Brian C. May;2020 Journal of Shoulder and Elbow Surgery. 29(5):924–930. doi: 10.1016/j.jse.2019.09.023. doi: 10.1016/j.jse.2019.09.023. [DOI] [PubMed] [Google Scholar]
  6. Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1) Piccinin Meghan A., Sayeed Zain, Kozlowski Ryan, Bobba Vamsy, Knesek David, Frush Todd. Apr;2018 Orthopedic Clinics of North America. 49(2):135–146. doi: 10.1016/j.ocl.2017.11.002. doi: 10.1016/j.ocl.2017.11.002. [DOI] [PubMed] [Google Scholar]
  7. Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center. Chalmers Peter N., Salazar Dane H., Romeo Anthony A., Keener Jay D., Yamaguchi Ken, Chamberlain Aaron M. Dec;2018 Journal of the American Academy of Orthopaedic Surgeons. 26(24):e504–e510. doi: 10.5435/jaaos-d-17-00075. doi: 10.5435/jaaos-d-17-00075. [DOI] [PubMed] [Google Scholar]
  8. Ambulatory Total Shoulder Arthroplasty: A Comprehensive Analysis of Current Trends, Complications, Readmissions, and Costs. Cancienne Jourdan M., Brockmeier Stephen F., Gulotta Lawrence V., Dines David M., Werner Brian C. Apr 19;2017 Journal of Bone and Joint Surgery. 99(8):629–637. doi: 10.2106/jbjs.16.00287. doi: 10.2106/jbjs.16.00287. [DOI] [PubMed] [Google Scholar]
  9. Outpatient Total Shoulder Arthroplasty Does Not Increase the 90-Day Risk of Complications Compared With Inpatient Surgery in Prescreened Patients. Nwankwo Chima D., Dutton Pascual, Merriman Jarrad A., Gajudo Gio, Gill Kanwaljit, Hatch Joshua. Jul;2018 Orthopedics. 41(4):e563–e568. doi: 10.3928/01477447-20180524-04. doi: 10.3928/01477447-20180524-04. [DOI] [PubMed] [Google Scholar]
  10. Increasing incidence of shoulder arthroplasty in the United States. Kim Sunny H, Wise Barton L, Zhang Yuqing, Szabo Robert M. Dec;2011 The Journal of Bone and Joint Surgery-American Volume. 93(24):2249–2254. doi: 10.2106/jbjs.j.01994. doi: 10.2106/jbjs.j.01994. [DOI] [PubMed] [Google Scholar]
  11. Comorbidity effects on shoulder arthroplasty costs analysis of a nationwide private payer insurance data set. Rosas Samuel, Sabeh Karim G., Buller Leonard T., Law Tsun Yee, Kalandiak Steven P., Levy Jonathan C. Jul;2017 Journal of Shoulder and Elbow Surgery. 26(7):e216–e221. doi: 10.1016/j.jse.2016.11.044. doi: 10.1016/j.jse.2016.11.044. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Discharge Destination After Shoulder Arthroplasty: An Analysis of Discharge Outcomes, Placement Risk Factors, and Recent Trends. Lavoie-Gagne Ophelie, Lu Yining, MacLean Ian, Forlenza Enrico, Forsythe Brian. 2021Journal of the American Academy of Orthopaedic Surgeons. 29(19):e969–e978. doi: 10.5435/jaaos-d-20-00294. doi: 10.5435/jaaos-d-20-00294. [DOI] [PubMed] [Google Scholar]
  13. Length of stay after shoulder arthroplasty—the effect of an orthopedic specialty hospital. Padegimas Eric M., Zmistowski Benjamin M., Clyde Corey T., Restrepo Camilo, Abboud Joseph A., Lazarus Mark D., Ramsey Matthew L., Williams Gerald R., Namdari Surena. Sep;2016 Journal of Shoulder and Elbow Surgery. 25(9):1404–1411. doi: 10.1016/j.jse.2016.01.010. doi: 10.1016/j.jse.2016.01.010. [DOI] [PubMed] [Google Scholar]
  14. Factors Affecting Length of Stay, Readmission, and Revision After Shoulder Arthroplasty: A Population-Based Study. Matsen Frederick A., III, Li Ning, Gao Huizhong, Yuan Shaoqing, Russ Stacy M., Sampson Paul D. Aug;2015 The Journal of Bone and Joint Surgery. 97(15):1255–1263. doi: 10.2106/jbjs.n.01107. doi: 10.2106/jbjs.n.01107. [DOI] [PubMed] [Google Scholar]
  15. Predictors of extended length of stay after elective shoulder arthroplasty. Menendez Mariano E., Baker Dustin K., Fryberger Charles T., Ponce Brent A. Oct;2015 Journal of Shoulder and Elbow Surgery. 24(10):1527–1533. doi: 10.1016/j.jse.2015.02.014. doi: 10.1016/j.jse.2015.02.014. [DOI] [PubMed] [Google Scholar]
  16. Length of Stay and Readmission After Total Shoulder Arthroplasty: An Analysis of 1505 Cases. Basques B. A., Gardner E. C., Toy J. O., Golinvaux N. S., Bohl D. D., Grauer J. N. 2015Am J Orthop (Belle Mead NJ) 44(8):E268–71. [PubMed] [Google Scholar]
  17. Modifiable Risk Factors Increase Length of Stay and 90-Day Cost of Care After Shoulder Arthroplasty. Burns Katherine A., Robbins Lynn M., LeMarr Angela R., Fortune Kathleen, Morton Diane J., Wilson Melissa L. 2021Journal of Shoulder and Elbow Surgery. 31(1):2–7. doi: 10.1016/j.jse.2021.08.010. doi: 10.1016/j.jse.2021.08.010. [DOI] [PubMed] [Google Scholar]
  18. Racial and sex disparities in utilization rates for shoulder arthroplasty in the United States disparities in shoulder arthroplasty. Eichinger Josef K., Greenhouse Alyssa R., Rao Meghana V., Gordon Eric R., Brinton Daniel, Li Xinning, Curry Emily J., Friedman Richard J. May;2019 Journal of Orthopaedics. 16(3):195–200. doi: 10.1016/j.jor.2019.02.029. doi: 10.1016/j.jor.2019.02.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Risk-Adjusted Variation of Publicly Reported Emergency Department Timeliness Measures. Sun Benjamin C., Laurie Amber, Prewitt Lela, Fu Rongwei, Chang Anna M., Augustine James, Reese Charles IV, McConnell K. John. Apr;2016 Annals of Emergency Medicine. 67(4):509–516.e7. doi: 10.1016/j.annemergmed.2015.05.029. doi: 10.1016/j.annemergmed.2015.05.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Health Care Spending in the United States and Other High-Income Countries. Papanicolas Irene, Woskie Liana R., Jha Ashish K. Mar 13;2018 JAMA. 319(10):1024–1039. doi: 10.1001/jama.2018.1150. doi: 10.1001/jama.2018.1150. [DOI] [PubMed] [Google Scholar]
  21. Region and Insurance Plan Type Influence Discharge Disposition After Hip and Knee Arthroplasty: Evidence From the Privately Insured US Population. Soley-Bori Marina, Soria-Saucedo Rene, Youn Bora, Haynes Alex B., Macht Ryan, Ryan Colleen M., Schneider Jeffrey C., Kazis Lewis E. Nov;2017 The Journal of Arthroplasty. 32(11):3286–3291.e4. doi: 10.1016/j.arth.2017.06.007. doi: 10.1016/j.arth.2017.06.007. [DOI] [PubMed] [Google Scholar]
  22. Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. Asemota Anthony O., George Benjamin P., Cumpsty-Fowler Carolyn J., Haider Adil H., Schneider Eric B. Dec 15;2013 Journal of Neurotrauma. 30(24):2057–2065. doi: 10.1089/neu.2013.3091. doi: 10.1089/neu.2013.3091. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Variation in Inpatient Rehabilitation Utilization After Hospitalization for Burn Injury in the United States. Greene Nathaniel H., Pham Tam N., Esselman Peter C., Rivara Frederick P. 2015Journal of Burn Care & Research. 36(6):613–618. doi: 10.1097/bcr.0000000000000200. doi: 10.1097/bcr.0000000000000200. [DOI] [PubMed] [Google Scholar]
  24. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. Day Judd S., Lau Edmund, Ong Kevin L., Williams Gerald R., Ramsey Matthew L., Kurtz Steven M. Dec;2010 Journal of Shoulder and Elbow Surgery. 19(8):1115–1120. doi: 10.1016/j.jse.2010.02.009. doi: 10.1016/j.jse.2010.02.009. [DOI] [PubMed] [Google Scholar]
  25. Predictors of length of stay after elective total shoulder arthroplasty in the United States. Dunn John C., Lanzi Joseph, Kusnezov Nicholas, Bader Julia, Waterman Brian R., Belmont Philip J., Jr. May;2015 Journal of Shoulder and Elbow Surgery. 24(5):754–759. doi: 10.1016/j.jse.2014.11.042. doi: 10.1016/j.jse.2014.11.042. [DOI] [PubMed] [Google Scholar]
  26. Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. Hammond JASON W., Queale WILLIAM S., Kim TAE KYUN, McFarland EDWARD G. Dec;2003 The Journal of Bone and Joint Surgery-American Volume. 85(12):2318–2324. doi: 10.2106/00004623-200312000-00008. doi: 10.2106/00004623-200312000-00008. [DOI] [PubMed] [Google Scholar]
  27. The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty. Jain Nitin, Pietrobon Ricardo, Hocker Shawn, Guller Ulrich, Shankar Anoop, Higgins Laurence D. Mar;2004 The Journal of Bone & Joint Surgery. 86(3):496–505. doi: 10.2106/00004623-200403000-00006. doi: 10.2106/00004623-200403000-00006. [DOI] [PubMed] [Google Scholar]
  28. Trends and Variability in the Use of Total Shoulder Arthroplasty for Medicare Patients. Zmistowski Benjamin, Padegimas Eric M., Howley Michael, Abboud Joseph, Williams Gerald, Jr., Namdari Surena. Feb;2018 Journal of the American Academy of Orthopaedic Surgeons. 26(4):133–141. doi: 10.5435/jaaos-d-16-00720. doi: 10.5435/jaaos-d-16-00720. [DOI] [PubMed] [Google Scholar]
  29. Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty. Routman Howard D., Israel Logan R., Moor Molly A., Boltuch Andrew D. Apr;2017 Journal of Shoulder and Elbow Surgery. 26(4):641–647. doi: 10.1016/j.jse.2016.09.033. doi: 10.1016/j.jse.2016.09.033. [DOI] [PubMed] [Google Scholar]
  30. Peripheral nerve blocks in shoulder arthroplasty: how do they influence complications and length of stay? Stundner Ottokar, Rasul Rehana, Chiu Ya-Lin, Sun Xuming, Mazumdar Madhu, Brummett Chad M., Ortmaier Reinhold, Memtsoudis Stavros G. May;2014 Clinical Orthopaedics & Related Research. 472(5):1482–1488. doi: 10.1007/s11999-013-3356-1. doi: 10.1007/s11999-013-3356-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty. Chalmers P.N., Salazar D., Fingerman M.E., Keener J.D., Chamberlain A. Oct;2017 Orthopaedics & Traumatology: Surgery & Research. 103(6):847–852. doi: 10.1016/j.otsr.2017.06.007. doi: 10.1016/j.otsr.2017.06.007. [DOI] [PubMed] [Google Scholar]
  32. Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay. Thompson Matthew, Simonds Robert, Clinger Bryce, Kobulnicky Kristen, Sima Adam P., Lahaye Laura, Boardman N. Douglas III. Apr;2017 Journal of Shoulder and Elbow Surgery. 26(4):656–661. doi: 10.1016/j.jse.2016.09.026. doi: 10.1016/j.jse.2016.09.026. [DOI] [PubMed] [Google Scholar]
  33. Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis. Ding David Y., Mahure Siddharth A., Mollon Brent, Shamah Steven D., Zuckerman Joseph D., Kwon Young W. Dec;2017 Journal of Orthopaedics. 14(4):417–424. doi: 10.1016/j.jor.2017.07.002. doi: 10.1016/j.jor.2017.07.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review. Berman Jacob E., Mata-Fink Ana, Kassam Hafiz F., Blaine Theodore A., Kovacevic David. Aug;2019 Journal of the American Academy of Orthopaedic Surgeons. 27(15):e696–e701. doi: 10.5435/jaaos-d-18-00244. doi: 10.5435/jaaos-d-18-00244. [DOI] [PubMed] [Google Scholar]
  35. Limitations of claims and registry data in surgical oncology research. Nathan Hari, Pawlik Timothy M. 2008Annals of Surgical Oncology. 15(2):415–423. doi: 10.1245/s10434-007-9658-3. doi: 10.1245/s10434-007-9658-3. [DOI] [PubMed] [Google Scholar]
  36. Administrative data for public health surveillance and planning. Virnig Beth A, McBean Marshall. May;2001 Annual Review of Public Health. 22(1):213–230. doi: 10.1146/annurev.publhealth.22.1.213. doi: 10.1146/annurev.publhealth.22.1.213. [DOI] [PubMed] [Google Scholar]
  37. Future patient demand for shoulder arthroplasty by younger patients: national projections. Padegimas Eric M., Maltenfort Mitchell, Lazarus Mark D., Ramsey Matthew L., Williams Gerald R., Namdari Surena. Jun;2015 Clinical Orthopaedics & Related Research. 473(6):1860–1867. doi: 10.1007/s11999-015-4231-z. doi: 10.1007/s11999-015-4231-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. Vitale MICHAEL G., Krant JESSICA J., Gelijns ANNETINE C., Heitjan DANIEL F., Arons RAYMOND R., Bigliani LOUIS U., Flatow EVAN L. Jun;1999 The Journal of Bone & Joint Surgery. 81(6):763–72. doi: 10.2106/00004623-199906000-00003. doi: 10.2106/00004623-199906000-00003. [DOI] [PubMed] [Google Scholar]

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