Thursday, May 31, 2018

The increased cost of shoulder arthroplasties in patients with health problems

Predicting adverse events, length of stay, and discharge disposition following shoulder arthroplasty: a comparison of the Elixhauser Comorbidity Measure and Charlson Comorbidity Index

These authors predicted adverse events and postoperative discharge destination after shoulder arthroplasty using data from the National Inpatient Sample for 90,490 patients who underwent total shoulder arthroplasty or reverse total shoulder arthroplasty between 2002 and 2014. 

Greater numbers of comorbidities were associated with increased rates of adverse events

The most common comorbidities were hypertension, diabetes without complications, chronic lung disease, and rheumatic disease. The mortality incidence was 0.1%. 15.7% of patients had an extended length of stay and 16.9% of patients were discharged to a skilled nursing facility or rehabilitation center. Overall, 3.4% of patients had a postoperative complication. The most common complication was renal (1.4%).

There was a correlation between age and increased number of comorbidities; 39.1% of patients aged ≥ 90 years had 3 or more comorbidities compared with 9.5% of patients in the group aged 18-29 years.
A higher proportion of female patients, African Americans, and patients with Medicaid had 3 or more comorbidities. Higher numbers comorbidities were associated with increased mortality with the incidence increasing from 0% in patients with no comorbidity to 0.2% in patients with 3 or more comorbidities.

The rate of any complication was 7.1% in patients with 3 or more comorbidities compared with 1.1% in patients with no comorbidity. The frequency of complications rose similarly with the number of comorbidities for all types of complications.

Comment: This study reinforces the observation that it is more costly to care for patients who are less healthy. In an era where hospitals are struggling to manage costs and to avoid penalties for readmissions, it may be tempting to limit access to shoulder arthroplasty for patients with comorbidities. As caring physicians we need to consider how to best manage patients with increased risk factors and to partner with our medical centers in managing the fiscal impact of caring for higher risk patients - an impact that is magnified if the patient's insurance reimburses at a lower level for services rendered.

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