Modifiable Risk Factors Increase Length of Stay and 90-Day Cost of Care After Shoulder Arthroplasty
These authors sought to determine the impact of pre-defined modifiable risk factors (MRF) on total encounter charges, hospital length of stay (LOS), related emergency department (ED) visits and charges, and related hospital readmissions within 90 days after shoulder arthroplasty.
They queried the electronic medical record (EPIC) for 1317 shoulder arthroplasty cases under DRG 483 within a regional seven-hospital system between October 2015 and December 2019. Data for patients who had one or more modifiable risk factors, defined as anemia (Hg<10g/dL), malnutrition (albumin<3.4g/dL), obesity (BMI body mass index>40kg/m2), uncontrolled diabetes (random glucose >180mg/dL or HgA1C>8.0%), tobacco use (ICD 10 code indicating patient is a smoker) and opioid use (opioid prescription within 90 days of surgery), were evaluated as potential covariates to assess the relationship between MRF and total encounter charges, LOS, ED visits, ED charges, and hospital readmissions.
Multivariable analysis demonstrated that anemia (+$19,847), malnutrition (+$5,850), and obesity (+$2,762) independently contributed to higher charges after shoulder arthroplasty. Mean LOS was higher in patients with anemia (5.0 days vs. 2.2 days, malnutrition (3.7 days vs. 2.2 days) and uncontrolled diabetes (2.8 vs. 2.3).
Univariate risk factors associated with a significant increase in total 90-day encounter charges included anemia (+$19,345), malnutrition (+$6,971), obesity (+$2,615), and uncontrolled diabetes (+$4,377). Univariate risk for readmission within 90 days was higher in patients with malnutrition.
Comment: This is a valuable study in that it highlights the effect of certain risk factors on the cost of arthroplasty, which, of course, is a critical element in determining the value of the procedure: the benefit to the patient divided by the cost of the arthroplasty, including complications (see this link). Since new technical innovations have yet to be shown to substantially increase the benefit of arthroplasty (see this link), the greatest opportunity for improving the value of the procedure may lie in reducing its cost.
Certain risk factors for expensive adverse outcomes, such as age, sex, severity of the pathology and untreatable medical co-morbidities are not modifiable.The question then becomes, "which risk factors are modifiable?".
Of the risk factors identified in this study, some are apparently modifiable as indicated in the references below.
A promising area for future clinical research is the study of the effectiveness of risk factor modification on the cost and outcomes of shoulder arthroplasty. This combined with minimizing the costs of imaging, implants, medications and therapy may go a long way toward improving the value of shoulder arthroplasty.
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