Modifiable risk factors increase length of stay and 90-day cost of care after shoulder arthroplasty
These authors queried the electronic medical record (EPIC) for 1317 houlder arthroplasty cases under DRG 483 within a regional 7-hospital system to calculate mean length of stay (LOS), total 90-day charges, related emergency department (ED) visits and charges, and related hospital readmissions after shoulder arthroplasty.
Data for patients who had 1 or more predefined modifiable risk factors (MRFs), defined as
anemia (hemoglobin < 10 g/dL),
malnutrition (albumin < 3.4 g/dL),
obesity (BMI > 40),
uncontrolled diabetes
(random glucose > 180 mg/dL or glycated hemoglobin > 8.0%),
tobacco use (International Classification of Diseases, Tenth Revision, 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 MRFs and total encounter charges, LOS, ED visits, ED charges, and hospital readmissions.
The prevalence of these risk factors is shown below
Multivariable analysis demonstrated that anemia ($19,847), malnutrition ($5850), and obesity ($2762) independently contributed to higher charges after shoulder arthroplasty as shown in the graph below.
Mean LOS was higher in patients with anemia (5.0 days), malnutrition (3.7), and uncontrolled diabetes (2.8).
Comment: The value of shoulder arthroplasty can be defined as the benefit to the patient divided by the cost of care. While this study did not assess the numerator (i.e. the benefit of arthroplasty in terms of patient assessed measures of comfort and function) it did demonstrate the increased costs care related to anemia, malnutrition and obesity.
While these three risk factors are - in theory - modifiable, how to most effectively modify them needs further study. For example, while anemia may be amenable to management preoperatively by iron supplementation, treatment with medication such as epoetin alpha, transfusion, and/or identification and correction of the underlying cause, it is uncertain how effective these approaches are in reducing cost: is a transfusion of two units the day prior to surgery likely to result in earlier discharge - might transfusion increase the risk of infection? Malnutrition exists for a reason (malabsorption, poverty, alcoholism) how effective is nutritional supplementation in increasing the serum albumin to the point of reducing cost? Obesity can be addressed by bariatric surgery which creates a relative starvation: does such a surgery reduce the cost of arthroplasty?
The purpose in asking these questions is a practical one: what should a surgeon tell the patient with painful arthritis who also has anemia, malnutrition, or obesity: "I'm not operating on you until you've corrected your hemoglobin, albumin, or BMI" or "We can do your surgery, but it is likely to cost (someone) more or to be associated with a longer length of stay in the hospital"?
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