Alcohol use disorder (AUD) refers to a pattern of alcohol use leading to clinically significant impairment or distress, for example continued consumption despite knowledge of physical or psychological problems due to alcohol, consumption of alcohol in excess of initial intention, persistent desire or failure to reduce consumption, cravings, failure to fulfill major roles due to alcohol use, continued use despite recurrent social problems, development of tolerance, or withdrawal with a time interval of 12 months. Approximately 14.4 million individuals over the age of 18 met these criteria for diagnosis with AUD in 2018. The national rate of AUD is rising.
These authors sought to determine whether patients who have alcohol use disorder (AUD) have higher in hospital lengths of stay (LOS), medical complications, and healthcare expenditures after total shoulder arthroplasty (TSA).
They queried the Medicare Claims Database identifying 5,479 patients who underwent primary TSA for glenohumeral OA and had AUD. These patients were 1:5 ratio to a comparison cohort of 27,367 patients matched by age, sex, and various comorbid conditions.
Patients with AUD had significantly longer in-hospital length of stay (4- vs. 2-days), addition to higher rates of 90-day complications (30.44% vs. 7.94%) such as surgical site infections (1.15 vs. 0.24%), cerebrovascular accidents (5.06 vs. 1.23%), respiratory failures (5.79 vs. 1.52%), myocardial infarctions (1.53 vs. 0.43%), acute kidney injuries (6.55 vs. 1.34%), and other complications.
Patients with AUD incurred significantly higher day of surgery ($12,160.60 vs. $11,308.48) and 90-day episode of care costs ($14,493.13 vs. $13,087).
Comment: Total shoulder arthroplasty in patients with alcohol use disorder is more risky and more costly.
A number of mechanisms may contribute to the adverse effects of AUD:
(1) AUD may simply increase the amount of patient care which is required for these patients, prolonging their in-hospital course prior to discharge.
(2) Patients who have AUD may have other psychiatric comorbidities, and the synergestic effects of AUD coupled with these mental health conditions could increase in-hospital LOS.
(3) Alcohol may impair dermal fibroblast function by decreasing the threshold for dermal wound-breaking strength for immature wounds increasing the risk of infection and failure of wound healing.
(4) Chronic alcohol use is thought to disrupt the function of alveolar macrophages with a decrease in phagocytic activity when they are exposed to bacteria.
(5) Alcohol-related inhibition of fibrinolysis and induction of an inflammatory state may predispose to cerebrovascular accidents.
(6) AUD may be associated with poor nutrition, less preventative health care, inferior social support, and lower self-esteem.
(7) AUD is likely to increase the risk of falling after a TSA, injuring the shoulder.
This brings up some important, yet currently unanswered questions:
(1) How treatable is alcohol use disorder?
(2) Can the negative effects of AUD be prevented by prospective management?
(3) How should the presence of AUD change the tipping point (see this link) for elective shoulder arthroplasty?
(4) Are alcohol use biomarkers (see this link) useful in managing the patient with AUD.
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