Predictors of Higher Costs Following Reverse Total Shoulder Arthroplasty

Document Type : RESEARCH PAPER

Authors

1Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas, USA, 75390

Abstract

Objectives: The rising popularity of reverse total shoulder arthroplasties (RTSA) demands attention to 
its growing costs on the healthcare system, especially with the implementation of bundled payments. 
Charges associated with patients’ inpatient stays can be mitigated with a better understanding of the 
drivers of cost following RTSA. In this study, we evaluate potential pre -operative and post-operative 
factors associated with higher inpatient costs following RTSA.
Methods: We identified 59,925 patients who underwent RTSA using the National Inpatient Sample between 2016 
and 2019. Total inpatient hospital charges were collected, and patients were divided into “normal cost” or “high cost”
groups. The high cost group was defined as patients with total costs greater than the 75th percentile. Univariate and 
multivariate analyses were performed on pre-operative demographic and comorbidity variables as well as postoperative surgical and medical complications to predict factors associated with higher costs. T-tests and Chi-squared 
tests were performed, and odds ratios were calculated.
Results: The mean total charges were $141.213.93 in the high cost group and $59,181.94 in the normal cost group. 
Following multivariate analysis, non-white patients were associated with higher costs by 1.31-fold (P<0.001), but 
sex and age were not. Cirrhosis and non-elective admission had higher odds of higher costs by 1.56-fold (P<0.001) 
and 3.13-fold (P<0.001), respectively. Among surgical complications, there were higher odds of high costs for 
periprosthetic infection by 2.43-fold (P<0.001), periprosthetic mechanical complication by 1.28-fold (P<0.001), and 
periprosthetic fracture by 1.56-fold (P<0.001). Medical complications generally had higher odds of high costs than 
surgical complications, with deep vein thrombosis having nearly five times (P<0.001) and myocardial infarction 
almost four times (P<0.001) higher odds of high inpatient costs.
Conclusion: Post-operative medical complications were the most predictive factors of higher cost following RTSA. 
Pre-operative optimization to prevent infection and medical complications is imperative to mitigate the economic 
burden of RTSA’s.
 Level of evidence: III

Keywords

Main Subjects

References

  1. Best MJ, Aziz KT, Wilckens JH, McFarland EG, Srikumaran U. Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2021; 30(5):1159-1166. doi:10.1016/j.jse.2020.08.010.
  2. Wagner ER, Farley KX, Higgins I, Wilson JM, Daly CA, Gottschalk MB. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg. 2020; 29(12):2601-2609. doi:10.1016/j.jse.2020.03.049.
  3. Davis DE, Paxton ES, Maltenfort M, Abboud J. Factors affecting hospital charges after total shoulder arthroplasty: an evaluation of the National Inpatient Sample database. J Shoulder Elbow Surg. 2014; 23(12):1860-1866. doi:10.1016/j.jse.2014.04.002.
  4. Menendez ME, Lawler SM, Shaker J, Bassoff NW, Warner JJP, Jawa A. Time-Driven Activity-Based Costing to Identify Patients Incurring High Inpatient Cost for Total Shoulder Arthroplasty. J Bone Joint Surg Am. 2018; 100(23):2050-2056. doi:10.2106/JBJS.18.00281.
  5. Chawla SS, Whitson AJ, Schiffman CJ, Matsen III FA, Hsu JE. Drivers of lower inpatient hospital costs and greater improvements in health-related quality of life for patients undergoing total shoulder and ream-and-run arthroplasty. J Shoulder Elbow Surg. 2021; 30(8):e503-e516. doi:10.1016/j.jse.2020.10.030.
  6. Carducci MP, Mahendraraj KA, Menendez ME, et al. Identifying surgeon and institutional drivers of cost in total shoulder arthroplasty: a multicenter study. J Shoulder Elbow Surg. 2021; 30(1):113-119. doi:10.1016/j.jse.2020.04.033.
  7. Steen BM, Cabezas AF, Santoni BG, et al. Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort. J Shoulder Elbow Surg. 2015; 24(9):1433-41. doi:10.1016/j.jse.2015.01.005.
  8. Kennon JC, Songy CE, Marigi E, et al. Cost analysis and complication profile of primary shoulder arthroplasty at a high-volume institution. J Shoulder Elbow Surg. 2020; 29(7):1337-1345. doi:10.1016/j.jse.2019.12.008.
  9. Bhat SB, Liss FE, Beredjiklian PK. Economic Analysis of the Cost of Implants Used for Treatment of Distal Radius Fractures. Arch Bone Jt Surg. 2018; 6(5):371-375.
  10. Chalmers PN, Kahn T, Broschinsky K, et al. An analysis of costs associated with shoulder arthroplasty. J Shoulder Elbow Surg. 2019; 28(7):1334-1340. doi:10.1016/j.jse.2018.11.065.
  11. Ponce BA, Menendez ME, Oladeji LO, Soldado F. Diabetes as a risk factor for poorer early postoperative outcomes after shoulder arthroplasty. J Shoulder Elbow Surg. 2014; 23(5):671-8. doi:10.1016/j.jse.2014.01.046.
  12. Chawla SS, Schiffman CJ, Whitson AJ, Matsen III FA, Hsu JE. Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg. 2022; 31(12):e586-e592. doi:10.1016/j.jse.2022.05.018.

 

  1. Gowd AK, Agarwalla A, Beck EC, et al. Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning. J Shoulder Elbow Surg. 2022; 31(12):2449-2456. doi:10.1016/j.jse.2022.07.013.
  2. Maugendre E, Gadisseux B, Chantelot C, et al. Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures. Orthop Traumatol Surg Res. 2019; 105(8):1509-1513. doi:10.1016/j.otsr.2019.07.026.
  3. Osterhoff G, O'Hara NN, D'Cruz J, et al. A Cost-Effectiveness Analysis of Reverse Total Shoulder Arthroplasty versus Hemiarthroplasty for the Management of Complex Proximal Humeral Fractures in the Elderly. Value Health. 2017; 20(3):404-411. doi:10.1016/j.jval.2016.10.017.
  4. Farley KX, Dawes AM, Wilson JM, et al. Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States: Trends from 2011 to 2017. JB JS Open Access. 2022; 7(2) doi:10.2106/JBJS.OA.21.00144.
  5. Markes AR, Pareek A, Mesfin A, Benjamin Ma C, Ward D. Racial and Gender Shoulder Arthroplasty Utilization Disparities of High- and Low-Volume Centers in New York State. J Shoulder Elb Arthroplast. 2021; 5:24715492211041901. doi:10.1177/24715492211041901.
  6. Ling K, Leatherwood W, Fassler R, Burgan J, Komatsu DE, Wang ED. Disparities in postoperative total shoulder arthroplasty outcomes between Black and White patients. JSES Int. 2023; 7(5):842-847. doi:10.1016/j.jseint.2023.05.009.
  7. Singh JA, Ramachandran R. Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes. J Racial Ethn Health Disparities. 2016; 3(2):259-66. doi:10.1007/s40615-015-0138-3.
  8. Best MJ, Aziz KT, McFarland EG, Martin SD, Rue JH, Srikumaran U. Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2021; 30(8):1844-1850. doi:10.1016/j.jse.2020.10.023.
  9. Cheppalli NS, Metikala S, Beale J, Mounsamy V, Sambandam S. Total Hip Arthroplasty in Cirrhosis is Associated with Increased Complications during the Hospital Stay, Length of Stay, and Cost of Care: A Propensity Matched Database Study. Arch Bone Jt Surg. 2023; 11(5):330-336. doi:10.22038/ABJS.2023.68339.3234.
  10. Metikala S, Venishetty N, Cheppalli N, Jones H, Mounsamy V, Sambandam S. Patients With Cirrhosis Have Higher Costs of Care, Longer Length of Stays, and More Perioperative Complications Following Total Knee Arthroplasty: A National Inpatient Sample-Based Study. Cureus. 2023; 15(10):e47317. doi:10.7759/cureus.47317.
  11. Parikh ND, Chang YH, Tapper EB, Mathur AK. Outcomes of Patients with Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample. J Clin Gastroenterol. 2019; 53(9):e356-e361. doi:10.1097/MCG.0000000000001091.
  12. Rosas S, Sabeh KG, Buller LT, Law TY, Kalandiak SP, Levy JC. Comorbidity effects on shoulder arthroplasty costs analysis of a nationwide private payer insurance data set. J Shoulder Elbow Surg. 2017; 26(7):e216-e221. doi:10.1016/j.jse.2016.11.044.
  13. Scaglione S, Kliethermes S, Cao G, et al. The Epidemiology of Cirrhosis in the United States: A Population-based Study. J Clin Gastroenterol. 2015; 49(8):690-6. doi:10.1097/MCG.0000000000000208.
  14. Cancienne JM, Dempsey IJ, Holzgrefe RE, Brockmeier SF, Werner BC. Is Hepatitis C Infection Associated With a Higher Risk of Complications After Total Shoulder Arthroplasty? Clin Orthop Relat Res. 2016; 474(12):2664-2669. doi:10.1007/s11999-016-4979-9.
  15. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest. 1999; 116(2):355-62. doi:10.1378/chest.116.2.355.
  16. Grocott MP, Mythen MG. Perioperative Medicine: The Value Proposition for Anesthesia? A UK Perspective on Delivering Value from Anesthesiology. Anesthesiol Clin. 2015; 33(4):617-28. doi:10.1016/j.anclin.2015.07.003.
  17. Levy N, Grocott MPW, Carli F. Patient optimisation before surgery: a clear and present challenge in peri-operative care. Anaesthesia. 2019; 74 Suppl 1:3-6. doi:10.1111/anae.14502.
  18. Althoff AD, Reeves RA, Traven SA, Wilson JM, Woolf SK, Slone HS. Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients. J Shoulder Elbow Surg. 2020; 29(3):491-496. doi:10.1016/j.jse.2019.07.012.
  19. Walters JD, George LW, 2nd, Walsh RN, et al. The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2020; 29(2):244-251. doi:10.1016/j.jse.2019.05.045.
  20. Morris BJ, O'Connor DP, Torres D, Elkousy HA, Gartsman GM, Edwards TB. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015; 24(2):161-6. doi:10.1016/j.jse.2014.05.020.
  21. Wells DB, Holt AM, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2018; 27(1):23-28. doi:10.1016/j.jse.2017.06.033.
  22. O'Connor O, Thahir A, Krkovic M. How Much Does an Infected Fracture Cost? Arch Bone Jt Surg. 2022; 10(2):135-140. doi:10.22038/abjs.2021.53590.2665.
  23. Schick S, Elphingstone J, Murali S, et al. The incidence of shoulder arthroplasty infection presents a substantial economic burden in the United States: a predictive model. JSES Int. 2023; 7(4):636-641. doi:10.1016/j.jseint.2023.03.013.
  24. Stokes SM, Scaife CL, Brooke BS, et al. Hospital Costs Following Surgical Complications: A Value-driven Outcomes Analysis of Cost Savings Due to Complication Prevention. Ann Surg. 2022; 275(2):e375-e381. doi:10.1097/SLA.0000000000004243.
  25. Healy MA, Mullard AJ, Campbell DA, Jr., Dimick JB. Hospital and Payer Costs Associated With Surgical Complications. JAMA Surg. 2016; 151(9):823-30. doi:10.1001/jamasurg.2016.0773.
  26. Cheng E, Lewin A, Churches T, Harris IA, Naylor J. Cost of investigations during the acute hospital stay following total hip or knee arthroplasty, by complication status. BMC Health Serv Res. 2020; 20(1):1036. doi:10.1186/s12913-020-05892-1.
  27. Musich S, Wang S, Hawkins K, Klemes A. The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures. Popul Health Manag. 2016; 19(6):389-397. doi:10.1089/pop.2015.0171.
  28. Shen C, Moss JL. Large variations in hospital pricing for standard procedures revealed. BMC Res Notes. 2022; 15(1):129. doi:10.1186/s13104-022-06014-2.
The Archives of Bone and Joint Surgery
Volume 12, Issue 7
July 2024
Pages 469-476

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History

  • Receive Date: 27 December 2023
  • Revise Date: 02 May 2024
  • Accept Date: 02 May 2024

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