Download PDF
J Knee Surg 2019; 32(06): 475-482
DOI: 10.1055/s-0038-1651529
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Impact of Medical Comorbidities on Primary Total Knee Arthroplasty Reimbursements

Karim G. Sabeh
1   Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida
,
Samuel Rosas
2   Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Leonard T. Buller
1   Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida
,
Andrew A. Freiberg
3   Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
,
Cynthia L. Emory
2   Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
,
Martin W. Roche
4   Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida
› Author Affiliations
Further Information

Publication History

20 November 2017

08 April 2018

Publication Date:
23 May 2018 (online)

    Permissions and Reprints

Abstract

Medical comorbidities have been shown to cause an increase in peri-and postoperative complications following total knee arthroplasty (TKA). However, the increase in cost associated with these complications has yet to be determined. Factors that influence cost have been of great interest particularly after the initiation of bundled payment initiatives. In this study, we present and quantify the influence of common medical comorbidities on the cost of care in patients undergoing primary TKA. A retrospective level of evidence III study was performed using the PearlDiver supercomputer to identify patients who underwent primary TKA between 2007 and 2015. Patients were stratified by medical comorbidities and compared using analysis of variance for reimbursements for the day of surgery and over 90 days postoperatively. A cohort of 137,073 US patients was identified as having undergone primary TKA between 2007 and 2015. The mean entire episode-of-care reimbursement was $23,701 (range: $21,294–26,299; standard deviation [SD] $2,611). The highest reimbursements were seen in patients with chronic obstructive pulmonary disease (mean $26,299; SD $3,030), hepatitis C (mean $25,662; SD $2,766), morbid obesity (mean $25,450; SD $2,154), chronic kidney disease (mean $25,131, $3,361), and cirrhosis (mean $24,890; SD $2,547). Medical comorbidities significantly impact reimbursements, and therefore cost, after primary TKA. Comprehensive preoperative optimization for patients with medical comorbidities undergoing TKA is highly recommended and may reduce perioperative complications, improve patient outcome, and ultimately reduce cost.

Keywords

total knee arthroplasty - replacement - medical comorbidities - cost - reimbursement - bundled payment
 

  • References

  • 1 Ponnusamy KE, Jain A, Thakkar SC, Sterling RS, Skolasky RL, Khanuja HS. Inpatient mortality and morbidity for dialysis-dependent patients undergoing primary total hip or knee arthroplasty. J Bone Joint Surg Am 2015; 97 (16) 1326-1332
    CrossrefPubMedSearch in Google Scholar
  • 2 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
    CrossrefPubMedSearch in Google Scholar
  • 3 Losina E, Walensky RP, Kessler CL. , et al; Patient Risk and Hospital Volume. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med 2009; 169 (12) 1113-1121
    CrossrefPubMedSearch in Google Scholar
  • 4 Kurtz SM, Ong KL, Schmier J. , et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am 2007; 89 (Suppl. 03) 144-151
    CrossrefPubMedSearch in Google Scholar
  • 5 Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplasty 2016; 31 (07) 1400-1406
    CrossrefPubMedSearch in Google Scholar
  • 6 Pugely AJ, Martin CT, Gao Y, Belatti DA, Callaghan JJ. Comorbidities in patients undergoing total knee arthroplasty: do they influence hospital costs and length of stay?. Clin Orthop Relat Res 2014; 472 (12) 3943-3950
    CrossrefPubMedSearch in Google Scholar
  • 7 Belatti DA, Pugely AJ, Phisitkul P, Amendola A, Callaghan JJ. Total joint arthroplasty: trends in Medicare reimbursement and implant prices. J Arthroplasty 2014; 29 (08) 1539-1544
    CrossrefPubMedSearch in Google Scholar
  • 8 Rosas S, Sabeh KG, Buller LT, Law TY, Roche MW, Hernandez VH. Medical comorbidities impact the episode-of-care reimbursements of total hip arthroplasty. J Arthroplasty 2017; 32 (07) 2082-2087
    CrossrefPubMedSearch in Google Scholar
  • 9 Alluri RK, Leland H, Heckmann N. Surgical research using national databases. Ann Transl Med 2016; 4 (20) 393
    CrossrefPubMedSearch in Google Scholar
  • 10 Bjorgul K, Novicoff WM, Saleh KJ. Evaluating comorbidities in total hip and knee arthroplasty: available instruments. J Orthop Traumatol 2010; 11 (04) 203-209
    CrossrefPubMedSearch in Google Scholar
  • 11 Hogan CA, Sandoval MF, Uhler LM. Centers for Medicare & Medicaid Services' Comprehensive Care for Joint Replacement: the present and future for orthopedic surgeons. Orthopedics 2017; 40 (02) 77-80
    CrossrefPubMedSearch in Google Scholar
  • 12 Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005; 87 (08) 1746-1751
    PubMedSearch in Google Scholar
  • 13 Cary Jr MP, Baernholdt M, Merwin EI. Changes in payment regulation and acute care use for total hip replacement: trends in length of stay, costs, and discharge, 1997–2012. Rehabil Nurs 2016; 41 (02) 67-77
    CrossrefPubMedSearch in Google Scholar
  • 14 González-Vélez AE, Romero-Martín M, Villanueva-Orbaiz R, Díaz-Agero-Pérez C, Robustillo-Rodela A, Monge-Jodra V. The cost of infection in hip arthroplasty: a matched case-control study [Article in Spanish]. Rev Esp Cir Ortop Traumatol 2016; 60 (04) 227-233
    PubMedSearch in Google Scholar
  • 15 Gutowski CJ, Zmistowski BM, Lonner JH, Purtill JJ, Parvizi J. Direct costs of aspirin versus warfarin for venous thromboembolism prophylaxis after total knee or hip arthroplasty. J Arthroplasty 2015; 30 (9, Suppl): 36-38
    CrossrefPubMedSearch in Google Scholar
  • 16 Kiridly DN, Karkenny AJ, Hutzler LH, Slover JD, Iorio R, Bosco III JA. The effect of severity of disease on cost burden of 30-day readmissions following total joint arthroplasty (TJA). J Arthroplasty 2014; 29 (08) 1545-1547
    CrossrefPubMedSearch in Google Scholar
  • 17 Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br 2010; 92 (09) 1253-1258
    PubMedSearch in Google Scholar
  • 18 Sabeh KG, Rosas S, Buller LT, Roche MW, Hernandez VH. The impact of discharge disposition on episode-of-care reimbursement after primary total hip arthroplasty. J Arthroplasty 2017; 32 (10) 2969-2973
    CrossrefPubMedSearch in Google Scholar
  • 19 Newman JM, Szubski CR, Barsoum WK, Higuera CA, Molloy RM, Murray TG. Day of surgery affects length of stay and charges in primary total hip and knee arthroplasty. J Arthroplasty 2017; 32 (01) 11-15
    CrossrefPubMedSearch in Google Scholar
  • 20 Wasielewski RC, Weed H, Prezioso C, Nicholson C, Puri RD. Patient comorbidity: relationship to outcomes of total knee arthroplasty. Clin Orthop Relat Res 1998; (356) 85-92
    PubMedSearch in Google Scholar
  • 21 Clement ND. Patient factors that influence the outcome of total knee replacement: a critical review of the literature. OA Orthopaedics 2013; 1: 11
    PubMedSearch in Google Scholar
  • 22 Scott CE, Bugler KE, Clement ND, MacDonald D, Howie CR, Biant LC. Patient expectations of arthroplasty of the hip and knee. J Bone Joint Surg Br 2012; 94 (07) 974-981
    PubMedSearch in Google Scholar
  • 23 Newman JM, Schiltz NK, Mudd CD, Szubski CR, Klika AK, Barsoum WK. Impact of cirrhosis on resource use and inpatient complications in patients undergoing total knee and hip arthroplasty. J Arthroplasty 2016; 31 (11) 2395-2401
    CrossrefPubMedSearch in Google Scholar
  • 24 Best MJ, Buller LT, Klika AK, Barsoum WK. Increase in perioperative complications following primary total hip and knee arthroplasty in patients with hepatitis C without cirrhosis. J Arthroplasty 2015; 30 (04) 663-668
    CrossrefPubMedSearch in Google Scholar
  • 25 Pour AE, Matar WY, Jafari SM, Purtill JJ, Austin MS, Parvizi J. Total joint arthroplasty in patients with hepatitis C. J Bone Joint Surg Am 2011; 93 (15) 1448-1454
    CrossrefPubMedSearch in Google Scholar
  • 26 Deleuran T, Vilstrup H, Overgaard S, Jepsen P. Cirrhosis patients have increased risk of complications after hip or knee arthroplasty. Acta Orthop 2015; 86 (01) 108-113
    CrossrefPubMedSearch in Google Scholar
  • 27 Salih S, Sutton P. Obesity, knee osteoarthritis and knee arthroplasty: a review. BMC Sports Sci Med Rehabil 2013; 5 (01) 25
    CrossrefPubMedSearch in Google Scholar
  • 28 Cho HJ, Morey V, Kang JY, Kim KW, Kim TK. Prevalence and risk factors of spine, shoulder, hand, hip, and knee osteoarthritis in community-dwelling Koreans older than age 65 years. Clin Orthop Relat Res 2015; 473 (10) 3307-3314
    CrossrefPubMedSearch in Google Scholar
  • 29 Ackerman IN, Osborne RH. Obesity and increased burden of hip and knee joint disease in Australia: results from a national survey. BMC Musculoskelet Disord 2012; 13: 254
    CrossrefPubMedSearch in Google Scholar
  • 30 Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty 2013; 28 (05) 714-721
    CrossrefPubMedSearch in Google Scholar
  • 31 Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 2009; 24 (6, Suppl): 84-88
    CrossrefPubMedSearch in Google Scholar
  • 32 Jibodh SR, Gurkan I, Wenz JF. In-hospital outcome and resource use in hip arthroplasty: influence of body mass. Orthopedics 2004; 27 (06) 594-601
    CrossrefPubMedSearch in Google Scholar
  • 33 Macario A. What does one minute of operating room time cost?. J Clin Anesth 2010; 22 (04) 233-236
    CrossrefPubMedSearch in Google Scholar
  • 34 Kakar PN, Roy PM, Pant V, Das J. Anesthesia for joint replacement surgery: issues with coexisting diseases. J Anaesthesiol Clin Pharmacol 2011; 27 (03) 315-322
    CrossrefPubMedSearch in Google Scholar
  • 35 Liao KM, Lu HY. Complications after total knee replacement in patients with chronic obstructive pulmonary disease: a nationwide case-control study. Medicine (Baltimore) 2016; 95 (37) e4835
    PubMedSearch in Google Scholar
  • 36 Bozic KJ, Lau E, Ong K. , et al. Risk factors for early revision after primary TKA in Medicare patients. Clin Orthop Relat Res 2014; 472 (01) 232-237
    CrossrefPubMedSearch in Google Scholar
  • 37 Courtney PM, Melnic CM, Gutsche J, Hume EL, Lee GC. Which patients need critical care intervention after total joint arthroplasty? A prospective study of factors associated with the need for intensive care following surgery. Bone Joint J 2015; 97-B (11) 1512-1518
    CrossrefPubMedSearch in Google Scholar
  • 38 Courtney PM, Rozell JC, Melnic CM, Lee GC. Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty. J Arthroplasty 2015; 30 (9, Suppl): 1-4
    CrossrefPubMedSearch in Google Scholar
  • 39 Restrepo MI, Mortensen EM, Pugh JA, Anzueto A. COPD is associated with increased mortality in patients with community-acquired pneumonia. Eur Respir J 2006; 28 (02) 346-351
    CrossrefPubMedSearch in Google Scholar
  • 40 Sullivan R, Jarvis LD, O'Gara T, Langfitt M, Emory C. Bundled payments in total joint arthroplasty and spine surgery. Curr Rev Musculoskelet Med 2017; 10 (02) 218-223
    CrossrefPubMedSearch in Google Scholar