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Unplanned hip arthroplasty imposes clinical and cost burdens on treating institutions
Atul F Kamath1, Daniel C Austin, Peter B Derman
1Department of Orthopedic Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Cupp 1, 39th and Market Streets, Philadelphia, PA, 19104, USA, akamath@post.harvard.edu.
Insights
Unplanned hip arthroplasty incurs 24% higher costs and a 67% longer hospital stay compared to elective procedures. However, mortality rates remain equivalent between unplanned and elective hip surgeries.
Area of Science:
- Orthopedic Surgery
- Health Economics
- Patient Outcomes
Background:
- Emergent surgery is a known risk factor for perioperative complications.
- Unplanned hip arthroplasty may increase patient morbidity, but its impact on mortality is debated.
- The financial implications of unplanned hip arthroplasties remain largely unquantified.
Purpose of the Study:
- To determine the institutional costs of unplanned hip arthroplasties.
- To assess the influence of surgery timing (unplanned vs. elective) on perioperative outcomes.
- To identify diagnoses associated with unplanned hip surgeries and analyze demographic/insurance differences.
Main Methods:
- Prospective study of 419 patients undergoing hip arthroplasty (primary, hemiarthroplasty, revision) in 2011.
- Comparison of 57 unplanned (urgent) cases with 362 elective cases.
- Statistical analysis of demographics, diagnoses, complications, and costs.
Main Results:
- Unplanned hip arthroplasty had 24% higher median costs and a 67% longer hospital stay than elective procedures.
- Mortality rates were similar between unplanned and elective groups (p=1.0).
- Higher rates of femoral fracture, periprosthetic fracture, infection, and dislocation were observed in unplanned cases.
Conclusions:
- Unplanned hip arthroplasty and urgent surgery present significant financial and clinical burdens.
- These increased burdens necessitate consideration in bundled quality and reimbursement strategies for hip arthroplasty procedures.
Background:
Emergent surgery has been shown to be a risk factor for perioperative complications. Studies suggest that patient morbidity is greater with an unplanned hip arthroplasty, although it is controversial whether unplanned procedures also result in higher patient mortality. The financial impact of these procedures is not fully understood, as the costs of unplanned primary hip arthroplasties have not been studied previously.
Questions/Purposes:
We asked: (1) What are the institutional costs associated with unplanned hip arthroplasties (primary THA, hemiarthroplasty, revision arthroplasty, including treatment of periprosthetic fractures, dislocations, and infections)? (2) Does timing of surgery (urgent/unplanned versus elective) influence perioperative outcomes such as mortality, length of stay, or need for advanced care? (3) What diagnoses are associated with unplanned surgery and are treated urgently most often? (4) Do demographics and insurance status differ between admission types (unplanned versus elective hip arthroplasty)?
Methods:
We prospectively followed all 419 patients who were admitted to our Level I trauma center in 2011 for procedures including primary THA, hemiarthroplasty, and revision arthroplasty, including the treatment of periprosthetic fractures, dislocations, and infections. Fifty-seven patients who were treated urgently on an unplanned basis were compared with 362 patients who were treated electively. Demographics, admission diagnoses, complications, and costs were recorded and analyzed statistically.
Results:
Median total costs were 24% greater for patients admitted for unplanned hip arthroplasties (USD 18,206 [USD 15,261-27,491] versus USD 14,644 [USD 13,511-16,309]; p < 0.0001) for patients admitted for elective arthroplasties. Patients with unplanned admissions had a 67% longer median hospital stay (5 days [range, 4-9 days] versus 3 days [range, 3-4 days]; p < 0.0001) for patients with elective admissions. Mortality rates were equivalent between groups (p = 1.0). Femoral fracture (p < 0.0001), periprosthetic fracture (p = 0.01), prosthetic infection (p = 0.005), and prosthetic dislocation (p < 0.0001) were observed at higher rates in the patients with unplanned admissions. These patients were older (p = 0.04), less likely to have commercial insurance (p < 0.0001), more likely to be transferred from another institution (p < 0.0001), and more likely to undergo a revision procedure (p < 0.0001).
Conclusions:
Unplanned arthroplasty and urgent surgery are associated with increased financial and clinical burdens, which must be accounted for when considering bundled quality and reimbursement measures for these procedures.
