Preoperative Hemoglobin A1c >7.5 Is Associated With Increased Bundled Payment Costs in Total Hip and Knee
Michelle Kavin1, Michael Yayac, Matthew J Grosso
1From the Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA.
Insights
Poor glycemic control in diabetic patients undergoing hip or knee replacement surgery increases costs and complications. Maintaining hemoglobin A1c below 7.5% is crucial for better outcomes and cost savings in these procedures.
Area of Science:
- Orthopedic Surgery
- Endocrinology
- Health Economics
Background:
- Patients with diabetes mellitus face higher risks and costs after total hip (THA) and total knee arthroplasties (TKA).
- The specific impact of poor glycemic control on episode-of-care costs in these patients remains under-explored.
- Understanding this relationship is key for optimizing patient care and managing healthcare expenditures.
Purpose of the Study:
- To investigate the association between preoperative hemoglobin A1c levels and episode-of-care costs in diabetic patients undergoing THA and TKA.
- To determine if elevated hemoglobin A1c correlates with increased complications and readmissions post-arthroplasty.
Main Methods:
- Retrospective review of 9,511 primary THA and TKA patients (2015-2018).
- Analysis of demographics, comorbidities, and hemoglobin A1c levels for diabetic patients.
- Comparison of complications, readmissions, and 90-day Medicare episode-of-care costs across A1c strata using multivariate logistic regression.
Main Results:
- Diabetic patients incurred higher episode-of-care costs ($20,577 vs $19,414) compared to non-diabetic patients.
- Increasing hemoglobin A1c levels correlated with higher mean episode-of-care costs, with costs exceeding $21,000 for A1c >8%.
- Hemoglobin A1c >7.5% was independently associated with significantly higher episode-of-care costs (+$2,331), increased complications (7% vs 3%), and higher readmission rates (11% vs 5%).
Conclusions:
- Preoperative hemoglobin A1c levels above 7.5% are linked to increased costs, complications, and readmissions following THA and TKA.
- Optimizing glycemic control before arthroplasty surgery is essential for improving patient outcomes.
- Better glycemic management can enhance the success of value-based care models like Medicare bundled payments.
Introduction:
Studies have shown that patients with diabetes mellitus are at an increased risk for complications and higher episode-of-care costs after total hip (THA) and total knee arthroplasties (TKA), but the effect of poor glycemic control on episode-of-care costs has yet to be addressed in the literature. The purpose of this study was to determine whether patients with a higher preoperative hemoglobin A1c have increased episode-of-care costs in diabetic patients undergoing THA and TKA.
Methods:
We reviewed a consecutive series of 9,511 primary THA and TKA patients between 2015 and 2018. We recorded demographics, medical comorbidities, and hemoglobin A1c for patients with diabetes mellitus. We compared complications, readmissions, and 90-day episode-of-care costs from Medicare claims data across A1c levels. A multivariate logistic regression analysis was done to assess the independent effect of A1c on episode-of-care costs.
Results:
Diabetic patients (n = 1,042) had higher episode-of-care costs ($20,577 vs $19,414, P < 0.001) than patients without diabetes. Higher stratified A1c levels were associated with increasing mean episode-of-care costs (6.5% to 6.9% = $18,912; 7.0% to 7.49% = $19,832; 7.5% to 7.9% = $20,827; >8% = $21,169). In multivariate analysis, patients with hemoglobin A1c >7.5% had higher episode-of-care costs ($2,331, 95% confidence interval, $511-$4,151, P = 0.012). Those with a hemoglobin A1c >7.5% had increased rates of complications (7% vs 3%, P = 0.049) and readmissions (11% vs 5%, P = 0.020).
Discussion:
Hemoglobin A1c levels above 7.5% are associated with increased episode-of-care costs, complications, and readmissions after THA and TKA. Optimizing glycemic control before surgery may improve quality of care and lead to success in Medicare bundled payment models.
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