Frailty is Associated with Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Shoulder Arthroplasty

Introduction: Frailty is an age-related state of multi-system decline that has been associated with negative outcomes after surgery. Numerous methods have been utilized to quantify frailty and predict postoperative outcomes with variable results. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is an independent predictor of postoperative complications and increased healthcare costs following elective primary total shoulder arthroplasty (TSA).

Methods: The Nationwide Readmissions Database was queried to select patients undergoing elective primary TSA from 2016-2020. HFRS was calculated for each patient and patients with scores of five or greater were considered frail. Demographic characteristics, preoperative comorbidities, postoperative complications, and healthcare resource utilization metrics were compared between frail and non-frail patients using bivariate analysis. Binary logistic regression was used to determine if HFRS was independently predictive of adverse postoperative outcomes.

Results: There were 44,118 frail patients and 210,032 control patients undergoing TSA included in this study. After logistic regression analysis, HFRS was shown to be independently predictive of any complication (p<0.001), readmission (p<0.001), and mortality (p<0.001) within 180 days of elective primary TSA. HFRS was predictive of periprosthetic fracture (p<0.001), acute respiratory distress syndrome (p<0.001), acute renal failure (p<0.001), cellulitis (p<0.001), pneumonia (p<0.001), sepsis (p<0.001), transfusion (p<0.001), and urinary tract infection (p<0.001). Frail patients had higher resource utilization than control patients, including a higher mean total cost of hospitalization ($20,991 vs. $18,869; p<0.001) and a longer mean hospital LOS (3.1 vs. 1.4 days; p<0.001). Frail patients were more likely to be discharged to a facility (p<0.001) or with home healthcare (p<0.001).

Conclusion: Frailty is independently associated with increased postoperative complications and healthcare utilization after elective primary TSA, and this study demonstrates the utility of HFRS as an adjunct for preoperative risk stratification and patient optimization prior to elective primary TSA. Frail patients had higher postoperative complications and healthcare costs after primary elective TSA compared to non-frail patients. The HFRS is easily calculated from routinely collected patient data and thus can help orthopedic surgeons and healthcare systems identify high-risk patients without significant burden to current provider workflows.