The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

Jonathan L Katzman; Jeremiah Thomas; Itay Ashkenazi; Claudette M Lajam; Joshua C Rozell; Ran Schwarzkopf

doi:10.1016/j.arth.2024.11.059

The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

J Arthroplasty. 2024 Dec 1:S0883-5403(24)01277-4. doi: 10.1016/j.arth.2024.11.059. Online ahead of print.

Authors

Jonathan L Katzman¹, Jeremiah Thomas¹, Itay Ashkenazi², Claudette M Lajam¹, Joshua C Rozell¹, Ran Schwarzkopf¹

Affiliations

¹ Department of Orthopedic Surgery, NYU Langone Health, New York, New York.
² Department of Orthopedic Surgery, NYU Langone Health, New York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

PMID: 39626796
DOI: 10.1016/j.arth.2024.11.059

Abstract

Background: Recent literature suggests a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, the impact of increased comorbidities on the cost-effectiveness of TKA is underexplored. This study aimed to compare the financial implications and perioperative outcomes of patients with and without a high comorbidity burden (HCB).

Methods: We retrospectively reviewed 10,647 patients who underwent elective, unilateral TKA between 2012 and 2021 at a single academic health center with available financial data. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups. A 1:1 propensity match was performed based on baseline characteristics, resulting in 1,536 matched patients (768 per group). Revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. Ninety-day readmissions and revisions were also analyzed.

Results: The HCB patients had significantly higher total (P < 0.001) and direct (P < 0.001) costs, while hospital revenue did not differ between cohorts (P = 0.638). This disparity resulted in a significantly decreased CM for the HCB group (P = 0.009). Additionally, HCB patients had a longer length of stay (P < 0.001) and a higher rate of 90-day readmissions (P = 0.005).

Conclusions: Increased inpatient costs for HCB patients undergoing TKA were not offset by proportional revenue, leading to a decreased CM. Furthermore, higher 90-day readmissions exacerbate the financial burden. These findings highlight potential challenges for hospitals in covering indirect expenses, which could jeopardize accessibility to care for HCB patients. Reimbursement models should be revised to better account for the increased financial burden associated with managing HCB patients.

Level of evidence: III.

Keywords: contribution margin; high comorbidity burden; hospital revenue; reimbursement models; total knee arthroplasty.