Medicaid Payer Status is Associated with Increased 90-Day Morbidity and Resource Utilization Following Primary Shoulder Arthroplasty: a Propensity-Score-Matched Analysis
Kevin Xavier Farley, BS1, David Shau, MD2, Michael Brandon Gottschalk, MD1, Charles A Daly, MD1 and Eric R Wagner, MD, MS2, (1)Emory University, Atlanta, GA, (2)Emory University, Department of Orthopaedics, Atlanta, GA
INTRODUCTION: Medicaid payer status has been shown to affect risk-adjusted patient outcomes and healthcare utilization across multiple medical specialties and orthopaedic procedures. However, the impact of Medicaid payer status on 90-day morbidity and resource utilization following primary shoulder arthroplasty (reverse, total, and hemi) has not yet been assessed. The purpose of this study was to examine 90-day readmission and reoperation rates, hospital length of stay (LOS), and direct cost following primary shoulder arthroplasty.
METHODS: The National Readmission Database (NRD) was queried for all patients undergoing primary reverse, total, and hemi- shoulder arthroplasty (aTSA, rTSA, HA) from 2011 to 2016. The corresponding “Medicaid” or “non-Medicaid” payer status were determined. One-to-one matching between the payer groups and type of arthroplasty (reverse, total, or hemi) was performed, and the relative risk (RR) and 95% confidence interval (CI) for 90-day readmission and reoperation rates were calculated along with a comparison of LOS and cost between the propensity score matched cohorts.
RESULTS: A total of 4,667 Medicaid and 161,147 non-Medicaid patients were identified from the 2011-2016 NRDs. Propensity score analysis was performed, and 4,637 Medicaid patients were matched to 4,637 non-Medicaid patients, each with 1504 (32.4%) rTSAs, 1934 (41.7%) aTSAs, and 1199 (25.9%) HAs. Patients with Medicaid payer status yielded significant increase in 90-day all-cause readmission rates of 11.6% vs 9.3% (p < 0.001; RR = 1.14 [95% CI, 1.06 to 1.22]), 90-day shoulder-related readmission rates of 3.3% versus 2.3% (p = 0.004; RR = 1.22 [95% CI, 1.05 to 1.41]), and 90-day reoperation rates of 2.0% vs. 1.3% (p = 0.008, RR=1.27 [95% CI, 1.05 to 1.54]). Furthermore, there was an increased risk of extended LOS ≥ 3 days (14.8% versus 12.0%; p < 0.001; RR = 1.14 [95% CI, 1.07 to 1.21]) along with increased direct cost ($20,300 versus $19,188; p < 0.001).
DISCUSSION AND CONCLUSION: This study demonstrates that Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, LOS, and direct cost following primary shoulder arthroplasty. With the evolving healthcare climate, providers may have a disincentive to treat certain patient populations who require increased resource utilization following surgery, such as Medicaid insurance status. Therefore, risk adjustment models accounting for risk factors, such as Medicaid payer status, are necessary to avoid decreased access to care for this patient population and to avoid the negative financial impacts of taking care of these patients for physicians and hospitals.
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