Preoperative Hemoglobin A1c >7.5 Is Associated With Increased Bundled Payment Costs in Total Hip and Knee Arthroplasties

Abstract

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.

Correlation between the Control of Blood Glucose Level and HbA1C and the Incidence of Surgical Site Infection after Emergent Surgery for the Lower Limb Fracture among Type II DM Patients Aged More Than 50 Years Old

“…A preoperative HbA1c of less than 7.850%, with postoperative HbA1c less than 6.650%, preoperative blood glucose less than 130.50 mg/dL, and postoperative blood glucose of less than 148.5 mg/dL indicated the importance of DM control quality postoperatively in the prevention of SSI for these patients with trauma. Our data on the perioperative glycemic control were similar to the suggested glycemic control data of studies focusing on elective lower limb surgery for total joint replacement [ 26 , 27 ]. Wexler et al conducted a study in 2008 of 695 patients admitted to an acute care hospital that revealed a prevalence of unrecognized probable diabetes of 18% based on HbA1c levels higher than 6.1%, with 5% of them having HbA1c over 6.5% [ 28 ].…”

Enhanced Recovery After Surgery: An Orthopedic Perspective

“…Preoperative optimization through a dedicated multidisciplinary clinic is a particularly effective means to reduce perioperative complications and improve patient outcomes. The evidence supporting smoking cessation [18], the diagnosis and management of diabetes [19,20], and the correction of anemia [21e23] is robust. Optimization of additional modifiable risk factors may provide further benefit; however, evidence in this area is still growing [24e26].…”

Movement Is Life—Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus

“…[15][16][17][18][19][20] These concerns are based on the association of diabetes mellitus with elevated postoperative glucose (defined as .194 21 or 200 22 mg/dL) and superficial and deep tissue infections. 19,23 In the current arthroplasty optimization paradigm, most of the orthopaedic surgeons set expectations for meeting HgA1C cutoffs 16,[24][25][26][27][28][29] (ranging from less than 7 to less than 8, which we found varied across institutions we interviewed). Of note, the literature is inconsistent in demonstrating a correlation between HgA1C levels and postoperative complications.…”

“…The Proceedings of the Second International Consensus Meeting on Musculoskeletal Infection identified a glucose .200 mg/L or a HgA1C .7% as risk factors for periprosthetic joint infection, 27,30 and this result is supported by multiple peer-reviewed studies. 16,[24][25][26]28,29 However, several studies have demonstrated that HgA1C cutoffs alone do not account for increased risk of infection. 21,[31][32][33] There are other metabolic factors such as the requirement for insulin versus oral treatment and postoperative hyperglycemia, which play a role.…”