Anatomic and reverse total shoulder arthroplasty: variables affecting 90-day overall reimbursement

Background

Total shoulder arthroplasty (TSA) is a common orthopedic procedure that can be performed as an anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA). These are effective procedures that are being performed with increasing frequency. Understanding the overall 90-day reimbursement variability and their drivers may help the health care systems better understand related considerations to reduce health-care expenditure. The current study predicts there will be large variability in reimbursement highlighting the need for further understanding.

Methods

Using the 2015-2021 Q1 M151 PearlDiver dataset, patients who underwent aTSA or rTSA were isolated. Patients were excluded if they were aged less than 18 years, had an indication of traumatic, infectious, or oncologic diagnoses within 90-days of surgery, or were not in the dataset for at least 90 days before and after surgery. Patient demographics, comorbidities, 90-day postoperative events, insurance type, and geographic region were abstracted. The overall 90-day reimbursements were then assessed and correlated with these variables having multivariable linear regression.

Results

A total of 112,188 TSA patients (aTSA: 36,164 [32.2%]; rTSA: 76,024 [67.8%]) were identified. The average ± standard deviation 90-day overall postoperative reimbursement for aTSA was $6714.26 ± 9587.46 and rTSA was $6246.45 ± 9506.59. The total reimbursement for aTSA was $242,814,515 and for rTSA was $474,836,301. Variables independently associated with greater 90-day overall reimbursement were mostly related to 90-day postoperative events, including hospital readmission [+$6694.51], emergency department visit [+$2129.89], and adverse events [+$2055.84]), geographic region of the country where the procedure was performed (relative to West, South [+$4302.88], Midwest [+$3428.84], and Northeast [+$530.92]), and insurance plan (relative to commercial, Medicare [-$1268.01], and Medicaid [-$901.79]) (P < .0001 for each). Lesser factors included male sex (relative to female +$207.30), Elixhauser-Comorbidity Index (+$51.93 per point increase), age (-$77.16 per year increase), and rTSA surgery type (relative to aTSA -$556.17).

Discussion and conclusion

The current study leveraged a large, administrative database to evaluate over 100,000 TSA patients and found large variations in 90-day overall reimbursements. The variables mostly associated with increased reimbursement were related to 90-day postoperative events (as might be expected and underscoring the need to minimize such events) and geographic regions and insurance plan (highlighting differences that might be able to be addressed). Interestingly, while patient demographics, comorbidities, and anatomic vs. reverse total shoulder were associated with reimbursements, these were to lesser extents. Understanding these results may help health-care systems further target variables associated with greater cost/reimbursement to the system.