Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty

Predictors of Discharge Home Versus Inpatient Rehabilitation Following Total Hip and Knee Arthroplasty-Cohort Study

BACKGROUND

This study aims to identify the prevalence of inpatient rehabilitation (IPR) use in an Australian private total joint arthroplasty (TJA) cohort and to identify factors predictive of IPR discharge, including components of the Risk Assessment and Prediction Tool (RAPT).

METHODS

Primary TJA patients at a Sydney private hospital, between 2021 and 2022 were identified from an institutional arthroplasty database. Variables previously deemed as predictive factors for IPR facility discharge in the literature and components of RAPT were assessed utilising multivariable generalised linear model analysis.

RESULTS

Of the 733 total hip arthroplasty (THA) and 776 total knee arthroplasty (TKA) patients included, 46% of THA and 64% of TKA subjects transferred to IPR post-acutely. Bilateral procedure (OR 7.91, p < 0.001), living alone (OR 5.23, p < 0.001), older age groups (66-75 (OR 2.14, p = 0.001)); (> 75 (OR 5.02, p < 0.001)), poorer walking distance (1-2 blocks (OR 1.64, p = 0.023)); (housebound (OR 2.68, p = 0.009)), were significant predictors of IPR following THA. In the TKA cohort, the significant predictors of IPR discharge were female (OR 2.47, p < 0.001), older age (66-75 (OR 1.73, p = 0.021)); (> 75 (OR 4.23, p < 0.001)), bilateral procedure (OR 6.86, p < 0.001), obesity (OR 1.76, p = 0.006), living alone (OR 2.86, p = 0.001) and surgeon (surgeon 3 (OR 2.30, p = 0.024)); (surgeon 4 (OR 3.04, p = 0.003)); (surgeon 5 (OR 2.18, p = 0.046)).

CONCLUSION

The use of IPR following TJA was associated with some clinically justifiable factors, such as bilateral procedure, older age, and living alone. However, other variables may be driven by inappropriate and potentially modifiable societal expectations, such as being female, obesity, treating surgeon, and limited walking distance.

Frailty Is Associated With Increased 30-day Readmissions and Costs After Total Shoulder Arthroplasty

BACKGROUND

Frailty has been associated with a greater risk of complications and higher treatment costs for various medical conditions and surgical procedures. The Modified Frailty Index, which analyzes five or six medical comorbidities, helps grade the severity of a patient's frailty. Patients with frailty, as recognized by this index, are more likely to face adverse medical and surgical events after total shoulder arthroplasty (TSA). However, these modified indices often do not consider less common medical conditions that contribute to frailty. As such, we believe that patients may be more readily misdiagnosed as not having frailty. A more comprehensive frailty score that more accurately recognizes frailty in a wider patient population is necessary.

QUESTION/PURPOSES

After analyzing for any possible differences due to confounding variables such as age, gender, socioeconomic variables, and insurance provider, we asked: (1) Was frailty, defined as a score of ≥ 5 on the Hospital Frailty Risk Score (HFRS), associated with a higher risk of reoperation or readmission within 30 days of primary TSA? (2) Was frailty associated with an increased risk of major medical or surgical complications after TSA? (3) Was frailty associated with higher hospital costs (assessed by insurance charge-to-cost ratio per admission) and length of stay for patients after TSA?

METHODS

This study examined the Nationwide Readmissions Database, which includes patients from 28 states, representing 60% of all US residents and 60% of all US hospitalizations. We identified adult patients who were discharged after both anatomic and reverse TSA for primary osteoarthritis between January and November of 2017 to 2019 (patients who underwent TSA in December of each year were excluded). The HFRS was calculated for each patient based on 109 differently weighted ICD-10 Clinical Modification codes as validated in previous studies. Patients with an HFRS of ≥ 5 were considered as having frailty. Of the 107,774 patients who underwent TSA and were recorded in this database, 15% (16,210) were classified as patients with frailty. Patients over age 65 years comprised a larger portion of patients with frailty than patients without frailty (81% [13,130 of 16,210] of patients with frailty versus 74% [67,757 of 91,564] of patients without frailty; p < 0.01). Women comprised a larger portion of patients with frailty than patients without frailty (62% [10,050 of 16,210] women with frailty versus 53% [48,528 of 91,564] women without frailty; p < 0.01). Patients paying with Medicare comprised a larger portion of patients with frailty than patients without frailty (80% [12,968 of 16,210] Medicare payers with frailty versus 72% [65,926 of 91,564] Medicare payers without frailty; p < 0.01). We used the Student t-test to compare demographics and complication risk. After analysis of these confounders and controlling for them, we used multivariate logistic regression to analyze 30-day readmissions and negative binomial regression to analyze length of stay and hospital costs (as estimated by insurance charge-to-cost ratios per patient admission). Length of stay was expressed as an incidence rate ratio (IRR) because it was recorded and analyzed as a continuous variable. The Student t-test was used to compare demographics and risk of major surgical and medical complications of similar severity.

RESULTS

After controlling for confounding variables such as age, gender, socioeconomic status, and insurance provider, we found that frailty was associated with increased odds of reoperation within 30 days (OR 1.61 [95% CI 1.22 to 2.09]; p < 0.001) and increased 30-day readmissions (OR 1.79 [95% CI 1.63 to 1.97]; p < 0.001). We also found that frailty was associated with higher 30-day major surgical complication risk (0.4% [70 of 16,210] versus 0.3% [266 of 91,564]; p < 0.01) and 30-day major medical complication risk (2.6% [421 of 16,210] versus 1.1% [1007 of 91,564]; p < 0.01). We also found that frailty was associated with greater hospitalization costs (IRR 1.09 [95% CI 1.09 to 1.10]; p < 0.001) and longer lengths of hospital stay (IRR 1.46 [95% CI 1.44 to 1.47]; p < 0.001).

CONCLUSION

Frailty, as measured by the HFRS, is associated with increased postoperative events and estimated hospitalizations costs after TSA. The HFRS is derived from routinely collected administrative data and could help clinicians quickly identify patients at risk of complications without increased cost. Once patients with frailty are identified, clinicians may be able to provide additional counseling regarding patients' increased risk for postoperative complications and costs. An automatically calculated, robust scoring tool such as the HFRS can also aid clinicians in operative decision-making, as patients with severe frailty may be advised against undergoing TSA if the procedure is not absolutely necessary.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Knee joint dysfunction in the patients immediately before arthroplasty was well reflected by locomotive syndrome, not physical frailty

OBJECTIVES

We assessed physical function by three different methods in patients with knee osteoarthritis just before total knee arthroplasty (TKA) and investigated the relationship with pre-operative factors.

METHODS

All patients scheduled to undergo TKA were assessed for basic attributes, clinical assessment, radiography, whole-body mode dual-energy X-ray absorptiometry, knee muscle strength, and frailty, sarcopenia, locomotive syndrome (LS) were evaluated.

RESULTS

Among 204 patients (213 knees), 172 women the overall distribution in frailty was no: 14.6%, pre-frailty: 58.5%, frailty: 26.8%; in sarcopenia no: 93.3%, yes: 3.4%, severe: 3.4%; and in LS Stage 0: 0%, Stage 1: 3.3%, Stage 2: 11.4%, Stage 3: 85.3% . Eighty-seven per cent of the patients with frailty and 92% with LS Stage 3 did not suffer from sarcopenia. Statistically significant relationships were observed between sarcopenia and frailty, while there was no relationship between LS and frailty or LS and sarcopenia. Multivariate analysis of related factors with severity levels for frailty and LS revealed statistically significant correlations for frailty with gait speed, and LS with Knee Society Score and muscle strength.

CONCLUSION

In patients with knee osteoarthritis frailty and LS were not related to sarcopenia. Knee joint dysfunction without sarcopenia was well reflected by LS, but not by frailty.

Frailty and associated healthcare expenditures among patients undergoing total hip and knee arthroplasty

BACKGROUND

Major joint surgery is one of the largest components of Medicare spending in the US and the most frequent major procedure performed in older adults. Increasing age is associated with increasing prevalence of frailty, but the influence of frailty on healthcare expenditures following arthroplasty has yet to be adequately explored.

OBJECTIVE

To explore the association between frailty and healthcare expenditures in the year following total hip and knee arthroplasties.

DESIGN

Retrospective cohort study SETTING: United States population PARTICIPANTS: Medicare beneficiaries 65 and older undergoing total knee or hip arthroplasty (n = 1,152,872) from 2017 through 2018.

MEASUREMENTS

Claims-based frailty index (exposure), total 1-year Medicare expenditures broken down by category (primary outcome), in-hospital complications, length of stay, discharge destination, readmission and mortality (secondary outcomes).

RESULTS

Among 435,496 patients who underwent hip (37.8 %) and 717,376 patients who underwent knee arthroplasty (62.2 %), the mean age was 73.7 years and 19.2 % were classified as frail. Median total expenditures in US dollars at one year were higher in those with frailty ($247,503; IQR [$169,400-$391,176]) relative to the prefrail ($179,379 [$127,396-$265,039]) and robust ($130,314 [$85,438-$199,605]) groups. Total expenditures included the index surgical admission, rehospitalization, skilled nursing care, and outpatient care, all of which were higher with increasing frailty. However, the surgical procedure accounted for less than a third of the total 1-year healthcare costs and was the category with the lowest degree of variation between patients. Frailty was also associated with longer lengths of stay, higher risks of complications, readmission, and mortality and lower likelihood of being discharged home after the procedure.

CONCLUSIONS

Among older adults undergoing total hip and knee arthroplasty, frailty is associated with higher healthcare expenditures, predominantly driven by longitudinal care during the year following the procedure. More research is needed to test interventions to improve outcomes and reduce cost in this high-risk population.

Orthopedic frailty risk stratification (OFRS): a systematic review of the frailty indices predicting adverse outcomes in orthopedics

BACKGROUND

With a growing number of elderly patients requiring elective and non-elective procedures, frailty-based preoperative risk stratification is an emerging tool in orthopedic surgery to minimize adverse postoperative outcomes. This paper sought to understand the current literature regarding preoperative Orthopedic Frailty Risk Stratification (OFRS) and describe the disparate frailty indices and their capabilities for discrimination in predicting adverse postoperative outcomes.

METHODS

A literature search was conducted in Pubmed, Cochrane, and Scopus for articles published during or prior to February 2024 assessing frailty following surgery for orthopedic pathologies. Qualitative variables including study characteristics and application of frailty were collected and synthesized. Quantitative meta-analysis was performed for pooled odds ratio (OR) and area under the curve (AUC) of frailty for mortality and complications. All methods were performed in accordance with PRISMA guidelines.

RESULTS

Of the 81 included articles, over half (52%) addressed traumatic orthopedic pathologies with traumatic hip fractures being the most studied in the OFRS (25 studies). Less common categories included oncology, sports, and foot/ankle. Functional status and independence were the most common frailty domain (25, 96.2%) and component across scales (20, 76.9%), respectively. The 5-Item Modified Frailty Index (mFI-5) was the most common frailty index (28 publications). Meta-analysis demonstrated increasing frailty was an independent predictor of mortality (30-day OR: 2.89, 95% CI: 2.00-4.18; 1 year OR: 1.81, 95% CI: 1.48-2.22, p < 0.001), major complications (OR: 1.63, 95% CI: 1.10-2.41, p = 0.02), and Clavien-Dindo IV complications (OR: 3.26, 95% CI: 2.18-4.87, p < 0.001). Frailty had good discriminatory accuracy for predicting mortality at 30-days (AUC: 0.71, 95% CI: 0.68-0.74, p < 0.001), 3-months (OR: 0.75, 95% CI: 0.65-0.83, p < 0.001), and 1-year (OR:0.74, 95% CI: 0.73-0.75, p < 0.001).

CONCLUSIONS

The orthopedic surgery frailty literature is extremely heterogeneous, with disparate frailty scales implemented to measure varying outcomes across many orthopedic pathologies. Despite no consensus on exact scales or definitions, various frailty indices have predicted adverse outcomes.

Predictive Value of Frailty on Outcomes of Patients With Cirrhosis: Systematic Review and Meta-Analysis

Background

Frailty is one of the most common symptoms in patients with cirrhosis. Many researchers have identified it as a prognostic factor for patients with cirrhosis. However, no quantitative meta-analysis has evaluated the prognostic value of frailty in patients with cirrhosis.

Objective

This systematic review and meta-analysis aimed to assess the prognostic significance of frailty in patients with cirrhosis.

Methods

The systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. We conducted a comprehensive search of the literature using databases such as PubMed, Cochrane Library, Embase, and Web of Science, as well as China National Knowledge Infrastructure, encompassing the period from inception to 22 December 2023. Data were extracted for frailty to predict adverse outcomes in patients with cirrhosis. RevMan (version 5.3) and R (version 4.2.2) were used to assess the extracted data.

Results

A total of 26 studies with 9597 patients with cirrhosis were included. Compared with patients having low or no frailty, the frail group had a higher mortality rate (relative ratio, RR=2.07, 95% CI 1.82-2.34, P<.001), higher readmission rate (RR=1.50, 95% CI 1.22-1.84, P<.001), and lower quality of life (RR=5.78, 95% CI 2.25-14.82, P<.001). The summary receiver operator characteristic (SROC) curve of frailty for mortality in patients with cirrhosis showed that the false positive rate (FPR) was 0.25 (95% CI 0.17-0.34), diagnostic odds ratio (DOR) was 4.17 (95% CI 2.93-5.93), sensitivity was 0.54 (95% CI 0.39-0.69), and specificity was 0.73 (95% CI 0.64-0.81). The SROC curve of readmission showed that the FPR, DOR, sensitivity, and specificity were 0.39 (95% CI 0.17-0.66), 1.38 (95% CI 0.64-2.93), 0.46 (95% CI 0.28-0.64), and 0.60 (95% CI 0.28-0.85), respectively.

Conclusions

This meta-analysis demonstrated that frailty is a reliable prognostic predictor of outcomes in patients with cirrhosis. To enhance the prognosis of patients with cirrhosis, more studies on frailty screening are required.

The effects of frailty on opioid consumption after total knee arthroplasty

PURPOSE

This study evaluated the effects of frailty on postoperative opioid consumption in elderly patients.

METHODS

Patients aged 65 and older scheduled for unilateral primary total knee arthroplasty under spinal anesthesia were included. A blinded anesthesiologist assessed patients using the FRAIL scale during the preoperative visit, classifying them into robust (Group I), pre-frail (Group II), and frail (Group III) categories. The main outcome measure was total opioid consumption over 24 h. Opioid consumption was recorded at 6 (T1), 12 (T2) and 24 (T3) hours postoperatively. Secondary outcomes included visual analog pain scores (VAS) at rest (VAS-R) and during 45° knee flexion (VAS-F), as well as postoperative nausea and vomiting.

RESULTS

Seventy-five patients were included in the study, with seventy-three completing it and two being excluded. Total opioid consumption was significantly higher in Groups II and III compared to Group I (p < 0.001 for both). There were no significant differences in VAS-R scores between groups at T0, T1, T2, and T3 (p = 0.659, p = 0.425, p = 0.994, and p = 0.689, respectively), and no significant differences in VAS-F scores at the same time points (p = 0.580, p = 0.739, p = 0.322, and p = 0.679, respectively).

CONCLUSION

Our study results indicate that frailty, easily assessed preoperatively in elderly surgical patients, is a significant predictor of postoperative opioid consumption.

Impact of the hospital frailty risk score on outcomes following primary total elbow arthroplasty

BACKGROUND

The Hospital Frailty Risk Score (HFRS) has demonstrated strong correlation with adverse outcomes in various joint replacement surgeries, yet its applicability in total elbow arthroplasty (TEA) remains unexplored. The purpose of this study is to assess the association between HFRS and postoperative complications following elective primary TEA.

METHODS

The Nationwide Readmissions Database was queried to identify patients undergoing primary TEA from 2016-2020. The HFRS was used to compare medical, surgical, and clinical outcomes of frail vs. nonfrail patients. Mean and relative costs, total hospital length of stay, and discharge disposition for frail and nonfrail patients were also compared.

RESULTS

We identified 2049 primary TEA in frail patients and 3693 in nonfrail patients. Frail patients had increased complication rates including acute respiratory failure (13.6% vs. 1.1%; P < .001), urinary tract infections (12.3% vs. 0.0%; P < .001), transfusions (3.9% vs. 1.1%; P < .001), pneumonia (1.1% vs. 0.2%; P < .001), acute respiratory distress syndrome (3.2% vs. 0.6%; P < .001), sepsis (0.7% vs. 0.1%; P < .001), and hardware failure (1.2% vs. 0.1%; P < .001). Frail patients also experienced higher rates of readmission (37% vs. 25%; P < .001) and death (1.7% vs. 0.2%; P < .001), while being less likely to undergo revision (6.5% vs. 17%; P < .001). Frail patients incurred higher health-care costs ($28,497 vs. $23,377; P < .001) and longer length of stay (5.3 days vs. 2.6 days; P < .001), with reduced likelihood of routine hospital stays (36% vs. 71%; P < .001) and increased utilization of short-term hospitalization (P < .001), care facilities (P < .001), and home health-care services (P < .001).

CONCLUSION

HFRS is a validated indicator of frailty and is strongly associated with increased rates of complications in patients undergoing elective primary TEA. These findings should be considered by orthopedic surgeons when assessing surgical candidacy and discussing treatment options in this at-risk patient population.

Association of preoperative cognitive frailty with postoperative complications in older patients under general anesthesia: a prospective cohort study

BACKGROUND

Cognitive frailty (CF) is characterized by the coexistence of physical frailty and cognitive impairment, and it is associated with adverse health outcomes. Older adults are particularly vulnerable to CF due to factors such as age-related brain changes and the presence of comorbidities.

OBJECTIVE

To investigate the effect of preoperative CF on postoperative complications in older patients.

METHODS

This prospective cohort study was conducted among 253 patients aged 60-85 years, who underwent elective orthopedic and abdominal surgery (with a postoperative hospital stay of ≥ 3 days) at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2023 to November 2023. CF was assessed using the Montreal Cognitive Assessment (MoCA) for the cognitive status and the Fried criteria for five frailty scales. Participants were split into four groups: Group A (neither frailty nor cognitive impairment), Group B (frailty without cognitive impairment), Group C (cognitive impairment without frailty), and Group D (cognitive frailty). The primary outcome was postoperative complications, while secondary outcomes included mobility disability, prolonged hospital stay (PLOS), re-operation and 90-day readmission.

RESULTS

The median age (interquartile range) of participants was 69 (65-73) years, of which 40.3% were male. The prevalence of CF was 17.8%. The incidence of postoperative complications was 18.2% in Group A, 50.0% in Group B, 37.4% in Group C, and 75.6% in Group D. Multivariate analysis revealed that, compared to the control group (without cognitive impairment or frailty), patients with CF had a significantly higher risk of postoperative complications (OR, 12.86; 95%CI, 4.23-39.08). "Patients with frailty without cognitive impairment" had an increased risk (OR, 6.53; 95%CI, 2.04-20.9), while "those with cognitive impairment without frailty" also showed a higher risk (OR, 3.46; 95%CI, 1.57-7.64).

CONCLUSIONS

Cognitive frailty is significantly associated with an increased risk of postoperative adverse outcomes in older patients undergoing orthopedic and abdominal surgeries with general anesthesia. It indicates that clinicians should pay much attention to these older adults with CF.

Preoperative frailty predicts postoperative pain after total knee arthroplasty in older patients: a prospective observational study

PURPOSE

Frailty is reportedly associated with postoperative adverse outcomes and may increase the risk of post-surgical pain. Our study aimed to explore whether frailty was an independent risk factor for pain after total knee arthroplasty (TKA) in older patients.

METHODS

Included in this prospective observational study were patients aged 65 or older who underwent primary TKA. Frailty of the patients was assessed before surgery using the comprehensive geriatric assessment-frailty index and pain was evaluated before and after surgery using the Numerical Rating Scale.

RESULTS

Of the 164 patients including 125 females with a mean age of 71.4 ± 4.6 years, 51 patients were identified as being frail. Patients with chronic post-surgical pain had a significantly higher frailty index than those without chronic post-surgical pain, which was the same in patients with acute post-surgical pain. After adjusting for other confounding factors, frailty was shown to be an independent risk factor for both acute (OR: 13.23, 95% CI 3.73-46.93, P < 0.001) and chronic post-surgical pain (OR: 4.24, 95% CI 1.29-14.00, P = 0.02). The area under the receiver operating characteristic curve for frailty predicting chronic post-surgical pain was 0.73 (P < 0.001, 95% CI 0.65-0.81).

CONCLUSIONS

Our findings demonstrated that preoperative frailty in older patients was a predictor of acute and chronic post-surgical pain after TKA, suggesting that frailty assessment should become a necessary procedure before operations, especially in older patients.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Total Hip Arthroplasty

BACKGROUND

Frailty has been associated with poor outcomes and higher costs after primary total hip arthroplasty. However, frailty has not been studied in relation to outcomes after revision total hip arthroplasty (rTHA). This study examined the relationship between the Hospital Frailty Risk Score (HFRS), postoperative outcomes, and cost profiles following rTHA.

METHODS

In this retrospective cohort study, we identified patients who underwent rTHA from January 2017 to November 2019 in the Nationwide Readmission Database. The 3 most frequently reported diagnosis codes for rTHA were then selected: dislocation; mechanical loosening; and infection. We calculated the HFRS for each patient to determine frailty status. We compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients, using multivariate logistic and negative binomial regressions to adjust for covariates. We identified 36,243 total patients who underwent rTHA. Overall, 15,448 patients had a revision for dislocation, 11,062 for mechanical loosening, and 9,733 for infection.

RESULTS

Compared to nonfrail patients, frail patients had higher rates of 30-day readmission, longer length of stay, and higher hospitalization cost. Frail patients had significantly higher rates of 30-day complication and 30-day reoperation.

CONCLUSIONS

Frailty, measured using HFRS, is associated with increased postoperative complications and costs after rTHA. The HFRS has the ability to efficiently identify frail patients at-risk for perioperative complications enabling care teams to better focus optimization interventions on this patient cohort.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Knee Arthroplasty

BACKGROUND

Frailty can predict adverse outcomes after various orthopaedic procedures, but is not well-studied in revision total knee arthroplasty (rTKA). We investigated the correlation between the Hospital Frailty Risk Score (HFRS) and post-rTKA outcomes.

METHODS

Using the Nationwide Readmissions Database, we identified rTKA patients discharged from January 2017 to November 2019 for the most common diagnoses (mechanical loosening, infection, and instability). Using HFRS, we compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients with multivariate and binomial regressions. The 30-day complication and reoperation rates were compared using univariate analyses. We identified 25,177 mechanical loosening patients, 12,712 infection patients, and 9,458 instability patients.

RESULTS

Frail patients had higher rates of 30-day readmission (7.8 versus 3.7% for loosening, 13.5 versus 8.1% for infection, 8.7 versus 3.9% for instability; P < .01), longer length of stay (4.1 versus 2.4 days for loosening, 8.1 versus 4.4 days for infection, 4.9 versus 2.4 days for instability; P < .01), and greater cost ($32,082 versus $27,582 for loosening, $32,898 versus $28,115 for infection, $29,790 versus $24,164 for instability; P < .01). Frail loosening patients had higher 30-day complication (6.8 versus 2.9%, P < .01) and reoperation rates (1.8 versus 1.2%, P = .01). Frail infection patients had higher 30-day complication rates (14.0 versus 8.3%, P < .01). Frail instability patients had higher 30-day complication (8.0 versus 3.5%, P < .01) and reoperation rates (3.2 versus 1.6%, P < .01).

CONCLUSIONS

The HFRS may identify patients at risk for adverse events and increased costs after rTKA. Further research is needed to determine causation and mitigate complications and costs.