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Total Joint Replacement, Bundled Payments and Patient Risk Factors

By William P. Barrett, MD on

In the February issue of The Journal of Arthroplasty, several articles examined the influence of various medical comorbidities and the risk for complication after hip and knee replacement. This is a very “hot topic” as the Centers for Medicare and Medicaid are moving to bundled payments where physicians and hospitals will be at risk for complications and readmission after joint replacement. This will increase the need for optimization of patients prior to surgery in order to minimize readmissions and complications. This is good for the cost of health care and for patients undergoing these elective procedures.

In the first article, “Calculating the Costs and Risk of Comorbidities in Total Joint Arthroplasty in the United States,” author Joshua Hustedt and his coauthors outline the most common preoperation comorbidities. These include hypertension in 66% of patients reviewed, diabetes in 20%, obesity in 19% and anemia in 16%. These patients were selected from a large Medicare database, representing a national estimate of over four million patients. The authors found that medical comorbidities increased with increasing age, all of these comorbidities increase the cost of the episode of care, and the most costly comorbidities were issues related to blood clotting, congestive heart failure and chronic failure.

In an article entitled “The Impact of Metabolic Syndrome on 30-Day Complications Following Joint Arthroplasty,” author Adam Edelstein and his coauthors reviewed the impact of metabolic syndrome, which is a constellation of findings related to obesity. A BMI greater than 30, truncal obesity, diabetes and elevated cholesterol all contribute to increased complications following surgery. In a review of over 100,000 patients, the researchers found that obese patients with metabolic syndrome had an increased risk of complication, wound problems and readmission following joint replacement surgery, and the greater degree of obesity was associated with a higher rate of complication.

As evolving data shows, it is incumbent upon patients to take control of their health and try and minimize their risk of complication. As Michael Greger, MD outlines in his book How Not to Die, the key to a healthier life begins with a more plant-based diet and avoiding many of the lifestyle choices that contribute to obesity and medical comorbidities.

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