Frailty & Comorbidity Raise Healthcare Costs 💰 | Total Shoulder Arthroplasty Insight

 

1. INTRODUCTION

The aging population has led to a rising demand for total shoulder arthroplasty (TSA) procedures among older adults. In this population, frailty and comorbidity burden emerge as significant clinical factors potentially impacting recovery and outcomes. While both frailty and comorbidities are independently recognized as risk factors for poor surgical outcomes, their individual and combined effects on postoperative healthcare utilization following TSA remain unclear. This study aims to explore and delineate these impacts by leveraging a large, national database. Understanding how frailty and comorbid conditions affect length of hospital stay, discharge disposition, and readmission risk can provide vital insight into optimizing perioperative care strategies and planning for postoperative resources more effectively.

2. DEFINING FRAILTY AND COMORBIDITY BURDEN IN TSA

Frailty and comorbidity are often confused but are distinct clinical entities. In this study, frailty was measured using the Johns Hopkins Adjusted Clinical Groups Frailty Index, which captures functional and physiological vulnerability. Comorbidity burden was assessed via the Elixhauser Comorbidity Index, where patients with more than two conditions were labeled "unhealthy." Patients were stratified into four categories: healthy, frail, unhealthy, and frail/unhealthy. This structured categorization enabled a nuanced evaluation of how these conditions, separately and together, influence surgical outcomes. Distinguishing these groups allows for better targeted interventions and more accurate risk stratification in TSA patients.

3. IMPACT OF FRAILTY AND COMORBIDITY ON LENGTH OF STAY

Postoperative length of stay (LOS) is a critical metric for assessing healthcare efficiency and recovery. This study found that the frail/unhealthy group experienced the most prolonged hospitalizations, with 65.06% staying more than two days postoperatively. Comparatively, frail patients had longer LOS than the unhealthy group alone (48.96% vs. 39.78%), underscoring the unique burden frailty imposes. These results highlight that frailty alone can be more predictive of extended LOS than comorbidity burden alone. Integrating frailty assessments into preoperative planning may allow clinicians to better allocate hospital resources and anticipate longer recovery periods.

4. DISCHARGE TO SKILLED NURSING FACILITIES (SNF)

Discharge destination is a key indicator of post-surgical recovery and independence. Patients classified as frail/unhealthy had the highest discharge rate to skilled nursing facilities at 29.90%. Even among those not frail/unhealthy, frail patients still had a higher SNF discharge rate compared to the unhealthy group (16.77% vs. 9.94%). These findings reinforce the influence of physical vulnerability over disease burden in determining postoperative care needs. Identifying patients likely to require SNF discharge can help healthcare providers plan earlier for transition care and reduce discharge delays.

5. READMISSION RATES AND THEIR IMPLICATIONS

Hospital readmission is a significant quality metric and cost driver in postoperative care. The study revealed the frail/unhealthy group had the highest readmission rate at 5.00%, compared to relatively similar rates in the frail (3.35%) and unhealthy (3.18%) groups. While comorbidities alone contribute to readmission, the combination with frailty amplifies this risk. This emphasizes the need for enhanced post-discharge monitoring and tailored follow-up plans, particularly for patients with overlapping vulnerabilities. Proactive intervention strategies may prevent avoidable readmissions and improve overall patient outcomes.

6. CLINICAL IMPLICATIONS AND FUTURE RESEARCH

The findings of this study illustrate that frailty and comorbidity burden, especially when combined, significantly influence healthcare utilization following TSA. These insights are valuable for informing both patient counseling and healthcare policy. By integrating frailty screening into standard preoperative evaluations and developing dedicated postoperative care pathways, clinicians can improve outcomes and reduce complications. Future research should focus on developing predictive tools and protocols that incorporate these factors to guide treatment planning and rehabilitation. Additionally, investigating whether targeted interventions in frail/unhealthy patients can mitigate the risk of adverse outcomes could further enhance care quality.

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