Unplanned hip arthroplasty imposes clinical and cost burdens on treating institutions.
BACKGROUND
Emergent surgery has been shown to be a risk factor for perioperative complications. Studies suggest that patient morbidity is greater with an unplanned hip arthroplasty, although it is controversial whether unplanned procedures also result in higher patient mortality. The financial impact of these procedures is not fully understood, as the costs of unplanned primary hip arthroplasties have not been studied previously.


OBJECTIVE
We asked: (1) What are the institutional costs associated with unplanned hip arthroplasties (primary THA, hemiarthroplasty, revision arthroplasty, including treatment of periprosthetic fractures, dislocations, and infections)? (2) Does timing of surgery (urgent/unplanned versus elective) influence perioperative outcomes such as mortality, length of stay, or need for advanced care? (3) What diagnoses are associated with unplanned surgery and are treated urgently most often? (4) Do demographics and insurance status differ between admission types (unplanned versus elective hip arthroplasty)?


METHODS
We prospectively followed all 419 patients who were admitted to our Level I trauma center in 2011 for procedures including primary THA, hemiarthroplasty, and revision arthroplasty, including the treatment of periprosthetic fractures, dislocations, and infections. Fifty-seven patients who were treated urgently on an unplanned basis were compared with 362 patients who were treated electively. Demographics, admission diagnoses, complications, and costs were recorded and analyzed statistically.


RESULTS
Median total costs were 24% greater for patients admitted for unplanned hip arthroplasties (USD 18,206 [USD 15,261-27,491] versus USD 14,644 [USD 13,511-16,309]; p < 0.0001) for patients admitted for elective arthroplasties. Patients with unplanned admissions had a 67% longer median hospital stay (5 days [range, 4-9 days] versus 3 days [range, 3-4 days]; p < 0.0001) for patients with elective admissions. Mortality rates were equivalent between groups (p = 1.0). Femoral fracture (p < 0.0001), periprosthetic fracture (p = 0.01), prosthetic infection (p = 0.005), and prosthetic dislocation (p < 0.0001) were observed at higher rates in the patients with unplanned admissions. These patients were older (p = 0.04), less likely to have commercial insurance (p < 0.0001), more likely to be transferred from another institution (p < 0.0001), and more likely to undergo a revision procedure (p < 0.0001).


CONCLUSIONS
Unplanned arthroplasty and urgent surgery are associated with increased financial and clinical burdens, which must be accounted for when considering bundled quality and reimbursement measures for these procedures.
Department of Orthopedic Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Cupp 1, 39th and Market Streets, Philadelphia, PA, 19104, USA, akamath@post.harvard.edu.
Atul F
AF
Kamath
Daniel C
DC
Austin
Peter B
PB
Derman
Craig L
CL
Israelite
D000328:Adult; D019644:Arthroplasty, Replacement, Hip / Q000191:economics*; D004638:Emergency Treatment / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006622:Hip Prosthesis / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011475:Prosthesis Failure; D012086:Reoperation; D012307:Risk Factors