Frailty risk score may predict increased complications, costs after revision TKA
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Key takeaways:
- Frailty was associated with loosening, infection, instability, longer length of stay, readmission and increased costs after revision TKA.
- Patients categorized as frail may need preoperative risk stratification.
Results showed patients categorized as frail may be at risk for loosening, infection, instability, longer length of stay, readmission and increased costs after revision total knee arthroplasty vs. with patients without frailty.
To evaluate the impact of frailty on surgical outcomes, researchers used the Nationwide Readmissions database to analyze patients who underwent revision TKA between January 2017 and November 2019. According to the study, outcomes were assessed at 30 days and included complications, readmissions, length of stay (LOS) and total hospital costs.
Patients were classified as frail if they had a hospital frailty risk score of five or greater. Among 25,177 patients who underwent surgery for mechanical loosening, 9.8% (n = 2,464) were classified as frail. Among 12,712 patients who underwent surgery for infection, 29.2% (n = 3,706) were classified as frail. Among 9,458 patients who underwent surgery for instability, 12.2% (n = 1,153) were classified as frail.
Overall, researchers found patients categorized as frail had higher rates of 30-day readmission compared with patients without frailty (7.8% vs. 3.7% for loosening; 13.5% vs. 8.1% for infection; and 8.7% vs. 3.9% for instability). Patients categorized as frail had longer LOS compared with patients without frailty (4.1 days vs. 2.4 days for loosening; 8.1 days vs. 4.4 days for infection; and 4.9 days vs. 2.4 days for instability. Patients categorized as frail also had greater hospital costs compared with patients without frailty ($32,082 vs. $27,582 for loosening; $32,898 vs. $28,115 for infection; and $29,790 vs. $24,164 for instability).
In addition, researchers noted patients categorized as frail had higher 30-day complication and reoperation rates vs. patients without frailty.
“Assessing patient frailty is a relatively novel and promising method for preoperative risk stratification,” the researchers wrote in the study.
Perspective
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This manuscript presents compelling data derived from an administrative database associating patient frailty with increased complications and hospital costs following revision total knee arthroplasty for loosening, infection and instability. While causation cannot be proven from a retrospective study of this nature, the odds and percentages of 30-day readmissions, complications and reoperations, along with length of stay and hospitalization costs, suggest that frailty predisposes to worse outcomes after revision TKA. This information can be utilized to inform shared decision-making discussions between patients and physicians, but also can anticipate the hospital resources associated with revision TKA in this patient population.
Ideally, the preoperative frailty score might also identify comorbidities, which could be optimized prior to surgery in order to reduce the score, and thereby, reduce complication risk and costs. Unfortunately, many of the ICD-10-CM diagnoses from which the frailty score is calculated are not necessarily modifiable. Ultimately, if frailty is not a modifiable risk factor, the health system, and society in general, will need to accept the higher risk of complications in these patients, and payers will need to risk-stratify these patients, so providers and hospitals are not penalized for performing necessary revision TKA on them.
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