The interplay between tobacco use and healthcare disparities: readmission rates and resource utilization after inpatient rotator cuff repair, a multistate analysis, 2007-2011
•Rotator cuff pathology is one of the most prevalent conditions in the United States, with more than 250,000 rotator cuff repairs (RCR) performed annually1
•While several prior studies have demonstrated differences in outcomes as a function of socioeconomic status after orthopedic surgeries, the literature examining healthcare disparities in RCR is scarce2
•With the development of the Medicare and Medicaid Bundled Payment for Care Improvement (BPCI) program, there is financial pressure to improve efficiency3
•We sought to identify socioeconomic risk factors which are associated with increased costs and readmissions after RCR
•We conducted a retrospective analysis of patients aged ≥18 undergoing inpatient rotator cuff repair ICD-9-CM code 83.63 using data from the State Inpatient Databases (SID, Healthcare Cost and Utilization Project, Agency for Health Research and Quality) from the years 2007-2011 for California, Florida, and New York
•Rotator cuff repairs were categorized as arthroscopic (80.21) or open (80.21 not present). Eligible diagnoses included rotator cuff syndrome of shoulder, disorder of bursae and tendons in shoulder region, unspecified (726.10), calcifying tendonitis of shoulder (726.11), other specified rotator cuff syndrome of shoulder and allied disorders (726.19), complete rupture of rotator cuff, non-traumatic (727.61), and sprains/strains of rotator cuff (840.4)
•During study period (2007-2011), 16,391 patients aged 18 year or older underwent inpatient RCR (Table 1)
–3.7% were insured by Medicaid, 1.1% were uninsured
–Majority (84.3%) reported never smoking; 8.9% were former smokers; 6.8% were current smokers
•Current tobacco use was most prevalent among the uninsured (20.2%) and Medicaid patients (18.1%) (Table 1)
•Medicaid patients had a 74% increase in odds of 90-day readmission over those with private insurance (Table 2)
•Medicaid patients and uninsured had longer length of stay than those with private insurance (Table 2)
•Uninsured patients were more likely to incur higher total hospital charges than privately insured patients (Table 2)
•Compared to patients who never smoked, current smokers more likely to be readmitted up to 90 days postoperatively, have longer lengths of stay, and incur higher total charges (Table 3)
•Descriptive statistics by insurance payer (Pearson’s Chi-square test, Fisher’s exact test, ANOVA, Mann-Whitney U test, Kruskal-Wallis test)
•Multivariate logistic regression models
•Multivariate generalized linear models with negative binomial distributions
•Multivariate models included the following variables: smoking status, age, race, categorical recode of van Walraven modification of Elixhauser comorbidities, hospital state, year, arthroscopic vs. open procedure, median income for patient ZIP code quartile, insurance payer
•Descriptive statistics are presented as N (%), mean (standard deviation), or median [interquartile range]
•Results from multivariate models are presented as odds ratio (95% confidence interval) for readmission models or incidence rate ratio (95% confidence interval) for length of stay and total charges models (both logged outcomes)
•Insurance payer and smoking status independently significantly associated with increased total hospital charges, length of stay, and readmissions after RCR
–According to CDC, adults who are uninsured or with Medicaid insurance smoke at rates more than double that of adults with private insurance or Medicare4
–Cigarette smoking also shown to be risk factor in development of rotator cuff disease and decreased healing after surgery5
•Given increasing cost burden of healthcare delivery in the US, it is important to consider payer status and modifiable risk factors such as cigarette smoking in preoperative risk stratification and for targeted interventions
1. Maher, R.C., et al., The societal and economic value of rotator cuff repair. J Bone Joint Surg Am. 2013;95:1993-2000.
2. Browne, J.A., et al., Medicaid Payer Status is Associated with In-Hospital Morbidity and Resource Utilization Following Primary Total Joint Arthroplasty. J Bone Joint Surg Am, 2014;96(21):e180.
3. Iorio, R., et al., Early results of Medicare’s bundled payment initiative for a 90-day total joint arthroplasty episode of care. J Arthroplasty, 2016 Feb;31(2):343-350.
4. CDC. Smoking rates for uninsured and adults on Medicaid more than twice those for adults with private health insurance. (accessed 08/20/2017); Available from: https://www.cdc.gov/media/releases/2015/p1112-smoking-rates.html
5. Bishop, J.Y., et al., Smoking predisposes to rotator cuff pathology and shoulder dysfunction: a systematic review. Arthroscopy. 2015 Aug;31(8):1598-1605.