Higher comorbidity, poor functional status and higher health care utilization in veterans with prevalent total knee arthroplasty or total hip arthroplasty

Abstract

The objective of this study was to compare comorbidity, functional ability, and health care utilization in veterans with total knee arthroplasty (TKA) or total hip arthroplasty (THA) versus matched control populations. A cohort of veterans using Veterans Affairs (VA) healthcare system reported limitations in six activities of daily living (ADLs; bathing, dressing, eating, walking, transferring, and using the toilet), demographics, and physician-diagnosed comorbidity. VA databases provided healthcare utilization and International Classification of Diseases-9/Common procedure terminology codes for TKA/THA. Patients were classified as: (1) primary TKA; (2) primary THA; (3) combination group (>or=1 procedure); and (4) control veteran population (no THA/TKA). Multivariable regression analyses compared the risk or counts of ADL limitation and in-/out-patient visits. After multivariable adjustment, TKA, THA or combination groups had significantly higher prevalence of the following compared to veteran controls: arthritis, diabetes, or heart disease (p < 0.0001 each), severe (>or=3) ADL limitation (33%, 42%, 42% vs. 24%; p < 0.0001), and annual hospitalization rate (24%, 19%, 26% vs. 16%, p < 0.0001). Annual outpatient surgery visits were more (2.5, 2.3, 2.3 vs. 2, p = 0.01) and risk of any mental health outpatient visit was lower (12%, 11%, 12% vs. 18%, p = 0.0039). All ADLs, except eating, were significantly more limited in arthroplasty groups (p <or= 0.0009). Severe ADL limitation was more prevalent in veterans with arthroplasty than in two age-matched US cohorts: 13.4 times in >or=65 years; and 1.2-, 1.6-, and 4-fold in >or=85, 75-84, and 65-74 years. Poorer function and higher comorbidity and utilization in veterans with TKA/THA suggest that this group is appropriate for interventions targeted at improving function and decreasing utilization.

Fig. 1

Age-matched comparisons of ADL limitation in veterans3 (current study) to the 1998 Health and Retirement Survey (≥65 years) from AHEAD Study (a) [28] and the San Luis Valley Health and Aging Study (≥60 years; b, c) [29]. (a) Y-axis represents percent of patients with limitation in each category. Veterans with arthroplasty ≥65 years were compared to an age-matched US Cohort from the 1998 Health and Retirement Survey (≥65 years) from the AHEAD Study, a population-based cohort. Veterans were 6.2, 11.2 and 13.4 times as likely as the age-matched HRS respondents with arthritis to have ≥1, ≥2 and ≥3 ADL limitations, respectively. (b) The figure shows limitation of each ADL as well as overall number of ADLs with limitation comparing veterans to an age-matched San Luis Valley cohort aged ≥60 years, a population-based cohort. Veterans with arthroplasty reported limitation in each of the five ADLs 1.5–2.6 times as often as the San Luis Valley cohort and 4.7 times to have limitation in walking. Any ADL limitation, 1–2 ADL limitation and ≥3 ADL limitation were each twice as frequent in veterans as in age-matched San Luis cohort. (c) Veterans with arthroplasty were twice as likely as the San Luis cohort to report moderate limitation (limitation of 1–2 ADLs) in each age group (65–74, 75–84, and ≥85). Compared to San Luis cohort in the same age groups, veterans with arthroplasty reported severe ADL limitation 3.9 times in the 65–74 year group, 1.6 times in 75–84 year group, and 1.2 times in the ≥85 year group

Fig. 2

Multivariable-adjusted^a and unadjusted estimates of proportion of patients with moderate [1, 2] ADL and severe (≥3) ADL limitation. TKA total knee arthroplasty; THA total hip arthroplasty. ^aAdjusted for age, gender, race, education level, employment status, marital status, smoking status, self-report of six physician-diagnosed comorbidities (asthma/COPD, arthritis, depression, diabetes, heart disease, hypertension), percent service connection, and single vs. multiple-site use

Fig. 3

Multivariable-adjusted^a estimates of limitation of the six activities of daily living (ADLs). ^aAdjusted for age, gender, race, education level, employment status, marital status, smoking status, self-report of six physician-diagnosed comorbidities (asthma/COPD, arthritis, depression, diabetes, heart disease, hypertension), percent service connection and single vs. multiple-site use