Investigating a Potential Limit to Access to Care: Preoperative Cutoff Values for Body Mass Index for Shoulder Arthroplasty.

INTRODUCTION

The primary purpose of this study was to determine the number of patients who would be denied a complication-free total shoulder arthroplasty (TSA) based on implementation of body mass index (BMI) eligibility cutoffs.

METHODS

The National Surgical Quality Improvement Program database was queried to identify all patients who underwent primary TSA. Patient demographics and 30-day postoperative complications were compared according to BMI stratification using the Pearson chi-square test and binary logistic regression analysis adjusted for age and modified Charlson comorbidity index. A BMI eligibility criterion of ≥40 kg/m2 was used to calculate the positive predictive value (PPV) to assess the number of complication-free TSAs that would be denied to avoid a complication in a single patient.

RESULTS

A total of 23,284 patients who underwent TSA met inclusion criteria. The overall complication rate was 7.2%. Using a BMI cutoff of ≥40 kg/m2 would yield a PPV of 7% for all Major Complications. This means that 14 complication-free procedures would be denied to avoid a Major Complication. In addition, BMI ≥40 kg/m2 served as an independent risk factor for acute renal failure, pulmonary embolism, ventilator use >48 hours, and readmission. The PPV for these clinically significant complications using BMI ≥40 kg/m2 as a cutoff was 4.9%. This translates into 20 patients being denied a complication-free procedure to avoid a single clinically significant medical complication. If this policy was enforced on the 2,426 patients who exceeded BMI ≥40 kg/m2 in this study, nearly 2,307 patients would be denied the potential benefit of surgery to prevent 119 complications.

CONCLUSION

The use of eligibility criteria for primary TSA or RSA based solely on BMI threshold values presents a potential limitation in access to care to these patients who otherwise would have a complication-free procedure.

LEVEL OF EVIDENCE

Level III, prognostic, retrospective cohort study.