Do Pluses Outweigh Costs for Routine Hemoglobin A1c Screening?

How cost effective, really, is routine hemoglobin A1c screening? A team from Stanford University and the University of California-San Francisco set out to determine the value of routine preoperative hemoglobin A1c screening.

Their work, “Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis,” was published in the July/August 2022 edition of Current Orthopaedic Practice.

The Medical Director of Value Based Care and Orthopaedics at Stanford University, Rob Kamal, M.D., M.B.A., M.S. was a co-author on this work and told OTW, “As healthcare costs continue to rise, there is an increasing emphasis on achieving higher care quality at the lowest reasonable cost. For example, the Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement models used by the Centers for Medicare and Medicaid Services are designed around episodes of care such that health systems are incentivized to reduce the rate of unexpected surgical complications, especially those that require costly subsequent treatments (e.g., periprosthetic joint infection after joint replacement).”

“As these novel payment models increase in prevalence, health systems will be rewarded for optimizing patients in care pathways prior to joint replacement, which will utilize low-cost screening tests and intervention in high-risk patients that results in lower infection rates.”

After creating a decision tree model to assess short-term costs and risk reduction for periprosthetic joint infections with routine screening of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients., the researchers calculated net costs and absolute risk reduction in periprosthetic joint infection for routine screening versus no screening.

In diabetes mellitus patients, routine screening before THA demonstrated a net cost savings of $81 per patient with 286 patients needing to be screened to prevent one periprosthetic joint infection; screening before TKA incurred net additional costs of $25,810 per periprosthetic joint infection prevented. In patients with no history of diabetes mellitus, routine screening before THA or TKA incurred net additional costs of $24,583 or $87,873 per periprosthetic joint infection prevented, respectively.

Dr. Kamal explained further to OTW, “For patients with a history of diabetes, administering a low-cost hemoglobin A1c assay and referring patients for glycemic optimization if they are found to have poorly controlled diabetes was a cost-saving strategy for preventing periprosthetic joint infection after total hip replacements in our model.”

“In contrast, universal hemoglobin A1c screening in patients without diabetes undergoing joint replacement is not likely to be cost saving because many more patients need to be screened to prevent one periprosthetic joint infection.”

“It is becoming increasingly recognized that optimization of medical comorbidities prior to surgery can improve patient outcomes. The results of our study suggest that care pathways might be designed to include low-cost hemoglobin A1c screening in patients with diabetes undergoing total hip replacement, and that such pathways would reduce the overall costs of joint replacement care. So as more innovative value-based care initiatives take hold in the future, our screening strategy can be applied at scale to help lower complication rates and overall costs.”