LEP was associated with higher hospitalization cost (adjusted IRR 1.08) after total joint arthroplasty

Description #

In this retrospective cohort of 4721 total joint arthroplasty (TJA) patients, those with limited English proficiency (LEP) had higher total hospitalization costs than English-proficient patients on univariate analysis (median [IQR], $15 387 [$13 016-$21 566] vs $14 179 [$12 142-$19 207]; P < .001). The association persisted in the adjusted negative binomial model: LEP was independently associated with higher costs with an incidence rate ratio of 1.08 (95% CI, 1.04-1.12; P < .001) — about 8% higher expected cost (Table 2).

"higher costs of hospitalization (median [IQR] $15 000 [$13 000-$22 000] vs $14 000 [$12 000-$19 000]) ... compared with patients with English proficiency." (Manuel, 2022, p. 3)

"LEP was associated with ... higher hospitalization costs (incidence rate ratio 1.08; 95% CI, 1.04-1.12)" (Manuel, 2022, p. 3)

"Total costs, median (IQR), $ 14 264 (12 184-19 388) 14 179 (12 142-19 207) 15 387 (13 016-21 566)" (Manuel, 2022, Table 2, p. 2)

Methods Context #

What? #ⓘ

The observable: total hospitalization cost, in US dollars.

"we examine the association of LEP with ... hospitalization cost, and rate of 30-day readmission after TJA." (Manuel, 2022, p. 1)

How? #ⓘ

Negative binomial regression (to accommodate right-skewed cost) adjusting for a pre-specified covariate set (demographics, insurance, ASA status, case class, case length, blood loss, and discharge disposition); reference group is English-proficient patients.

"The distribution of LOS and total hospitalization cost both exhibited overdispersion caused by right skew, which was accommodated using negative binomial regression." (Manuel, 2022, p. 1)

Who? #ⓘ

Patients aged 18 years or older who underwent TJA from 2015 to 2019 at a single urban academic medical center (N = 4721; 4343 English proficient, 378 LEP).

"This study used electronic health data of patients aged 18 years or older who underwent TJA from 2015 to 2019 at an urban academic medical center" (Manuel, 2022, p. 1)

Other Notes #

The Results text reports rounded cost figures (LEP $15 000 [$13 000-$22 000] vs EP $14 000 [$12 000-$19 000], p. 3); the precise medians are in Table 2 (LEP $15 387 [13 016-21 566] vs EP $14 179 [12 142-19 207]). The Description uses the precise Table 2 values; both are quoted here for fidelity.

Caveats #

• Observational single-center EHR-derived cohort with LEP defined by interpreter request; residual confounding precludes causal inference The findings are from a retrospective observational cohort at a single urban academic medical center, using variables derived from the electronic health record, and can establish association but not causation. The authors explicitly acknowledge the limitations inherent to observational EHR-based analysis (with further detail deferred to an unavailable eAppendix). Residual and unmeasured confounding is possible despite multivariable adjustment; the exposure (LEP) was operationalized as a non-English language preference plus a recorded request for interpreter services, which may misclassify patients who are LEP but did not request an interpreter, and single-center results may not generalize to other settings or payer/case mixes.