The Triple Aim for Payment Reform in Joint Replacement Surgery: Quality, Spending, and Disparity Reduction

Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy

OBJECTIVE

To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model.

DATA SOURCES AND STUDY SETTING

Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention.

STUDY DESIGN

This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015.

DATA COLLECTION/EXTRACTION METHODS

Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded.

PRINCIPAL FINDINGS

After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function.

CONCLUSIONS

We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.

Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries

INTRODUCTION

This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality.

METHODS

This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included. For the market-level analysis, we assessed the association of social vulnerability with the presence of a high-quality hip and knee replacement center. For the hospital-level analysis, we assessed the association of disproportionate share hospital (DSH) percentage with each high-quality designation. Healthcare markets were approximated by hospital referral regions. All associations were assessed with fractional regressions using generalized linear models with binomial family and logit links.

RESULTS

We found that healthcare markets in the most vulnerable quartile were less likely to have a hip and knee replacement hospital that did better than the national average (odds ratio [OR] 0.22, P = 0.02) but not more or less likely to have a hospital certified as advanced by JC (OR 0.41, P = 0.16). We found that hip and knee replacement hospitals in the highest DSH quartile were less likely to be designated by the Centers for Medicare and Medicaid Services as better than the national average (OR 0.18, P = 0.001) but not more or less likely to be certified as advanced by JC (OR 1.40, P = 0.28).

DISCUSSION

Geographic distribution of high-quality hospitals may contribute to socioeconomic disparities in patients' access to and utilization of high-quality hip and knee replacement. Equal access to and utilization of hospitals with high-quality surgical processes does not necessarily indicate equitable access to and utilization of hospitals with high-quality outcomes.

LEVEL OF EVIDENCE

Level III.

Equity-Driven Implementation of Patient-Reported Outcome Measures in Musculoskeletal Care: Advancing Value for All

ABSTRACT

The clinical use of patient-reported outcome measures (PROMs) in musculoskeletal care is expanding, encompassing both individual patient management and population-level applications. However, without thoughtful implementation, we risk introducing or exacerbating disparities in care processes or outcomes. We outline examples of opportunities, challenges, and priorities throughout PROM implementation to equitably advance value-based care at both the patient and population level. Balancing standardization with tailored strategies can enable the large-scale implementation of PROMs while optimizing care processes and outcomes for all patients.

Association of Rurality and Neighborhood Level Socioeconomic Deprivation with Perioperative Health Status in Total Joint Arthroplasty Patients: Analysis from a Large, Tertiary Care Hospital

BACKGROUND

Individual socioeconomic status (SES) is associated with disparities in access to care and worse outcomes in total joint arthroplasty (TJA). Neighborhood-level SES measures are sometimes used as a proxy for individual-level SES, but the validity of this approach is unknown. We examined neighborhood level SES and rurality on perioperative health status in TJA.

METHODS

The study population comprised 46,828 TJA surgeries performed at a tertiary care hospital. Community area deprivation index (ADI) was derived from the 2015 American Census Survey. Logistic regression was used to examine perioperative characteristics by ADI and rurality.

RESULTS

Compared to patients from the least deprived neighborhoods, patients from the most deprived neighborhoods were likely to be female (odds ratioOR 1.46, 95% confidence interval CI: 1.33-1.61), non-white (OR 1.36, 95% CI: 1.13-1.64), with education high school or less (OR 4.85, 95% CI: 4.35-5.41), be current smokers (OR 2.20, 95% CI: 1.61-2.49), have BMI>30 kg/m² (OR 1.43, 95% CI: 1.30-1.57), more limitation on instrumental activities of daily living (OR 1.75, 95% CI: 1.55-1.97) and American Society of Anesthesiologists (ASA) score > II (OR 2.0, 95% CI: 1.11-1.37). There was a progressive association between the degree of area level deprivation with preexisting comorbidities. Patients from rural communities were more likely to be male, white, have body mass index (BMI)>30 kg/m² and lower education levels. However, rurality was either not associated or negatively associated with comorbidities.

CONCLUSION

TJA patients from lower SES neighborhoods have worse behavioral risk factors and higher comorbidity burden than patients from higher SES neighborhoods. Patients from rural communities have worse behavioral risk factors but not comorbidities.

Overuse, underuse, and misuse: Improving effective primary care at a Federally Qualified Health Center

BACKGROUND

U.S. healthcare costs have increased exponentially to almost $4 trillion. Despite increased costs, patient outcomes remain suboptimal. It is imperative that primary care providers are intentional with testing and medical technology to improve effective care.

LOCAL PROBLEM

Preintervention chart audits showed average overspending of $79.41 per provider per day. Despite overspending, outcomes are not optimal. Only 48% of persons with hypertension and 38% of persons with diabetes at Orange Blossom Family Health (OBFH) are controlled. The aim of this 8-week quality improvement (QI) project was to decrease lab spending by 20% for adult primary care patients at OBFH.

METHODS

A rapid cycle QI initiative of four Plan-Do-Study-Act cycles, 2 weeks each, was completed to implement four interventions concurrently. The data was assessed every 2 weeks with iterative tests of change as indicated.

INTERVENTIONS

The primary care quality metrics chart audit and preclinical care coordination tools were developed, and the My Life, My Healthcare tool and medical assistant (MA)-provider huddles were initiated with the focus on effective patient care.

RESULTS

A savings of $3406.43 on overordering of labs by one provider in 8 weeks was identified. The average provider compliance to national guidelines was found to be 54.1%. There was a 19.3% increase in referrals. MA-provider huddles were balanced for this initiative.

CONCLUSIONS

The initiative addressed effective care through awareness of resource allocation, patient engagement, and team communication. Continued application of these core interventions will ensure consistent and quality healthcare.

Measuring Racial Inequities In The Quality Of Care Across Oncology Practices In The US

Racial inequities in clinical performance diminish overall health care system performance; however, quality assessments have rarely incorporated reliable measures of racial inequities. We studied care for more than one million Medicare fee-for-service beneficiaries with cancer to assess the feasibility of calculating reliable practice-level measures of racial inequities in chemotherapy-associated emergency department (ED) visits and hospitalizations. Specifically, we used hierarchical models to estimate adjusted practice-level Black-White differences in these events and described differences across practices. We calculated reliable inequity measures for 426 and 322 practices, depending on the measure. These practices reflected fewer than 10 percent of practices treating Medicare beneficiaries with chemotherapy, but they treated approximately half of all White and Black Medicare beneficiaries receiving chemotherapy and two-thirds of Black Medicare beneficiaries receiving chemotherapy. Black patients experienced chemotherapy-associated ED visits and hospitalizations at higher rates (54.2 percent and 35.8 percent, respectively) than White patients (45.7 percent and 31.9 percent, respectively). The median within-practice Black-White difference was 8.1 percentage points for chemotherapy-associated ED visits and 2.7 percentage points for chemotherapy-associated hospitalizations. Additional research is needed to identify other reliable measures of racial inequities in health care quality, measure care inequities in smaller practices, and assess whether providing practice-level feedback could improve equity.