1
|
Kilaru AS, Liao JM, Wang E, Zhao Y, Zhu J, Ng G, Shirk T, Cousins DS, Kanter GP, Ibrahim S, Navathe AS. Association between mandatory bundled payments and changes in socioeconomic disparities for joint replacement outcomes. Health Serv Res 2024; 59:e14369. [PMID: 39128893 PMCID: PMC11366957 DOI: 10.1111/1475-6773.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
OBJECTIVE To determine whether mandatory participation by hospitals in bundled payments for lower extremity joint replacement (LEJR) was associated with changes in outcome disparities for patients dually eligible for Medicare and Medicaid. DATA SOURCES AND STUDY SETTING We used Medicare claims data for beneficiaries undergoing LEJR in the United States between 2011 and 2017. STUDY DESIGN We conducted a retrospective observational study using a differences-in-differences method to compare changes in outcome disparities between dual-eligible and non-dual eligible beneficiaries after hospital participation in the Comprehensive Care for Joint Replacement (CJR) program. The primary outcome was LEJR complications. Secondary outcomes included 90-day readmissions and mortality. DATA EXTRACTION METHODS We identified hospitals in the US market areas eligible for CJR. We included beneficiaries in the intervention group who received joint replacement at hospitals in markets randomized to participate in CJR. The comparison group included patients who received joint replacement at hospitals in markets who were eligible for CJR but randomized to control. PRINCIPAL FINDINGS The study included 1,603,555 Medicare beneficiaries (mean age, 74.6 years, 64.3% women, 11.0% dual-eligible). Among participant hospitals, complications decreased between baseline and intervention periods from 11.0% to 10.1% for dual-eligible and 7.0% to 6.4% for non-dual-eligible beneficiaries. Among nonparticipant hospitals, complications decreased from 10.3% to 9.8% for dual-eligible and 6.7% to 6.0% for non-dual-eligible beneficiaries. In adjusted analysis, CJR participation was associated with a reduced difference in complications between dual-eligible and non-dual-eligible beneficiaries (-0.9 percentage points, 95% CI -1.6 to -0.1). The reduction in disparities was observed among hospitals without prior experience in a voluntary LEJR bundled payment model. There were no differential changes in 90-day readmissions or mortality. CONCLUSIONS Mandatory participation in a bundled payment program was associated with reduced disparities in joint replacement complications for Medicare beneficiaries with low income. To our knowledge, this is the first evidence of reduced socioeconomic disparities in outcomes under value-based payments.
Collapse
MESH Headings
- Humans
- United States
- Female
- Male
- Aged
- Retrospective Studies
- Medicare/statistics & numerical data
- Medicare/economics
- Socioeconomic Factors
- Healthcare Disparities/statistics & numerical data
- Patient Care Bundles/economics
- Arthroplasty, Replacement/economics
- Arthroplasty, Replacement/statistics & numerical data
- Patient Readmission/statistics & numerical data
- Aged, 80 and over
- Medicaid/statistics & numerical data
- Medicaid/economics
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Socioeconomic Disparities in Health
Collapse
Affiliation(s)
- Austin S. Kilaru
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Joshua M. Liao
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal Medicine, Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Erkuan Wang
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yueming Zhao
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jingsan Zhu
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Grace Ng
- Department of NeurosurgeryMassachusetts General HospitalBostonMassachusettsUSA
| | - Torrey Shirk
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Deborah S. Cousins
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Genevieve P. Kanter
- Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Said Ibrahim
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Amol S. Navathe
- The Parity Center, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Medical Ethics and Health Policy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of MedicineCorporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA
| |
Collapse
|
2
|
Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Insurance. J Arthroplasty 2024; 39:1637-1639. [PMID: 38360281 DOI: 10.1016/j.arth.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
3
|
Kim H, Hart KD, Senders A, Schabel K, Ibrahim SA. Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups. Popul Health Manag 2024; 27:128-136. [PMID: 38442304 DOI: 10.1089/pop.2023.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.
Collapse
Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle D Hart
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela Senders
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn Schabel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Said A Ibrahim
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, USA
| |
Collapse
|
4
|
Chakraborty A, Zhuang T, Shapiro LM, Amanatullah DF, Kamal RN. Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance? J Arthroplasty 2024; 39:606-611.e6. [PMID: 37778640 DOI: 10.1016/j.arth.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. METHODS Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. RESULTS Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). CONCLUSIONS Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.
Collapse
Affiliation(s)
- Aritra Chakraborty
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Thompson Zhuang
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Robin N Kamal
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| |
Collapse
|
5
|
Kumar N, Akosman I, Mortenson R, Xu G, Kumar A, Mostafa E, Rivlin J, De La Garza Ramos R, Krystal J, Eleswarapu A, Yassari R, Fourman MS. Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100315. [PMID: 38533185 PMCID: PMC10964016 DOI: 10.1016/j.xnsj.2024.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/13/2024] [Accepted: 02/12/2024] [Indexed: 03/28/2024]
Abstract
Background Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types. Methods A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007). Conclusions Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.
Collapse
Affiliation(s)
- Neerav Kumar
- Weill Cornell School of Medicine, New York, NY,
USA
| | | | | | - Grace Xu
- Princeton University, Princeton, NJ, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Oddleifson DA, Xu X, Wiznia D, Gibson D, Spatz ES, Desai NR. Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries. J Am Acad Orthop Surg 2023; 31:e961-e973. [PMID: 37543752 DOI: 10.5435/jaaos-d-23-00183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/11/2023] [Indexed: 08/07/2023] Open
Abstract
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.
Collapse
|
7
|
Dlott CC, Miguez S, Wilkins SG, Khunte A, Johnson CB, Kurek D, Wiznia DH. Metrics for Monitoring Preoperative Optimization Programs for Total Joint Arthroplasty: A Survey of Orthopaedic Nurses. Orthop Nurs 2023; 42:158-164. [PMID: 37262375 DOI: 10.1097/nor.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Preoperative optimization programs are becoming more common for patients seeking total joint arthroplasty; yet, limited research has been conducted to monitor the long-term effects of these programs on patient outcomes. Our aim was to develop a set of metrics that programs can use to monitor the success of preoperative optimization programs. As part of a larger survey of orthopaedic nurses, we collected data regarding current monitoring techniques for preoperative optimization programs and the feasibility of collecting specific variables. Surgical factors such as length of stay and 30-day readmissions were most often used to monitor the success of preoperative optimization programs. Surgical factors were the most likely to be accessible using the electronic medical record. Surgical factors and patient characteristics are the most feasible components for programs to monitor in order to track the outcomes of patients participating in preoperative optimization programs.
Collapse
Affiliation(s)
- Chloe C Dlott
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Sofia Miguez
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Sarah G Wilkins
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Akshay Khunte
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Charla B Johnson
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Donna Kurek
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Daniel H Wiznia
- Chloe C. Dlott, BS, Yale School of Medicine, New Haven, CT
- Sofia Miguez, BA, Yale School of Medicine, New Haven, CT
- Sarah G. Wilkins, BS, Yale School of Medicine, New Haven, CT
- Akshay Khunte, BS, Yale School of Medicine, New Haven, CT
- Charla B. Johnson, DNP, RN-BC, ONC, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Donna Kurek, MSN, MHA, RN, ONC, CMSRN, OrthoVirginia, Chesterfield, VA
- Daniel H. Wiznia, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
| |
Collapse
|
8
|
Li G, Yu F, Liu S, Weng J, Qi T, Qin H, Chen Y, Wang F, Xiong A, Wang D, Gao L, Zeng H. Patient characteristics and procedural variables are associated with length of stay and hospital cost among unilateral primary total hip arthroplasty patients: a single-center retrospective cohort study. BMC Musculoskelet Disord 2023; 24:6. [PMID: 36600222 PMCID: PMC9811718 DOI: 10.1186/s12891-022-06107-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is a successful treatment for many hip diseases. Length of stay (LOS) and hospital cost are crucial parameters to quantify the medical efficacy and quality of unilateral primary THA patients. Clinical variables associated with LOS and hospital costs haven't been investigated thoroughly. METHODS The present study retrospectively explored the contributors of LOS and hospital costs among a total of 452 unilateral primary THA patients from January 2019 to January 2020. All patients received conventional in-house rehabilitation services within our institute prior to discharge. Outcome parameters included LOS and hospital cost while clinical variables included patient characteristics and procedural variables. Multivariable linear regression analysis was performed to assess the association between outcome parameters and clinical variables by controlling confounding factors. Moreover, we analyzed patients in two groups according to their diagnosis with femur neck fracture (FNF) (confine THA) or non-FNF (elective THA) separately. RESULTS Among all 452 eligible participants (266 females and 186 males; age 57.05 ± 15.99 year-old), 145 (32.08%) patients diagnosed with FNF and 307 (67.92%) diagnosed with non-FNF were analyzed separately. Multivariable linear regression analysis revealed that clinical variables including surgery duration, transfusion, and comorbidity (stroke) among the elective THA patients while the approach and comorbidities (stoke, diabetes mellitus, coronary heart disease) among the confine THA patients were associated with a prolonged LOS (P < 0.05). Variables including the American Society of Anesthesiologists classification (ASA), duration, blood loss, and transfusion among the elective THA while the approach, duration, blood loss, transfusion, catheter, and comorbidities (stoke and coronary heart disease) among the confine THA were associated with higher hospital cost (P < 0.05). The results revealed that variables were associated with LOS and hospital cost at different degrees among both elective and confine THA. CONCLUSIONS Specific clinical variables of the patient characteristics and procedural variables are associated the LOS and hospital cost, which may be different between the elective and confine THA patients. The findings may indicate that evaluation and identification of detailed perioperative factors are beneficial in managing perioperative preparation, adjusting patients' anticipation, decreasing LOS, and reducing hospital cost.
Collapse
Affiliation(s)
- Guoqing Li
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Fei Yu
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Su Liu
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Jian Weng
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Tiantian Qi
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Haotian Qin
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Yixiao Chen
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Fangxi Wang
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Ao Xiong
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Deli Wang
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| | - Liang Gao
- Center for Clinical Medicine, Huatuo Institute of Medical Innovation (HTIMI), 10787 Berlin, Germany ,Sino Euro Orthopaedics Network (SEON), Berlin, Germany
| | - Hui Zeng
- grid.440601.70000 0004 1798 0578Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036 ,grid.440601.70000 0004 1798 0578National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, Shenzhen, People’s Republic of China 518036
| |
Collapse
|
9
|
Orthopaedic Nurse Navigator Involvement in Preoperative Optimization for Total Joint Arthroplasty. Orthop Nurs 2023; 42:48-52. [PMID: 36702096 DOI: 10.1097/nor.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Patients seeking total joint arthroplasty frequently undergo preoperative optimization with the assistance of nurse navigators to facilitate interactions between patients, consulting services, and the orthopaedic surgical team. Given the enormous impact nurse navigator programs have on reducing postoperative complications, our aim is to characterize the involvement of nurse navigators in preoperative optimization programs across the country. We conducted a survey of nurse navigators identified through the National Association of Orthopaedic Nurses to assess the involvement of nurse navigators in the preoperative optimization process. Sixty-seven percent of responding nurse navigators were involved in preoperative optimization, including components such as heart disease (53%) and poorly controlled diabetes (52%). Orthopaedic nurse navigators are commonly involved in preoperative optimization programs for total joint arthroplasty but most of these involve gated yes/no checklists with limited established referral care pathways. Only some of the programs include standardized referrals for specific medical comorbidities.
Collapse
|
10
|
Ng MK, Lam A, Diamond K, Piuzzi NS, Roche M, Erez O, Wong CHJ, Mont MA. What are the Causes, Costs and Risk-Factors for Emergency Department Visits Following Primary Total Hip Arthroplasty? An Analysis of 1,018,772 Patients. J Arthroplasty 2023; 38:117-123. [PMID: 35863689 DOI: 10.1016/j.arth.2022.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/26/2022] [Accepted: 07/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Well-powered studies analyzing the relationship and nature of emergency department (ED) visits following primary total hip arthroplasties (THAs) are limited. The aim of this study was to: 1) compare baseline demographics of patients with/without an ED visit; 2) determine leading causes of ED visits; 3) identify patient-related risk factors; and 4) quantify 90-day episode-of-care healthcare costs divided by final diagnosis. METHODS Patients undergoing primary THA between January 1, 2010 and October 1, 2020 who presented to the ED within 90-days postoperatively were identified using the Mariner dataset of PearlDiver, yielding 1,018,772 patients. This included 3.9% (n = 39,439) patients who did and 96.1% (n = 979,333) who did not have an ED visit. Baseline demographics between the control/study cohorts, ED visit causes, risk-factors, and subsequent costs-of-care were analyzed. Using Bonferroni-correction, a P-value less than 0.002 was considered statistically significant. RESULTS Patients who presented to the ED post-operatively were most often aged 65-74 years old (41.09%) or female sex (55.60%). Nonmusculoskeletal etiologies comprised 66.8% of all ED visits. Risk factors associated with increased ED visits included alcohol abuse, depressive disorders, congestive heart failure, coagulopathy, and electrolyte/fluid derangements (P < .001 for all). Pulmonary ($28,928.01) and cardiac ($28,574.69) visits attributed to the highest costs of care. CONCLUSION Nonmusculoskeletal causes constituted the majority of ED visits. The top five risk factors associated with increased odds of ED visits were alcohol abuse, electrolyte/fluid derangements, congestive heart failure, coagulopathy, and depression. This study highlights potential areas of pre-operative medical optimization that may reduce ED visits following primary THA.
Collapse
Affiliation(s)
- Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Aaron Lam
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Keith Diamond
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Nicolas S Piuzzi
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Martin Roche
- Hospital for Special Surgery, Department of Orthopaedic Surgery, West Palm Beach, Florida
| | - Orry Erez
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Che Hang Jason Wong
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Michael A Mont
- Hospital for Special Surgery, Department of Orthopaedic Surgery, West Palm Beach, Florida; Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| |
Collapse
|
11
|
Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities. ARTHROPLASTY (LONDON, ENGLAND) 2022; 4:36. [PMID: 36184658 PMCID: PMC9528115 DOI: 10.1186/s42836-022-00137-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/13/2022] [Indexed: 11/07/2022]
Abstract
Background Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. Methods A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, “disparities”, “arthroplasty”, “income”, “insurance”, “outcomes”, and “hospital volume” in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. Results A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. Conclusion This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients’ access to, utilization of, and outcomes after TJA. Level of evidence IV. Supplementary Information The online version contains supplementary material available at 10.1186/s42836-022-00137-4.
Collapse
Affiliation(s)
- Paul M. Alvarez
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - John F. McKeon
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Andrew I. Spitzer
- grid.50956.3f0000 0001 2152 9905Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, USA
| | - Chad A. Krueger
- grid.512234.30000 0004 7638 387XDepartment of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Matthew Pigott
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Mengnai Li
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Sravya P. Vajapey
- grid.412332.50000 0001 1545 0811Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
| |
Collapse
|
12
|
Suleiman LI, Tucker K, Ihekweazu U, Huddleston JI, Cohen-Rosenblum AR. Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration. J Arthroplasty 2022; 37:1421-1425. [PMID: 35158005 DOI: 10.1016/j.arth.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/16/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.
Collapse
Affiliation(s)
- Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL
| | | | | | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Anna R Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| |
Collapse
|
13
|
Muchiri S, Pakdil F, Beazoglou H. The length of stay and readmissions of THA and TKA patients: A longitudinal analysis using a nationwide readmissions data. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Steve Muchiri
- Department of Economics and Finance, Eastern Connecticut State University, Willimantic, CT, USA
| | - Fatma Pakdil
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
| | - Hannah Beazoglou
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
| |
Collapse
|
14
|
The Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain After Primary Total Hip Arthroplasty. J Am Acad Orthop Surg 2022; 30:e998-e1004. [PMID: 35412501 DOI: 10.5435/jaaos-d-21-01057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/08/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients. METHODS A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients. RESULTS A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P < 0.001, P < 0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P < 0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P < 0.001). Surgical time (113 versus 96 versus 98 mins; P < 0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P < 0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P < 0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P < 0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P < 0.001 and 73.8 versus 28.4 versus 29.8; P < 0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P < 0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P < 0.001). CONCLUSIONS Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.
Collapse
|
15
|
Bernstein JA, Rana A, Iorio R, Huddleston JI, Courtney PM. The Value-Based Total Joint Arthroplasty Paradox: Improved Outcomes, Decreasing Cost, and Decreased Surgeon Reimbursement, Are Access and Quality at Risk? J Arthroplasty 2022; 37:1216-1222. [PMID: 35158003 DOI: 10.1016/j.arth.2022.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Adam Rana
- Department of Orthopedics and Sports Medicine, Maine Medical Center, Portland, ME
| | - Richard Iorio
- Brigham and Women's Hospital, Harvard Medical School, Department of Orthopaedic Surgery, Boston, MA
| | | | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
16
|
Kammien AJ, Galivanche AR, Gouzoulis MJ, Moore HG, Mercier MR, Grauer JN. Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 10:100122. [PMID: 35637647 PMCID: PMC9144013 DOI: 10.1016/j.xnsj.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 10/28/2022]
Abstract
Background Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use. Methods Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression. Results Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001). Conclusions More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.
Collapse
Affiliation(s)
- Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA
| | - Anoop R. Galivanche
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA
| | - Michael J. Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA
| | | | - Michael R. Mercier
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510, USA
| |
Collapse
|
17
|
Dlott CC, Pei X, Ittner JL, Lefar SL, O'Connor MI. Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:3060-3066.e1. [PMID: 34099350 DOI: 10.1016/j.arth.2021.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/18/2021] [Accepted: 04/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the number of total hip arthroplasty and total knee arthroplasty (THA and TKA) increases, individuals of color continue to be less likely to undergo these procedures. Socioeconomic status may be a key influencer of THA and TKA utilization and outcomes. We explore the influence of net worth and race on THA and TKA utilization and outcomes of length of stay and readmissions using a large patient database. METHODS The StrataSphere data set, an aggregation of 49 health systems representing 209 hospitals, was used for primary THA and TKA procedures performed in the calendar year 2019. Net worth was determined from Market Vue Partners' data sources. Statistical analyses were performed to investigate relationships between net worth and patients undergoing THA or TKA. RESULTS When comparing our overall patient cohorts with the US population using Census data, we found differences in the utilization pattern indicated by index ratios most clearly in the lowest net worth categories. In the <$10K net worth category, THA and TKA index ratios were 0.51 and 0.54, respectively. In addition, we found that patients in the $100-250 and $250-500K net worth categories had increased utilization of both THA (index ratios of 1.39, 1.53) and TKA (index ratios of 1.45, 1.47) surgeries. CONCLUSION Net worth is a strong driver of disparities in utilization of THA and TKA with lower utilization of these surgeries in patients with net worth <$10K and increased utilization in patients with net worth from $100-250 and $250-500K.
Collapse
Affiliation(s)
| | - Xun Pei
- Strata Decision Technology, Chicago, IL
| | | | | | | |
Collapse
|
18
|
Pritchard KT, Hong I, Goodwin JS, Westra JR, Kuo YF, Ottenbacher KJ. Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement. J Am Med Dir Assoc 2021; 22:1735-1743.e3. [PMID: 33041232 PMCID: PMC8026771 DOI: 10.1016/j.jamda.2020.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/07/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Understand the association between social determinants of health and community discharge after elective total joint arthroplasty. DESIGN Retrospective cohort design using Optum de-identified electronic health record dataset. SETTING AND PARTICIPANTS A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018. METHODS Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics. RESULTS Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively. CONCLUSIONS AND IMPLICATIONS Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.
Collapse
Affiliation(s)
- Kevin T Pritchard
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Ickpyo Hong
- Department of Occupational Therapy, Yonsei University, Wonju-si, South Korea.
| | - James S Goodwin
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, Galveston, TX, USA; Department of Internal Medicine, School of Medicine, University of Texas Medical Branch, Galveston, TX, USA; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan R Westra
- Department of Preventive Medicine and Population Health, School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA; Department of Preventive Medicine and Population Health, School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, Galveston, TX, USA; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
19
|
Liang Y, Rascati K, Richards K. Prevalence of primary immune thrombocytopenia and related healthcare resource utilization among Texas Medicaid beneficiaries. Curr Med Res Opin 2021; 37:1315-1322. [PMID: 33910428 DOI: 10.1080/03007995.2021.1923469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To estimate the prevalence of primary immune thrombocytopenia (ITP) and describe ITP-associated healthcare resource utilization (HRU) among Texas Medicaid beneficiaries. METHODS A retrospective analysis using 2012-2015 Texas Medicaid claims data was conducted to estimate the annual prevalence of ITP. HRU was summarized for the 12-month period following initial ITP diagnosis. Logistic regression and generalized linear model were used to investigate predictors for all-cause and ITP-related HRU. RESULTS The average annual prevalence of ITP was 17.0 per 100,000 persons; higher among females vs males (17.4 vs 13.6 per 100,000) and highest among adults aged ≥ 65 years (36.7 per 100,000). Among 325 patients included in the HRU analyses, 49.2% received ITP therapies. More than half of patients had at least one all-cause emergency department (ED) visit (70.5%) and/or hospitalization (56.0%). One-third (32.6%) experienced at least one ITP-related ED visit and 40.3% had at least one ITP-related hospitalization. Compared to adults aged 18-49 with ITP, children aged 0-4 (odds ratio [OR] = 3.65, p = .0008) and aged 5-17 (OR = 2.68, p = .0074) were more likely to have an ITP-related hospitalization; children aged 0-4 (OR = 4.36, p = .0005) and children aged 5-17 (OR = 4.09, p = .0005) were more likely to have an ITP-related ED visit during the follow-up period. CONCLUSION There are 17 patients diagnosed with ITP for every 100,000 Texas Medicaid enrollees annually, with higher prevalence in females and the elderly. Children are more likely to experience hospitalizations and ED visits associated with ITP. ITP patients in Texas Medicaid utilize more healthcare resources compared to the general Medicaid population.
Collapse
Affiliation(s)
- Yi Liang
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Karen Rascati
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE-Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kristin Richards
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE-Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| |
Collapse
|
20
|
Racial and socioeconomic disparities among patients undergoing hip arthroplasty: a New York State population analysis. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Karnuta JM, Dalton S, Bena J, Farrow LD, Featherall J, Jones MH, Miniaci AA, Parker RD, Rosneck JT, Saluan P, Strnad G, Spindler KP, Williams JS, Oak SR. Do Narcotic Use, Physical Therapy Location, or Payer Type Predict Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction? Orthop J Sports Med 2021; 9:2325967121994833. [PMID: 33997058 PMCID: PMC8085373 DOI: 10.1177/2325967121994833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors' integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric-Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score. RESULTS A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (-4.551, P = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score. CONCLUSION Increased narcotic use surrounding surgery, physical therapy location within the authors' health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Kurt P. Spindler
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | | | | |
Collapse
|
22
|
Li Y, Ying M, Cai X, Thirukumaran CP. Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients. Med Care 2021; 59:101-110. [PMID: 33273296 PMCID: PMC7855778 DOI: 10.1097/mlr.0000000000001473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.
Collapse
Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Orthopaedics, University of Rochester Medical Center
| |
Collapse
|
23
|
Krueger CA, Yayac M, Vannello C, Wilsman J, Austin MS, Courtney PM. Are We at the Bottom? BPCI Programs Now Disincentivize Providers Who Maintain Quality Despite Caring for Increasingly Complex Patients. J Arthroplasty 2021; 36:13-18. [PMID: 32800668 DOI: 10.1016/j.arth.2020.07.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The Bundled Payments for Care Improvement (BPCI) initiative has been successful at reducing Medicare costs after total joint arthroplasty (TJA). Target pricing is based on each institution's historical performance and is periodically reset. The purpose of this study was to examine the performance of our BPCI program accounting for patient complexity, quality, and resource utilization. METHODS We reviewed a consecutive series of 9195 Medicare patients undergoing primary TJA from 2015 to 2018. Demographics, comorbidities, and readmissions by year were compared. We then examined 90-day episode-of-care costs, changes in target price, and financial margins during the duration of the BPCI program using Medicare claims data. RESULTS Patients undergoing TJA in 2018 had a higher prevalence of diabetes and cardiac disease (all P < .001) as compared with those in 2015. From 2015 to 2018, there was a decrease in the rate of discharge to rehabilitation facilities (23% vs 14%, P < .001) and length of stay (2.1 vs 1.7 days, P < .001) with no difference in readmissions (6% vs 6%, P = .945). There was a reduction in postacute care costs ($6076 vs $4,890, P < .001) and 90-day episode-of-care costs ($19,954 vs $18,449, P < .001). However, the target price also decreased ($22,280 vs $18,971, P < .001), and the per-patient margin diminished ($2683 vs $522, P < .001). CONCLUSION Surgeons have maintained quality of care at a reduced cost despite increasing patient complexity. The target price adjustments resulted in declining margins during the course of our BPCI experience. Policy makers should consider changes to target price methodology to encourage participation in these successful cost-saving programs.
Collapse
Affiliation(s)
- Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Michael Yayac
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Chris Vannello
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - John Wilsman
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Matthew S Austin
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| |
Collapse
|
24
|
Maldonado-Rodriguez N, Ekhtiari S, Khan MM, Ravi B, Gandhi R, Veillette C, Leroux T. Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:3038-3045.e1. [PMID: 32540306 DOI: 10.1016/j.arth.2020.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Recent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty. METHODS PubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means. RESULTS Twenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits. CONCLUSION ED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.
Collapse
Affiliation(s)
- Naomi Maldonado-Rodriguez
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin M Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Veillette
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| | - Timothy Leroux
- Division of Orthopaedic Surgery, Department of Surgery, The Arthritis Program, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
25
|
Plate JF, Ryan SP, Bergen MA, Hong CS, Mont MA, Bolognesi MP, Seyler TM. Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty. Orthopedics 2020; 43:295-302. [PMID: 32931589 DOI: 10.3928/01477447-20200818-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/25/2019] [Indexed: 02/03/2023]
Abstract
Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [Orthopedics. 2020;43(5):295-302.].
Collapse
|
26
|
Li Y, Ying M, Cai X, Kim Y, Thirukumaran CP. Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016. JAMA Netw Open 2020; 3:e200368. [PMID: 32129866 PMCID: PMC7057132 DOI: 10.1001/jamanetworkopen.2020.0368] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown. OBJECTIVES To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits. DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted of PAC use and outcomes among Medicare fee-for-service patients undergoing hip or knee replacement surgery from January 1, 2013, to December 31, 2016, in approximately 3000 hospitals, using Medicare claims, assessment, hospital, and skilled nursing facility (SNF) files. Statistical analysis was performed from October 1, 2018, to December 17, 2019. MAIN OUTCOMES AND MEASURES Risk-adjusted differences among dual-eligible groups in institutional PAC use (SNF, inpatient rehabilitation, or long-term hospital care), readmission rate, and payment for readmissions; for patients discharged to a SNF, risk-adjusted differences in SNF quality measured by star ratings, proportion successfully discharged to the community, proportion transitioned to long-stay residence, and SNF length of stay and payments. RESULTS The sample included 1 302 256 patients (837 256 women [64.3%]; mean [SD] age, 75.4 [7.2] years) who underwent joint replacement. The proportion of patients discharged to institutional PAC and the 30-day and 90-day readmission rates decreased for all 3 groups during the period from 2013 to 2016. In 2013, institutional PAC use was 43.7% (95% CI, 43.5%-43.9%) for Medicare-only patients (n = 1 182 555), 70.1% (95% CI, 69.4%-70.8%; n = 60 461) for dual-eligible patients with full benefits, and 70.3% (95% CI, 69.6%-71.0%; n = 59 240) for dual-eligible patients with partial benefits; in 2016, the rates decreased to 32.5% (95% CI, 32.4%-32.7%) for Medicare-only patients, 62.3% (95% CI, 61.5%-63.0%) for dual-eligible patients with full benefits, and 61.5% (95% CI, 60.7%-62.3%) for dual-eligible patients with partial benefits. Among patients discharged to SNFs, outcomes remained flat over time. For example, the proportion of patients successfully discharged to the community remained at 80.5% (95% CI, 80.4%-80.7%) for Medicare-only patients, 59.8% (95% CI, 59.3%-60.3%) for dual-eligible patients with full benefits, and 50.0% (95% CI, 49.4%-50.5%) for dual-eligible patients with partial benefits. Multivariable analyses with adjustment for patient, hospital (or SNF), and geographical covariates suggested maintained or enlarged gaps in all outcomes. CONCLUSIONS AND RELEVANCE This study suggests that, during the period from 2013 to 2016, Medicare patients undergoing hip or knee replacement showed reduced institutional PAC use, reduced readmissions, and, among those discharged to SNFs, roughly unchanged outcomes. However, dual-eligible patients, especially those with partial Medicaid benefits, had persistently worse outcomes than Medicare-only patients.
Collapse
Affiliation(s)
- Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Meiling Ying
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - Yeunkyung Kim
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Caroline Pinto Thirukumaran
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
27
|
Halawi MJ, Stone AD, Gronbeck C, Savoy L, Cote MP. Medicare coverage is an independent predictor of prolonged hospitalization after primary total joint arthroplasty. Arthroplast Today 2019; 5:489-492. [PMID: 31886395 PMCID: PMC6920717 DOI: 10.1016/j.artd.2019.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to investigate the association between insurance type and length of stay (LOS) in primary total joint arthroplasty. A retrospective review of 848 patients was performed. Patients were divided into 3 groups based on their insurance type: Medicare, Medicaid, or commercial coverage. Medicare patients had a significantly higher rate of LOS > 2 days than the Medicaid and commercial groups (P < .0001). The effect of Medicare coverage on LOS remained significant even after controlling for baseline differences among the study groups. There were no differences in the rates of 90-day emergency room visits and readmissions between the 3 groups (P > .05). Arthroplasty surgeons not experienced with outpatient surgery should not be pressured to default to outpatient admission in Medicare patients.
Collapse
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Andrew D Stone
- University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Lawrence Savoy
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| |
Collapse
|
28
|
Response to Letter to the Editor on "Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty". J Arthroplasty 2019; 34:1857-1858. [PMID: 31036451 DOI: 10.1016/j.arth.2019.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 02/01/2023] Open
|
29
|
Stambough JB, Shnaekel AW, White RS. Letter to the Editor on "Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty". J Arthroplasty 2019; 34:1856-1857. [PMID: 31031159 DOI: 10.1016/j.arth.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/03/2019] [Indexed: 02/01/2023] Open
Affiliation(s)
- Jeffrey B Stambough
- Department of Orthopaedic Surgery, The University of Arkansas for Medical Sciences, Little Rock, AR
| | - Asa W Shnaekel
- Department of Orthopaedic Surgery, The University of Arkansas for Medical Sciences, Little Rock, AR
| | - Robert S White
- Department of Anesthesiology, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| |
Collapse
|