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1.
Ronald E. Delanois Chukwuweike U. Gwam Jeffrey J. Cherian Jennifer I. Etcheson Nequesha S. Mohamed Kathleen A. Schneider Michael A. Mont 《The Journal of arthroplasty》2019,34(1):15-19
Background
Maryland was granted a waiver to implement a Global Budget Revenue (GBR) reimbursement model. Statewide results for combined medical and surgical services have been reported for fiscal years 2015 and 2016. A paucity of studies exists exploring the change in care costs and outcomes for total knee arthroplasty (TKA) recipients under GBR. This study aims to assess the effects of GBR on cost of care and resource utilization related to TKA at a single institution before and after GBR.Methods
The Maryland Center for Medicare and Medicaid Services database was used to find Medicare patients who underwent TKA at a single institution before (2012-2013) and after (2014-2015) GBR. A total of 150 and 161 TKAs were performed in 2012 and 2015. Cost differences were compared for each inpatient care episode, postacute care period, and readmissions. We also evaluated differences in length of stay, discharge disposition, and complication rates.Results
Mean inpatient cost was significantly lower in 2015 vs 2012 (P = .0014); however, analysis of postacute costs showed a nonsignificant increase in price between years (P = .1008). We demonstrated significant increase in home health (P < .0001) and significant decrease in acute rehabilitation (P = .0481). Durable medical equipment costs significantly decreased (P = .0087).Conclusion
We demonstrate lower mean inpatient costs since GBR initiation. We reveal increased mean postacute care costs, which may be due to increased acuity for patients needing postacute care. Our results show nonsignificant reductions in length of stay, complications, and increased rate of home discharge, suggesting GBR may be effective in orchestrating reduced costs for TKA at high-volume institutions. 相似文献2.
Ronald E. Delanois Chukwuweike U. Gwam Jeffrey J. Cherian Jennifer I. Etcheson Iciar M. Dávila Castrodad Kurt P. Spindler Michael A. Mont 《The Journal of arthroplasty》2019,34(2):201-205
Background
Maryland is the only state utilizing the Global Budget Revenue (GBR) model to reduce costs. The purpose of this study is to evaluate whether the GBR payment model effectively reduced the following: (1) costs of inpatient hospital stays; (2) post-acute care costs; (3) lengths of stay (LOS); (4) readmission rates; and (5) discharge disposition in patients who underwent primary total hip and knee arthroplasty (THA and TKA).Methods
We evaluated the Maryland Centers for Medicare & Medicaid Service database for THAs and TKAs performed at 6 hospitals 1 year prior to (2012) and after the initiation of GBR (2015). We compared differences in costs for each inpatient care episode, post-acute care periods (total costs, acute rehabilitation, short-term nursing facility, home health, durable medical equipment), readmissions, LOS, and discharge disposition.Results
Hospitals had a significant reduction in mean inpatient care costs for THA and TKA (P < .0001). There was a significant reduction in total post-acute care costs following THA (P < .001). Home healthcare had a significant increase in cost following THA and TKA (P < .0001). There was a significant reduction in durable medical equipment costs for THA (P < .0001). There was a significant decrease in LOS for THA and TKA (P < .0001). There was a significant increase in patients discharged home (THA, P = .0262; TKA, P = .0058).Conclusion
The Maryland healthcare model may be associated with a reduction in inpatient and post-acute care costs. Furthermore, implementation of GBR may result in reductions in LOS and readmission rates. 相似文献3.
P. Maxwell Courtney Tori Edmiston Brian Batko Brett R. Levine 《The Journal of arthroplasty》2017,32(11):3263-3267
Background
Although some bundled payment models have had success in total joint arthroplasty, concerns exist about access to care for higher cost patients who use more resources. The purpose of this study is to determine whether Medicaid patients have increased hospital costs and more resource utilization in a 90-day episode of care than Medicare or privately insured patients.Methods
We retrospectively reviewed a consecutive series of 7268 primary hip and knee arthroplasty patients at a single institution. Using a propensity score-matching algorithm for demographic variables, we matched the 92 consecutive Medicaid patients with 184 privately insured and 184 Medicare patients. Hospital-specific costs, discharge disposition, complications, and 90-day readmissions were analyzed.Results
Medicaid patients had higher mean inpatient hospital costs than both of the matched Medicare and privately insured groups ($15,396 vs $12,165 vs $13,864, P < .001) with longer length of stay (3.34 vs 2.49 vs 1.46 days, P < .001). Medicaid and Medicare patients were more likely to be discharged to a rehabilitation facility than privately insured patients (17% vs 21% vs 1%, P < .001). When controlling for demographic factors and comorbidities, Medicaid insurance was a significant independent risk factor for increased hospital costs (odds ratio 3.64, 95% confidence interval 1.80-7.38, P < .001).Conclusion
Because of increased hospital costs, current bundled payment models should not include Medicaid patients because of concerns about patient selection and access to care. Further study is needed to determine whether bundling Medicaid arthroplasty costs in a stand-alone program with a separate target price will result in improved outcomes and decreased costs. 相似文献4.
Brandon A. Haghverdian David J. Wright Ran Schwarzkopf 《The Journal of arthroplasty》2017,32(2):367-374
Background
The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.Methods
We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.Results
LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.Conclusion
Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones. 相似文献5.
Karim G. Sabeh Samuel Rosas Leonard T. Buller Martin W. Roche Victor H. Hernandez 《The Journal of arthroplasty》2017,32(10):2969-2973
Background
Total joint arthroplasty (TJA) accounts for more Medicare expenditure than any other inpatient procedure. The Comprehensive Care for Joint Replacement model was introduced to decrease cost and improve quality in TJA. The largest portion of episode-of-care costs occurs after discharge. This study sought to quantify the cost variation of primary total hip arthroplasty (THA) according to discharge disposition.Methods
The Medicare and Humana claims databases were used to extract charges and reimbursements to compare day-of-surgery and 91-day postoperative costs simulating episode-of-care reimbursements. Of the patients who underwent primary THA, 257,120 were identified (204,912 from Medicare and 52,208 from Humana). Patients were stratified by discharge disposition: home with home health, skilled nursing facility, or inpatient rehabilitation facility.Results
There is a significant difference in the episode-of-care costs according to discharge disposition, with discharge to an inpatient rehabilitation facility the most costly and discharge to home the least costly.Conclusion
Postdischarge costs represent a sizeable portion of the overall expense in THA, and optimizing patients to allow safe discharge to home may help reduce the cost of THA. 相似文献6.
P. Maxwell Courtney Nicholas B. Frisch Daniel D. Bohl Craig J. Della Valle 《The Journal of arthroplasty》2018,33(1):1-5
Background
Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals.Methods
We queried the Centers for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 2702 hospitals that performed a total of 458,259 primary arthroplasty procedures in 2014. Centers were defined as low (performing <100 total joint arthroplasty [TJA] per year) or high volume and mean total hospital-specific charges and inpatient payments were obtained. Patient satisfaction scores as well 30-day risk-adjusted complication and readmission scores were obtained from the multiyear CMS Hospital Compare database.Results
Of all the hospitals, 1263 (47%) hospitals were classified as low volume and performed 60,895 (12%) TJA cases. Higher volume hospitals had lower mean total hospital-specific charges ($56,323 vs $60,950, P < .001) and mean Medicare inpatient payments ($12,131 vs $13,289, P < .001). Higher volume facilities had a lower complication score (2.96 vs 3.16, P = .015), and a better CMS hospital star rating (3.14 vs 2.89, P < .001). When controlling for hospital geographic and demographic factors, lower volume hospitals are more likely to be in the upper quartile of inpatient Medicare costs (odds ratio 2.127, 95% confidence interval 1.726-2.621, P < .001).Conclusion
Hospitals that perform <100 TJA cases per year may benefit from adopting the practices of higher volume centers in order to improve quality and reduce costs. 相似文献7.
Trevor R. Grace Joseph T. Patterson Jennifer Tangtiphaiboontana Justin D. Krogue Thomas P. Vail Derek T. Ward 《The Journal of arthroplasty》2018,33(6):1681-1685
Background
The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD).Methods
Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group.Results
A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P < .001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021).Conclusion
Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care. 相似文献8.
William B. Weeks William J. Schoellkopf Lyle S. Sorensen Andrew L. Masica Robert E. Nesse James N. Weinstein 《The Journal of arthroplasty》2017,32(3):702-708
Background
Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value.Methods
We conducted a retrospective, cross-sectional observational cohort study of 30-day episodes of care for hip and knee arthroplasty in fee-for-service Medicare beneficiaries aged 65 or older who had hip or knee osteoarthritis and used 1 of 13 HVHC member systems for uncomplicated primary hip arthroplasty (N = 8853) or knee arthroplasty (N = 16,434), respectively, in 2012 or 2013. At the system level, we calculated: per-capita utilization rates; postoperative complication rates; standardized total, acute, and postacute care Medicare expenditures for 30-day episodes of care; and the modeled impact of reducing episode expenditures or per-capita utilization rates.Results
Adjusted per-capita utilization rates varied across HVHC systems and postacute care reimbursements varied more than 3-fold for both types of arthroplasty in both years. Regression analysis confirmed that total episode and postacute care reimbursements significantly differed across HVHC members after considering patient demographic differences. Potential Medicare cost savings were greatest for knee arthroplasty surgery and when lower total reimbursement targets were achieved.Conclusion
The substantial variation that we found offers opportunities for learning and collaboration to collectively improve outcomes, reduce costs, and enhance value. Ceteris paribus, reducing per-episode reimbursements would achieve greater Medicare cost savings than reducing per-capita rates. 相似文献9.
Background
The Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities.Methods
This practice implemented a standardized CP focused on patient education, managing patient expectations, and maximizing cost outcomes. We retrospectively reviewed all primary total joint arthroplasty patients during the initial 2-year “at risk” period for both BPCI and API and determined discharge disposition, LOS, and readmission rate.Results
During the “at risk” period, the average LOS decreased in our total joint arthroplasty patients and our patients discharged home >94%. Patients within the BPCI group had a decreased discharge to home and decreased readmission rates after total hip arthroplasty, but also tended to be older than both API and nonbundled payment patients.Conclusion
While participating in the BPCI and API, continued use of a standardized CP in a high-performing, high-volume total joint practice resulted in maintenance of a low-average LOS. In addition, BPCI patients had similar outcomes after total knee arthroplasty, but had decreased rates of discharge to home and readmission after total hip arthroplasty. 相似文献10.
Jessica L.H. Phillips Alexander J. Rondon Zylyftar Gorica Yale A. Fillingham Matthew S. Austin P. Maxwell Courtney 《The Journal of arthroplasty》2018,33(12):3607-3611
Background
Due to concerns about higher complication rates, surgeons debate whether to perform simultaneous bilateral total joint arthroplasty (BTJA), particularly in the higher-risk Medicare population. Advances in pain management and rehabilitation protocols have called into question older studies that found an overall cost benefit for simultaneous procedures. The purpose of this study was to compare 90-day episode-of-care costs between staged and simultaneous BTJA among Medicare beneficiaries.Methods
We retrospectively reviewed a consecutive series of 319 simultaneous primary TJAs and 168 staged TJAs (336 procedures) at our institution between 2015 and 2016. We recorded demographics, comorbidities, readmission rates, and 90-day episode-of-care costs based upon Centers for Medicare and Medicaid Services claims data. To control for confounding variables, we performed a multivariate regression analysis to identify independent risk factors for increased costs.Results
Simultaneous patients had decreased inpatient facility costs ($19,402 vs $23,025, P < .001), increased post-acute care costs ($13,203 vs $10,115, P < .001), and no difference in total episode-of-care costs ($35,666 vs $37,238, P = .541). Although there was no difference in readmissions (8% vs 9%, P = .961), simultaneous bilateral patients were more likely to experience a thromboembolic event (2% vs 0%, P = .003). When controlling for demographics, procedure, and comorbidities, a simultaneous surgery was not associated with an increase in episode-of-care costs (P = .544). Independent risk factors for increased episode-of-care costs following BTJA included age ($394 per year increase, P < .001), cardiac disease ($4877, P = .025), history of stroke ($14,295, P = .010), and liver disease ($12,515, P = .016).Conclusion
In the Medicare population, there is no difference in 90-day episode-of-care costs between simultaneous and staged BTJA. Surgeons should use caution in performing a simultaneous procedure on older patients or those with a history of stroke, cardiac, or liver disease. 相似文献11.
Udai S. Sibia Justin J. Turcotte James H. MacDonald Paul J. King 《The Journal of arthroplasty》2017,32(9):2655-2657
Background
The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule.Methods
The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3.Results
A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486.Conclusion
The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated. 相似文献12.
John M. Yanik Nicholas A. Bedard Jessica M. Hanley Jesse E. Otero John J. Callaghan John L. Marsh 《The Journal of arthroplasty》2018,33(10):3138-3142
Background
Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.Methods
In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.Results
After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).Conclusion
In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty. 相似文献13.
Jarrett Williams Benjamin S. Kester Joseph A. Bosco James D. Slover Richard Iorio Ran Schwarzkopf 《The Journal of arthroplasty》2017,32(3):714-718
Background
To curb the unsustainable rise in health care expenses, health care payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered to patients. Payers are utilizing various metrics, such as length of stay (LOS) and unplanned readmissions, to track progression of quality metrics. Relevant to orthopedic surgeons, the Centers for Medicare and Medicaid Services announced in 2015 the Comprehensive Care for Joint Replacement Payment Model—a program aimed at improving the quality of health care delivered to patients by shifting more of the financial risk of patient care onto providers.Methods
We analyzed the medical records of 1329 consecutive lower extremity total joint patients enrolled in Centers for Medicare and Medicaid Services' Bundled Program for Care Improvement treated over a 21-month period. The goal of this study was to ascertain if hospital LOS is associated with unplanned readmissions within 90 days of admission for a total hip or knee arthroplasty.Results
After controlling for multiple demographic variables including sex, age, comorbidities and discharge location, we found that hospital LOS greater than 4 days is a significant risk factor for unplanned readmission within 90 days (odd ratio = 1.928, P = .010). Total knee arthroplasty (TKA) and discharge to a location other than home are also independent risk factors for 90-day readmission.Conclusion
Our results demonstrate that increased LOS is a significant risk factor for readmission within 90 days of admission for a hip or knee arthroplasty in the Medicare population. 相似文献14.
Background
As early implementors of the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative, our private practice sought to compare our readmission rates, post-acute care utilization, and length of stay for the first year under BPCI compared to baseline data.Methods
We used CMS data to compare total expenditures of all diagnosis-related groups (DRGs). Medicare patients who underwent orthopedic surgery between 2009 and 2012 were defined as non-BPCI (n = 8415) and were compared to Medicare BPCI patients (n = 4757) who had surgery in 2015. Ninety-day post-acute events including inpatient rehabilitation facility or subacute nursing facility admission, home health (HH), and readmissions were analyzed.Results
The median expenditure for non-BPCI patients was $22,193 compared to $19,476 for BPCI patients (P < .001). Median post-acute care spend was $6861 for non-BPCI and $5360 for BPCI patients (P < .001). Compared to non-BPCI patients, BPCI patients had a lower rate of subacute nursing facility admissions (non-BPCI 43% vs 37% BPCI; P < .001), inpatient rehabilitation facility admissions (non-BPCI 3% vs 4% BPCI; P = .005), HH (non-BPCI 79% vs 73% BPCI; P < .001), and readmissions (non-BPCI 12% vs 10% BPCI; P = .02). Changes in length of stay for post-acute care were only significant for HH with BPCI patients using a median 12 days and non-BPCI using 24 days.Conclusion
The objective of BPCI was to improve healthcare value. Through substantial efforts both financially and utilization of human resources to contain costs with clinical practice guidelines, patient navigators, and a BPCI management team, the expenditures for CMS were significantly lower for BPCI patients. 相似文献15.
Robert B. Hawkins J. Hunter Mehaffey Kenan W. Yount Leora T. Yarboro Clifford Fonner Irving L. Kron Mohammed Quader Alan Speir Jeffrey Rich Gorav Ailawadi 《The Journal of thoracic and cardiovascular surgery》2018,155(1):182-188
Objectives
The Centers for Medicare and Medicaid Services plans to institute a 5-year trial of bundled payments for coronary artery bypass grafting through 90 days after discharge. To investigate the impact, we reviewed actual inpatient costs for patients undergoing bypass surgery relative to the target price.Methods
A total of 13,276 Medicare patients with estimated cost data underwent isolated coronary artery bypass grafting from 2008 to 2015 in 18 hospitals over 8 Medicare-defined regions within the Commonwealth of Virginia. Actual 2015 inpatient costs were compared with estimated target prices for each year of the pilot, based on the previous 3 years and stratified by Diagnosis-Related Group.Results
The mean 2015 cost per patient was $50,394 with high variation (range, $27,862-$74,169). On average, hospitals would receive a refund of $17,682 in year 1, but then owe Medicare increasing amounts up to $367,985 in year 5. If 2015 were the final year of the pilot, 13 of the 18 hospitals (72%) would have owed Medicare for cost overruns averaging $614,270 (range, $67,404-$2,102,292). Costs were below the target price at 5 of 18 hospitals, and the Centers for Medicare and Medicaid Services would have paid them an extra $272,355 on average (range, $88,628-$567,429).Conclusions
Hospitals will face immediate financial pressure due to average cost increases of 3.6% per year and an automatic reduction in payment. As regional pricing is phased in, hospitals can expect to owe Medicare increasing amounts. The net effect is shifting of financial risks to hospitals, which could restrict access to care for higher-risk patients. 相似文献16.
Mitchell C. Weiser Kelvin Y. Kim Afshin A. Anoushiravani Richard Iorio Roy I. Davidovitch 《The Journal of arthroplasty》2018,33(11):3502-3507
Background
Interest in outpatient/same-day discharge (SDD) total hip arthroplasty (THA) has been increasing over the last several years. There is considerable debate in the literature regarding the complication and readmission rates of these patients. To evaluate and validate the safety and efficacy of our institutional SDD THA care pathway, we compared the outcomes of patients undergoing SDD THA with patients who had a similar comorbidity profile and underwent inpatient THA.Methods
A retrospective review was conducted on 164 patients who underwent SDD THA from January 2015 to September 2016. The Risk of Readmission Tool, a validated risk stratification instrument, was applied to all inpatient THAs performed from June 2014 to December 2016. A cutoff Risk of Readmission Tool score < 3 was used to produce a cohort of 1858 inpatient THA patients, all of whom had a similar risk profile to patients who underwent SDD THA. Medicare patients were excluded from the inpatient THA cohort, which left a final inpatient sample of 1315 patients.Each cohort was evaluated for demographic variables, length of stay, 30-/90-day readmissions, and discharge disposition.Results
The SDD THA cohort had significantly lower body mass index (26.9 vs 28.2 kg/m2; P = .002), had fewer minorities (89.6% vs 66.3% Caucasians; P < .001), was exclusively commercial insurance (100% vs 36.3%), had a shorter length of stay (0.37 vs 2.3 days, P < .001), and was exclusively discharged home (100% vs 92.6%). There was no statistically significant difference in 30-day readmission rates between either cohort (SDD 0.6% vs inpatient 1.6%; P = .325). However, the SDD cohort had a significantly lower rate of 90-day readmissions than the inpatient cohort (0.6% vs 3.6%; P = .014).Conclusion
The use of an institutional SDD THA care pathway can produce results with equivalent or better short-term outcomes than that of traditional inpatient THA. 相似文献17.
Omar Z. Maniya Richard C. Mather David E. Attarian Bipin Mistry Aneesh Chopra Matt Strickland Kevin A. Schulman 《The Journal of arthroplasty》2017,32(11):3268-3273.e4
Background
The Medicare program has initiated Comprehensive Care for Joint Replacement (CJR), a bundled payment mandate for lower extremity joint replacements. We sought to determine the degree to which hospitals will invest in care redesign in response to CJR, and to project its economic impacts.Methods
We defined 4 potential hospital management strategies to address CJR: no action, light care management, heavy care management, and heavy care management with contracting. For each of 798 hospitals included in CJR, we used hospital-specific volume, cost, and quality data to determine the hospital's economically dominant strategy. We aggregated data to assess the percentage of hospitals pursuing each strategy; savings to the health care system; and costs and percentages of CJR-derived revenues gained or lost for Medicare, hospitals, and postacute care facilities.Results
In the model, 83.1% of hospitals (range 55.0%-100.0%) were expected to take no action in response to CJR, and 16.1% of hospitals (range 0.0%-45.0%) were expected to pursue heavy care management with contracting. Overall, CJR is projected to reduce health care expenditures by 0.5% (range 0.0%-4.1%) or $14 million (range $0-$119 million). Medicare is expected to save 2.2% (range 2.2%-2.2%), hospitals are projected to lose 3.7% (range 4.7% loss to 3.8% gain), and postacute care facilities are expected to lose 6.5% (range 0.0%-12.8%). Hospital administrative costs are projected to increase by $63 million (range $0-$148 million).Conclusion
CJR is projected to have a negligible impact on total health care expenditures for lower extremity joint replacements. Further research will be required to assess the actual care management strategies adopted by CJR hospitals. 相似文献18.
Addie Middleton Yu-Li Lin James E. Graham Kenneth J. Ottenbacher 《The Journal of arthroplasty》2017,32(9):2639-2647.e1
Background
In an effort to improve quality and reduce costs, payments are being increasingly tied to value through alternative payment models, such as episode-based payments. The objective of this study was to better understand the pattern and variation in outcomes among Medicare beneficiaries receiving lower extremity joint arthroplasty over 90-day episodes of care.Methods
Observed rates of mortality, complications, and readmissions were calculated over 90-day episodes of care among Medicare fee-for-service beneficiaries who received elective knee arthroplasty and elective or nonelective hip arthroplasty procedures in 2013-2014 (N = 640,021). Post–acute care utilization of skilled nursing and inpatient rehabilitation facilities was collected from Medicare files.Results
Mortality rates over 90 days were 0.4% (knee arthroplasty), 0.5% (elective hip arthroplasty), and 13.4% (nonelective hip arthroplasty). Complication rates were 2.1% (knee arthroplasty), 3.0% (elective hip arthroplasty), and 8.5% (nonelective hip arthroplasty). Inpatient rehabilitation facility utilization rates were 6.0% (knee arthroplasty), 6.7% (elective hip arthroplasty), and 23.5% (nonelective hip arthroplasty). Skilled nursing facility utilization rates were 33.9% (knee arthroplasty), 33.4% (elective hip arthroplasty), and 72.1% (nonelective hip arthroplasty). Readmission rates were 6.3% (knee arthroplasty), 7.0% (elective hip arthroplasty), and 19.2% (nonelective hip arthroplasty). Patients' age and clinical characteristics yielded consistent patterns across all outcomes.Conclusion
Outcomes in our national cohort of Medicare beneficiaries receiving lower extremity joint arthroplasties varied across procedure types and patient characteristics. Future research examining trends in access to care, resource use, and care quality over bundled episodes will be important for addressing the challenges of value-based payment reform. 相似文献19.
Inpatient Consults and Complications During Primary Total Joint Arthroplasty in a Bundled Care Model
Billy T. Baumgartner Vasili Karas Beau J. Kildow Daniel J. Cunningham Mitchell R. Klement Cindy L. Green David E. Attarian Thorsten M. Seyler 《The Journal of arthroplasty》2018,33(4):973-975
Background
The Centers for Medicare and Medicaid Services (CMS) are implementing changes in hospital reimbursement models for total joint arthroplasty (TJA), moving to value-based bundled payments from the fee-for-service model. The purpose of this study is to identify consults and complications during the perioperative period that increase financial burden.Methods
We combined CMS payment data for inpatient, professional, and postoperative with retrospective review of patients undergoing primary TJA and developed profiles of patients included in the Comprehensive Care for Joint Replacement bundle undergoing TJA. Statistical comparison of episode inpatient events and payments was conducted. Multiple regression analysis was adjusted for length of stay, disposition, and Charlson-Deyo comorbidity profile.Results
Median total payment was $21,577.36, which exceeded the median bundle target payment of $20,625.00. Adjusted analyses showed that psychiatry consults (increase of $73,123.32; P < .001), internal medicine consults ($5789.38; P ≤ .001), pulmonary embolism ($35,273.68; P < .001), intensive care unit admission ($14,078.37; P < .001), and deep vein thrombosis ($9471.26; P = .019) resulted in increased payments using multivariate analysis adjusted for length of stay, Charlson-Deyo comorbidities, and discharge disposition.Conclusion
Patients with inpatient complications such as pulmonary embolism and/or deep vein thrombosis, intensive care unit admission, and medical/psychiatric consultation exceeded the CMS target. Although study results showed typical complication rates, acute inpatient consultation significantly increased utilization beyond the CMS target even when adjusted for length of stay, patient comorbidities, and discharge. Needed medical care should continue to be a priority for inpatients, and allowance for individual outliers should be considered in policy discussions. 相似文献20.
Alexander T. Bradley Jeremiah R. Cohen Jay R. Lieberman 《The Journal of arthroplasty》2017,32(11):3298-3303.e6