Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.
Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.
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DOI：
10.1001/jamanetworkopen.2021.11858
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发表时间：
2021-05-03
影响因子：
13.8
通讯作者：
Glance LG
中科院分区：
文献类型：
--
作者：
Thirukumaran CP;Kim Y;Cai X;Ricciardi BF;Li Y;Fiscella KA;Mesfin A;Glance LG
这项队列研究评估了大规模医疗保险政策的实施是否与来自不同种族/族裔群体和社会经济背景的老年人对关节置换护理的不平等使用和获取有关。关节置换综合护理 (CJR) 模式是否与老年医疗保险受益人中全髋关节置换或全膝置换使用中种族/民族和社会经济差异的恶化有关？在这项针对 4~447~205 名医疗保险受益人的队列研究中，CJR 模型与非西班牙裔白人受益人全膝关节置换术使用率的增加和非西班牙裔黑人受益人的全膝关节置换术使用率的下降相关。 CJR 模型还与具有非双重医疗补助资格的非西班牙裔白人受益人与具有非双重资格或双重资格的非西班牙裔黑人受益人相比，全膝关节置换术使用差距的扩大有关；对于全髋关节置换术，没有发现这种间隙扩大。研究发现，CJR 模型与全膝关节置换术使用中种族/民族和社会经济差异的适度恶化有关，这凸显了需要进行支付改革以激励减少差异。关节置换综合护理 (CJR) 模式是 Medicare 的强制性捆绑支付改革，旨在提高需要全髋关节置换术 (THR) 或全膝关节置换术 (TKR) 的受益人的质量和支出，但它没有考虑种族/民族和收入等社会人口风险因素。这项研究的结果可以成为医疗保险支付改革的基础，以解决关节置换护理中的不平等问题。在考虑了有风险或有资格接受这些手术的患者群体后，研究 CJR 模型与老年医疗保险受益人使用选择性 THR 和 TKR 的种族/民族和社会经济差异之间的关系。该队列研究使用 2013 年至 2017 年国家医疗保险数据和三重差异估计的多变量逻辑回归。医疗保险受益人年龄在 65 至 99 岁之间，有权享受医疗保险，在日历年末仍健在，并且居住在被授权参与 CJR 模型的 67 个大都市统计区 (MSA) 或居住在 104 个对照 MSA。诊断为关节炎的一部分 Medicare 受益人接受了 THR 或 TKR。对 2020 年 3 月至 12 月的数据进行了分析。2016 年实施了 CJR 模型。结果是受益人是否接受 THR 或 TKR 的单独二元指标。关键自变量是 MSA 治疗状态、CJR 模型实施之前或之后阶段、种族/民族（非西班牙裔白人、非西班牙裔黑人和西班牙裔受益人）和双重资格的组合以及它们的相互作用。 Logistic 回归模型用于控制患者特征、MSA 固定效应和时间趋势。 2013 年队列包括 4 447 205 名医疗保险受益人，其中 2 025 357 (45.5%) 居住在采用 CJR 模式的 MSA 中。该队列的平均 (SD) 年龄为 77.18 (7.95) 岁，由 2 951 140 名女性 (66.4%)、3 928 432 名非西班牙裔白人 (88.3%) 和 657 073 名双重合格受益人 (14.8%) 组成。在 CJR 模型实施之前，在采用 CJR 模型的 MSA 中，非西班牙裔白人非双重资格受益人中 THR 使用率为 1.25%（95% CI，1.24%-1.26%），TKR 使用率为 2.28%（95% CI，2.26%-2.29%）。与没有 CJR 模型以及类似种族/民族和双重资格组的 MSA 相比，CJR 模型与非西班牙裔白人非双重资格受益人的 TKR 使用增加 0.10 (95% CI, 0.05-0.15; P < .001) 个百分点相关，与 0.11 (95% CI, 0.05-0.15; P < .001) 个百分点相关。非西班牙裔白人双重资格受益人增加 0.004-0.21；P = .04) 个百分点，非西班牙裔黑人非双重资格受益人减少 0.15（95% CI，-0.29 至 -0.01；P = .04）个百分点（95% CI，-0.34 至 -0.01；P = .03）非西班牙裔黑人双重资格受益人下降了百分点。这些与 CJR 模型相关的 TKR 使用变化对于非西班牙裔黑人非双重资格受益人降低了 0.25 个百分点（95% CI，-0.40 至 -0.10；P = .001），对于非双重资格受益人则降低了 0.27 个百分点（95% CI，-0.45 至 -0.10；P = .002）个百分点。非西班牙裔黑人双重资格受益人与非西班牙裔白人非双重资格受益人的模型相关变化进行了比较。没有发现 CJR 模型与种族/族裔和双重资格群体之间 THR 使用差距扩大之间存在关联。这项研究的结果表明，CJR 模型与非西班牙裔黑人与非西班牙裔白人受益人之间本已存在的 TKR 使用差异的适度增加有关； THR 没有发现差异。这些发现支持了人们的广泛担忧，即支付改革可能会加剧获得关节置换护理的不平等。
This cohort study evaluates whether the implementation of a large-scale Medicare policy is associated with unequal use of and access to joint replacement care among older adults from various racial/ethnic groups and socioeconomic backgrounds. Is the Comprehensive Care for Joint Replacement (CJR) model associated with worsening of racial/ethnic and socioeconomic disparities in total hip replacement or total knee replacement use among older Medicare beneficiaries? In this cohort study of 4 447 205 Medicare beneficiaries, the CJR model was associated with an increase in total knee replacement use for non-Hispanic White beneficiaries and a decrease for non-Hispanic Black beneficiaries. The CJR model was also associated with widening of the gap in total knee replacement use among non-Hispanic White beneficiaries with non–dual eligibility for Medicaid compared with non-Hispanic Black beneficiaries with either non–dual eligibility or dual eligibility; no such widening of the gap was found for total hip replacement use. The study found that the CJR model was associated with modest worsening of racial/ethnic and socioeconomic disparities in total knee replacement use, highlighting the need for payment reforms that incentivize the reduction of disparities. The Comprehensive Care for Joint Replacement (CJR) model is Medicare’s mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Implementation of the CJR model in 2016. Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort’s mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non–dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non–dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, −0.29 to −0.01; P = .04) percentage-point decrease for non-Hispanic Black non–dual-eligible beneficiaries, and a 0.18 (95% CI, −0.34 to −0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model–associated changes in TKR use were 0.25 (95% CI, −0.40 to −0.10; P = .001) percentage points lower for non-Hispanic Black non–dual-eligible beneficiaries and 0.27 (95% CI, −0.45 to −0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model–associated changes for non-Hispanic White non–dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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