Association of Total Knee Replacement Removal From the Inpatient-Only List With Outpatient Surgery Utilization and Outcomes in Medicare Patients.
Association of Total Knee Replacement Removal From the Inpatient-Only List With Outpatient Surgery Utilization and Outcomes in Medicare Patients.
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DOI：
10.1001/jamanetworkopen.2023.16769
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发表时间：
2023-06-01
影响因子：
13.8
通讯作者：
Thirukumaran, Caroline P.
中科院分区：
文献类型：
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作者：
Schloemann, Derek T.;Sajda, Thomas;Ricciardi, Benjamin F.;Thirukumaran, Caroline P.
2018年从仅限医疗保险住院患者(IPO)名单中移除全膝关节置换术(TKR)是否与医疗保险患者预后的变化有关？在这项对美国州行政数据库中37个 588医疗保险收费程序的队列研究中，年龄较大的、黑人和女性患者以及在安全网医院接受治疗的患者较不可能接受门诊TKR。与全髋关节置换术相比，除了每次手术增加770美元外，IPO政策与TKRS后结果的变化无关。这些结果表明，在获得门诊TKR方面可能存在差异；将TKR从IPO列表中移除导致手术费用略有增加，但在术后卫生保健利用方面没有差异。这项队列研究检查了与从医疗保险住院患者名单中移除全膝关节置换术相关的手术率和结果。人们对2018年从仅限医疗保险住院患者(IPO)名单中移除全膝关节置换术(TKR)与医疗保险患者预后的相关性知之甚少。评估(1)与门诊TKR使用相关的患者因素，以及(2)IPO政策是否与TKR患者术后结果的变化相关。这项队列研究包括纽约州全州规划和研究合作系统的行政索赔数据。纳入的患者是2016至2019年在纽约州接受TKR或全髋关节置换术(THR)的医疗保险服务费受益人。多变量广义线性混合模型被用来确定与门诊TKR使用相关的患者因素，并使用差异差异策略来检查IPO政策与TKR后结果与Medicare患者THR后结果的相关性。2021年至2022年进行了数据分析。2018年IPO政策执行情况。使用门诊或住院TKR；次要结果包括30天和90天再次住院，30天和90天术后急诊科就诊，非家庭出院，以及手术总费用。2016年至2019年共为18例 819例患者施行了37例 588全膝关节置换术，其中2018年至2019年门诊全膝关节置换术1684例(平均年龄73.8[5.9]岁； 240女性12例[65.0%]；西班牙裔823例[4.4%]；非西班牙裔黑人982例[5.2%]；非西班牙裔白人15例 714例[83.5%])。老年人(例如，75岁与65岁：调整后的差异，−1.65%；95%CI，−2.31%对−0.99%)，黑人(−1.44%；95%CI，−2.81%对−0.07%)，女性患者(−0.91%；95%CI，−1.52%对−0.29%)，以及在安全网医院接受治疗的患者(不成比例的份额医院费用四分位数4：−18.09%；95%CI，−为31.81%，−为4.36%)，不太可能进行门诊全膝关节置换术。在新股上市政策实施后，调整后的30天再入院(调整后差异[AD]，−2.11%；95%CI，−2.73%至−1.48%；P <； .001)、90天再入院(−3.23%；95%CI，−4.04%至−2.42%；P <； .001)、30天急诊(−2.45%；95%CI，−3.17%至−1.72%；P <； .001)，90天急诊(−4.01%；95%CI，−4.91%至−3.11%；P <； .001)和更高的每次相遇成本(2,988美元；95%CI，415至5,561美元；P = .03)。然而，这些变化与Thr队列中的变化没有区别，只是与Thr相比，TKR的每次遭遇成本增加了770美元(770美元；95%CI，83美元至1457美元；P = .03)。在这项对接受TKR和THR的患者的队列研究中，我们发现老年、黑人和女性患者以及在安全网医院接受治疗的患者获得门诊TKR的机会可能较少，这突出了对差异的担忧。IPO政策与TKR后整体医疗保健使用或结果的变化无关，但每次TKR遭遇增加770美元。
Was total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 associated with changes in outcomes in Medicare patients? In this cohort study of 37 588 Medicare fee-for-service procedures in a US state administrative database, older, Black, and female patients, as well as patients treated at safety-net hospitals, were less likely to undergo outpatient TKR. When compared with total hip replacements, the IPO policy was not associated with changes in outcomes after TKRs, except for an increase of $770 per encounter. These results suggest that there may be disparities in access to outpatient TKRs; TKR removal from the IPO list resulted in a modest increase in cost for surgical encounters but no difference in postoperative health care utilization. This cohort study examines rates of surgery and outcomes associated with the removal of total knee replacement from the Medicare inpatient-only list. Little is known about the association of total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 with outcomes in Medicare patients. To evaluate (1) patient factors associated with outpatient TKR use and (2) whether the IPO policy was associated with changes in postoperative outcomes for patients undergoing TKR. This cohort study included data from administrative claims from the New York Statewide Planning and Research Cooperative System. Included patients were Medicare fee-for-service beneficiaries undergoing TKRs or total hip replacements (THRs) in New York State from 2016 to 2019. Multivariable generalized linear mixed models were used to identify patient factors associated with outpatient TKR use, and with a difference-in-differences strategy to examine association of the IPO policy with post-TKR outcomes relative to post-THR outcomes in Medicare patients. Data analysis was performed from 2021 to 2022. IPO policy implementation in 2018. Use of outpatient or inpatient TKR; secondary outcomes included 30-day and 90-day readmissions, 30-day and 90-day postoperative emergency department visits, non–home discharge, and total cost of the surgical encounter. A total of 37 588 TKR procedures were performed on 18 819 patients from 2016 to 2019, with 1684 outpatient TKR procedures from 2018 to 2019 (mean [SD] age, 73.8 [5.9] years; 12 240 female [65.0%]; 823 Hispanic [4.4%], 982 non-Hispanic Black [5.2%], 15 714 non-Hispanic White [83.5%]). Older (eg, age 75 years vs 65 years: adjusted difference, −1.65%; 95% CI, −2.31% to −0.99%), Black (−1.44%; 95% CI, −2.81% to −0.07%), and female patients (−0.91%; 95% CI, −1.52% to −0.29%), as well as patients treated in safety-net hospitals (disproportionate share hospital payments quartile 4: −18.09%; 95% CI, −31.81% to −4.36%), were less likely to undergo outpatient TKR. After IPO policy implementation in the TKR cohort, there were lower adjusted 30-day readmissions (adjusted difference [AD], −2.11%; 95% CI, −2.73% to −1.48%; P < .001), 90-day readmissions ( −3.23%; 95% CI, −4.04% to −2.42%; P < .001), 30-day ED visits ( −2.45%; 95% CI, −3.17% to −1.72%; P < .001), 90-day ED visits (−4.01%; 95% CI, −4.91% to −3.11%; P < .001) and higher cost per encounter ($2988; 95% CI, $415 to $5561; P = .03). However, these changes did not differ from changes in the THR cohort except for increased TKR cost of $770 per encounter ($770; 95% CI, $83 to $1457; P = .03) relative to THR. In this cohort study of patients undergoing TKR and THR, we found that older, Black, and female patients and patients treated in safety-net hospitals may have had lesser access to outpatient TKRs highlighting concerns of disparities. IPO policy was not associated with changes in overall health care use or outcomes after TKR, except for an increase of $770 per TKR encounter.
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