Which Clinical and Patient Factors Influence the National Economic Burden of Hospital Readmissions After Total Joint Arthroplasty?
Which Clinical and Patient Factors Influence the National Economic Burden of Hospital Readmissions After Total Joint Arthroplasty?
复制标题
DOI：
10.1007/s11999-017-5244-6
复制
发表时间：
2017-12-01
影响因子：
4.2
通讯作者：
Manley, Michael T.
中科院分区：
文献类型：
--
作者：
Kurtz, Steven M.;Lau, Edmund C.;Manley, Michael T.
2010年的《平价医疗法案》推进了全关节置换术（TJA）捆绑支付的经济模式，其中医院将对再入院负责，通常是在手术后90天。然而，人们对再入院的经济负担以及什么样的患者、临床和医院因素会导致再入院成本知之甚少。(1)在美国，THA和TKA再入院的发生率、支付者组合和人口统计学特征是什么？(2)哪些患者、临床和医院因素与初次THA和TKA术后30天和90天再入院的费用相关？(3)支付方之间THA和TKA再入院的经济负担是否存在差异？(4)哪种类型的THA和TKA再入院对美国医院系统来说成本最高？最近开发的来自医疗保健成本和利用项目的全国再入院数据库（来自21个州的2006家医院）用于根据国际疾病分类第9版临床修改代码确定2013年前9个月的719，394例原发性TJA和62，493例90天再入院。我们将再入院的原因分为手术相关或医疗相关。使用全国再入院数据库提供的费用比计算THA和TKA的90天再入院的个体患者费用，作为单独的一般线性模型中的连续变量。支付者、患者、临床和医院因素作为协变量处理。我们根据支付者和再入院原因估计了再入院的国家负担，THA术后30天和90天的再入院率分别为4%（95%置信区间[CI]，4.2%-4.5%）和8%（95% CI，7.5%-8.1%）。初次TKA后30天和90天再住院的全国比率分别为4%（95% CI，3.8%-4.0%）和7%（95% CI，6.8%-7.2%）。影响90天THA再入院费用的5个最重要变量（按等级顺序，基于III型F统计量，p < 0.001）为住院时间（LOS）、所有患者精确诊断相关组（APR DRG）严重程度、再入院类型（即，医疗与手术相关）、医院所有权和年龄。同样，导致90天TKA再住院费用的五个最重要变量是LOS、APR DRG严重程度、性别、医院手术量和医院所有权。调整协变量后，私人保险报销的THA和TKA平均90天再入院费用分别比Medicare高1324美元和1372美元（p < 0.001）。在TJA后的90天内，每年再入院总费用的三分之二由医疗保险支付。在THA后90天内，更多的再入院仍与手术相关并发症相关，包括感染、脱位和假体周围骨折，这些并发症总计占美国医疗保健系统总再入院成本的59%（95%CI，59.1%-59.6%）。对于TKA，美国90天内总再入院成本的49%（95% CI，48.8%-49.6%）与手术问题相关，最显著的包括感染。TJA后90天内的再入院对美国医疗保健系统构成了巨大的经济负担。在美国，每年再入院的总经济负担中约有一半是医疗费用，与关节置换手术无关，另一半与手术并发症有关。这项全国性研究强调，再入院期间的LOS是主要的成本驱动因素，这表明医院和医生应尽可能进一步优化再入院患者住院的临床路径。由于感染、脱位和假体周围骨折导致的再入院患者是最昂贵的再入院类型，因此减少这些类型再入院的LOS的努力将对他们的经济负担产生最大的影响。需要进行额外的临床研究，以确定在不牺牲护理质量或获得护理的情况下，再入院期间的LOS可以减少到何种程度（如果有的话）。
The Affordable Care Act of 2010 advanced the economic model of bundled payments for total joint arthroplasty (TJA), in which hospitals will be financially responsible for readmissions, typically at 90 days after surgery. However, little is known about the financial burden of readmissions and what patient, clinical, and hospital factors drive readmission costs.(1) What is the incidence, payer mix, and demographics of THA and TKA readmissions in the United States? (2) What patient, clinical, and hospital factors are associated with the cost of 30- and 90-day readmissions after primary THA and TKA? (3) Are there any differences in the economic burden of THA and TKA readmissions between payers? (4) What types of THA and TKA readmissions are most costly to the US hospital system?The recently developed Nationwide Readmissions Database from the Healthcare Cost and Utilization Project (2006 hospitals from 21 states) was used to identify 719,394 primary TJAs and 62,493 90-day readmissions in the first 9 months of 2013 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. We classified the reasons for readmissions as either procedure- or medical-related. Cost-to-charge ratios supplied with the Nationwide Readmissions Database were used to compute the individual per-patient cost of 90-day readmissions as a continuous variable in separate general linear models for THA and TKA. Payer, patient, clinical, and hospital factors were treated as covariates. We estimated the national burden of readmissions by payer and by the reason for readmission.The national rates of 30- and 90-day readmissions after THA were 4% (95% confidence interval [CI], 4.2%-4.5%) and 8% (95% CI, 7.5%-8.1%), respectively. The national rates of 30- and 90-day readmissions after primary TKA were 4% (95% CI, 3.8%-4.0%) and 7% (95% CI, 6.8%-7.2%), respectively. The five most important variables responsible for the cost of 90-day THA readmissions (in rank order, based on the Type III F-statistic, p < 0.001) were length of stay (LOS), all patient-refined diagnosis-related group (APR DRG) severity, type of readmission (that is, medical- versus procedure-related), hospital ownership, and age. Likewise, the five most important variables responsible for the cost of 90-day TKA readmissions were LOS, APR DRG severity, gender, hospital procedure volume, and hospital ownership. After adjusting for covariates, mean 90-day readmission costs reimbursed by private insurance were, on average, USD 1324 and USD 1372 greater than Medicare (p < 0.001) for THA and TKA, respectively. In the 90 days after TJA, two-thirds of the total annual readmission costs were covered by Medicare. In 90 days after THA, more readmissions were still associated with procedure-related complications, including infections, dislocations, and periprosthetic fractures, which in aggregate account for 59% (95% CI, 59.1%-59.6%) of the total readmission costs to the US healthcare system. For TKA, 49% of the total readmission cost (95% CI, 48.8%-49.6%) in 90 days for the United States was associated with procedure issues, most notably including infections.Hospital readmissions up to 90 days after TJA represent a massive economic burden on the US healthcare system. Approximately half of the total annual economic burden for readmissions in the United States is medical and unrelated to the joint replacement procedure and half is related to procedural complications.This national study underscores LOS during readmission as a primary cost driver, suggesting that hospitals and doctors further optimize, to the extent possible, the clinical pathways for the hospitalization of readmitted patients. Because patients readmitted as a result of infection, dislocation, and periprosthetic fractures are the most costly types of readmissions, efforts to reduce the LOS for these types of readmissions will have the greatest impact on their economic burden. Additional clinical research is needed to determine the extent to which, if any, the LOS during readmissions can be reduced without sacrificing quality or access of care.