Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias.
Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias.
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DOI：
10.1001/jamahealthforum.2021.5111
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发表时间：
2022-03
期刊：
影响因子：
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通讯作者：
Glance LG
中科院分区：
文献类型：
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作者：
Thirukumaran CP;Ricciardi BF;Cai X;Holloway RG;Li Y;Glance LG
本队列研究评估了关节置换综合护理模式与老年痴呆症及相关痴呆医疗保险受益人使用关节置换的关系。关节置换术综合护理（CJR）模式是否与老年痴呆症和相关痴呆（ADRD）医疗保险受益人髋关节和膝关节置换术使用的变化相关？在这项队列研究中，对9624461名独特的受益人进行了2459729年的观察，CJR与有无ADRD的受益人使用髋关节置换术的减少有统计学意义上的显著相关；然而，这些群体之间的使用差距并没有随着CJR的实施而改变。CJR模型与膝关节置换术使用的改变无关。本研究发现CJR模型与患有ADRD的医疗保险受益人使用关节置换术的不成比例的减少无关。患有阿尔茨海默病和相关痴呆（ADRD）的医疗保险受益人是一个特别脆弱的群体，关节炎是一个经常发生的合并症。联邦医疗保险强制性的捆绑支付改革——关节置换综合护理（CJR）模式——旨在提高质量并减少对接受关节炎关节置换手术的受益人的支出。在缺乏临床风险调整的情况下，医院可能会避免为患有ADRD的受益人进行选择性关节置换。评估CJR模型与患有ADRD的医疗保险受益人使用关节置换的关系。该队列研究使用2013年至2017年的国家医疗保险数据，采用多变量线性概率模型和三重差异估计方法。诊断为关节炎的医疗保险受益人来自67个被要求参加CJR的大都市统计区（msa）和104个对照msa。数据分析时间为2020年7月至2021年7月。2016年CJR模式的实施。结果是单独的二元指标，表明受益人是否接受了髋关节或膝关节置换术。关键的自变量是MSA组、cjr前后阶段、ADRD诊断及其相互作用。线性概率模型控制了受益人特征、MSA固定效应和时间趋势。该研究包括对9624461名独特受益人的24598729个受益年观察，其中250168名受益人接受了髋关节置换术，477451名接受了膝关节置换术。2013年队列的平均（SD）年龄为77.1（7.9）岁，女性3110 922人（66.4%），非西班牙裔白人3 928 432人（83.8%），双重医疗补助资格792 707人（16.9%），诊断为ADRD的885 432人（18.9%）。在实施CJR之前，患有ADRD的受益人的关节置换率较低（髋关节置换术：有和没有ADRD的受益人分别为0.38%和1.17%;P < 0.001；膝关节置换术：0.70%对2.25%;P < 0.001）。在控制相关协变量后，CJR与ADRD受益人髋关节置换术下降0.07个百分点相关(95% CI, - 0.13至- 0.001;P =。046)，无ADRD的受益人下降0.07个百分点(95% CI, - 0.12至- 0.02;P =。01)与控制型msa受益人相比，居住在CJR msa中。然而，患有ADRD的受益人的髋关节置换率的变化与没有ADRD的受益人的变化在统计学上没有显著差异（百分点差异：0.01;95% CI, - 0.08至0.09;P = 0.88）。与实施CJR的无ADRD患者相比，ADRD患者的膝关节置换率没有统计学上的显著变化（百分点差异：- 0.03,95% CI, - 0.09至0.02;P = 0.27）。在这项针对患有关节炎的医疗保险受益人的队列研究中，CJR模型在项目的前2年与患有ADRD的受益人相比，与关节置换术使用率下降无关，从而减轻了患者选择的担忧。
This cohort study evaluates the association of the Comprehensive Care for Joint Replacement model with utilization of joint replacements for Medicare beneficiaries with Alzheimer disease and related dementias. Is the Comprehensive Care for Joint Replacement (CJR) model associated with changes in hip and knee replacement use for Medicare beneficiaries with Alzheimer disease and related dementias (ADRD)? In this cohort study of 24 598 729 beneficiary-year observations among 9 624 461 unique beneficiaries, CJR was statistically significantly associated with a decrease in hip replacement use for beneficiaries with and without ADRD; however, the gap in use between these groups did not change with CJR implementation. The CJR model was not associated with changes in knee replacement use. This study found that the CJR model was not associated with a disproportionate reduction in joint replacement use for Medicare beneficiaries with ADRD. Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare’s mandatory bundled payment reform—the Comprehensive Care for Joint Replacement (CJR) model—was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Implementation of the CJR model in 2016. Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, −0.13 to −0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, −0.12 to −0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, −0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: −0.03, 95% CI, −0.09 to 0.02; P = .27). In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.