Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers

项目摘要/摘要 CMS最近开始为#年进行的全膝关节置换手术(关节成形术；TKA)买单 医院门诊部(HOPD)，并正在考虑报销HOPD全髋关节 关节成形术(THA)许多观察人士预计，医疗保险将在门诊为TKA和THA支付费用 手术中心(ASC)紧随其后。目前，正在进行全关节置换 在HOPD和越来越多的ASC中有商业保险的患者。然而，尽管 ASCS的医生所有者声称门诊全关节置换术是合适的， 对于大部分候选人来说，迄今为止的证据是基于一组有限的研究，这些研究使用的是 在HOPD接受治疗的患者样本非常少。随着ASCs稳步扩大其 商业和越来越复杂的手术，一些专家担心他们忽略了高风险 健康问题。然而，有可能在减少依赖的情况下取得类似的结果。 关于传统卫生系统资源的问题。在美国，大多数关节置换接受者。 是联邦医疗保险受益人，这一人群中门诊TKA的结果数据将不会 在一段时间内可用。在此期间，我们建议比较TKA和THA的结果，并 在住院患者、HOPD和ASC设置中使用大量商业- 有保险的病人。我们将确定接受全膝关节置换术或全髋关节置换术的老年患者 2014-2019年住院或门诊ASC设置，并连续参加 手术后90天。我们将选择住院患者的匹配样本，HOPD 以及使用倾向分数技术的ASC设置，与以下项生成的风险分数匹配 HHS分级条件分类风险调整模型的设计 适用于商业保险人群的ACA。我们将确定以下情况 相关的30天和90天再次住院，以及翻修手术后90天内的病例，外科手术 部位感染、深静脉血栓形成、肺栓塞和脱位/松动/断裂 假肢。我们将使用统计技术测试不同站点之间的差异。最后，我们会 衡量护理事件的相对成本，包括在 住院后90天住院或ASC遭遇。这个项目将启发CMS的潜力 进一步过渡到门诊手术的健康后果。对于提供商，它将标识 潜在患者安全失误的领域，以及干预的目标。最后，它将促进 通过告知门诊关节的“灰色区域”候选人，让患者参与到护理中来 替代者在做出关于在哪里接受手术的更明智的决定方面。

Project Summary/Abstract CMS recently began paying for total knee replacement surgery (arthroplasty; TKA) performed in hospital outpatient departments (HOPDs) and is considering reimbursing for HOPD total hip arthroplasty (THA). Many observers expect Medicare payment for TKA and THA in ambulatory surgery centers (ASCs) to follow. Currently, total joint replacements are being performed on commercially insured patients in HOPDs and in a growing number of ASCs. However, despite claims by physician-owners of ASCs that outpatient total joint replacement is appropriate and safe for a large portion of candidates, evidence to date is based on a limited set of studies using very small samples of patients treated in HOPDs. As ASCs have steadily expanded their business and taken on increasingly complex surgeries, some experts fear they overlook high-risk health problems. Yet it is possible that comparable outcomes can be achieved with less reliance on traditional health system resources. The majority of joint replacement recipients in the U.S. are Medicare beneficiaries, and outcomes data on outpatient TKA in this population will not be available for some time. In the interim, we propose to compare TKA and THA outcomes and payments across inpatient, HOPD, and ASC settings using a large sample of commercially- insured patients. We will identify near elderly patients who underwent TKA or THA in an inpatient or outpatient ASC setting during 2014-2019 and who were continuously enrolled for 90 days following surgery. We will select matched samples of patients across inpatient, HOPD and ASC settings using propensity score techniques, matching with risk scores generated from the HHS Hierarchical Condition Categories risk adjustment model which was designed under the ACA for application to the commercially-insured population. We will identify cases of related 30-day and 90-day readmission, and cases within 90-days of revision surgery, surgical site infection, deep-vein thrombosis, pulmonary embolism, and dislocation/loosening/breakage of prosthesis. We will test differences across sites using statistical techniques. Finally, we will measure the relative cost of episodes of care including related expenditures incurred during the 90-day post-inpatient stay or ASC encounter. This project will enlighten CMS on potential health consequences of further transitions to outpatient surgery. For providers, it will identify areas of potential patient safety lapses, and targets for interventions. Finally, it will facilitate patient engagement in their care by informing “gray area” candidates for outpatient joint replacement in making wiser decisions about where to undergo surgery.