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

项目总结/摘要 CMS最近开始支付全膝关节置换手术（关节成形术; TKA）， 医院门诊部（HOPD），并正在考虑报销HOPD全髋关节 关节成形术（THA）。许多观察家预计，医疗保险支付TKA和THA在门诊 手术中心（ASCs）。目前，全关节置换术正在进行， 在HOPD和越来越多的ASC中，商业保险患者。但尽管 ASC的医生所有者声称门诊全关节置换术是适当的， 对于大部分候选人来说是安全的，迄今为止的证据是基于一组有限的研究， 在HOPD中接受治疗的患者样本非常少。随着ASC稳步扩大其 一些专家担心，他们忽视了高风险， 健康问题然而，有可能在较少依赖的情况下实现类似的结果 传统卫生系统资源。在美国，大多数关节置换接受者 是医疗保险受益人，该人群中门诊TKA的结局数据将不会 一段时间内可用。在此期间，我们建议比较TKA和THA的结局， 使用大样本的商业- 有保险的病人我们将在一个研究中识别接受TKA或THA的近老年患者， 2014-2019年期间住院或门诊ASC设置，并连续入组 手术后90天。我们将从住院患者、HOPD患者中选择匹配的患者样本， 和ASC设置，使用倾向评分技术，与从 HHS分层条件类别风险调整模型， ACA适用于商业保险人群。我们将查明 相关的30天和90天再入院，以及翻修手术后90天内的病例，手术 部位感染、深静脉血栓形成、肺栓塞和脱位/松动/断裂 的假肢。我们将使用统计技术来测试各研究中心之间的差异。最后我们将 衡量护理阶段的相对成本，包括护理期间发生的相关支出。 90-住院后第1天或ASC就诊。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。对于供应商，它将确定 潜在的患者安全漏洞领域和干预目标。最后，它将促进 通过告知门诊联合的“灰色区域”候选人， 在决定在哪里做手术时做出更明智的决定。

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.