Quantifying Underuse and Overuse of Knee Replacement

 描述（申请人提供）：全膝关节置换术（TKR）的使用率正在上升，未来20年将增加6倍的预测已经引起了政策制定者的警觉，他们采取了几项旨在限制成本的举措。1然而，这些预测并没有排除TKR使用不足的情况，这在2004年得到了NIH共识小组的强烈支持，并且经常在文献中讨论并得到政策制定者的认可。根据《平价医疗法案》，保险范围将扩大到5000多万低收入美国人，1其中包括据报道未充分使用TKR的亚群。3仅仅提供保险并不能完全解决使用差距。4，5需要查明与使用不足和过度使用有关的因素，以便在考虑成本的情况下制定解决这两种现象的政策。控制压力。几乎没有对TKR使用不足和过度使用的程度进行调查。现有的关于传统呼吸道保护措施利用方面的差异的文献（例如白人和非裔美国人之间的差异）部分地涉及这一问题。然而，由于这篇文献关注的是实际的手术，它未能回答这样的问题：白人和非洲裔美国人之间的差距是完全由于非洲裔美国人对手术的利用不足，还是部分原因是白人过度使用手术？通过利用骨关节炎倡议（OAI）和多中心骨关节炎研究（MOST）的近8,000名膝关节骨关节炎患者或有膝关节骨关节炎风险的纵向数据集，该提案采用“前瞻性”方法研究美国膝关节置换术的使用不足和过度使用。我们将应用适当性分类系统，这是一种用于评估外科手术过度使用和使用不足的循证指标，以研究TKR的使用情况。6我们建议将该系统应用于患有膝关节骨关节炎或有膝关节骨关节炎风险的OAI和MOST受试者，以估计及时使用、过度使用和使用不足的比率。然后，我们研究了TKR过度使用和使用不足的预测因素。本研究将首次前瞻性评估美国TKR使用不足和过度使用的程度。研究结果将有助于公共和私人保险公司在制定报销政策时考虑使用不足和过度使用，并与供应商一起设计针对使用不足和过度使用者的干预措施。此外，该项目的研究结果将为在美国制定基于共识的循证适当性标准提供至关重要的信息。

 DESCRIPTION (provided by applicant): Utilization of total knee replacement (TKR) is on the rise and projections of a 6-fold increase over the next 2 decades have alarmed policy makers, with several initiatives aimed at restraining costs.1 Yet, these projections do not dismiss TKR underuse, which was strongly endorsed by an NIH consensus panel in 2004 and is often discussed in the literature and acknowledged by policy makers.2 Starting in 2014, insurance expansion under the Affordable Care Act will include more than 50 million low-income Americans,1 among whom are subpopulations who have been reported to underuse TKR.3 Simply providing insurance will not fully address the utilization gap.4, 5 Factors associated with underuse and overuse need to be identified so that policies to address both phenomena can be developed in the context of cost control pressures. Little has been done to investigate the extent of underuse and overuse of TKR. The available literature on disparities in TKR utilization (e.g. between whites and African Americans) partially addresses this issue. However, because this literature is focused on actual surgeries, it fails to answer questions like: Is the gap in utilizaion between Whites and African-Americans due entirely to the African-Americans underutilizing the surgery or is part of it Whites overusing the surgery? By utilizing the Osteoarthritis Initiative (OAI) and Multicenter Osteoarthritis Study (MOST) longitudinal datasets of almost 8,000 persons with or at risk for knee osteoarthritis, this proposal takes a "prospective" approach to studying underuse and overuse of knee replacement in the US. We will apply appropriateness classification systems, which are evidence-based metrics used to assess both overuse and underuse of surgical procedures, to study utilization of TKR.6 We propose to apply the system to OAI and MOST subjects with or at risk of knee osteoarthritis to estimate rates of timely use, overuse and underuse. We then study the predictors of overuse and underuse of TKR. This study will be the first to prospectively assess the extent of underuse and overuse of TKR in the US. Results will help public and private insurers to consider underuse and overuse in developing reimbursement policies and to design along with providers interventions aimed at under and over users. In addition, findings from this project will provide critically important information for developing consensus-based evidence-based appropriateness criteria in the US.