Effects of Comprehensive Care for Joint Replacement Model on Racial Disparities in Lower Extremity Joint Replacements

综合护理关节置换模式对下肢关节置换种族差异的影响

• 批准号: 9285678
• 负责人: HYUNJEE KIM
• 金额: $ 48.35万
• 依托单位: OREGON HEALTH & SCIENCE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-05-18 至 2021-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9285678
• 关键词: Acute; Admission activity; Adverse event; Affect; African American; Area; Arthritis; Awareness; Caring; Case Study; Cessation of life; Complex; Comprehensive Health Care; Evaluation; Face; Fee-for-Service Plans; Future; Geographic Locations; Goals; Health system; Healthcare; Hospitals; Incentives; Knowledge; Lead; Lower Extremity; Medicare; Medicare claim; Modeling; Nursing Homes; Operative Surgical Procedures; Outcome; Patient-Focused Outcomes; Patients; Policy Maker; Provider; Public Health; Quality of Care; Quality of life; Randomized; Recovery; Replacement Arthroplasty; Research; Social Work; Socioeconomic Status; Subgroup; Surgical complication; System; United States Centers for Medicare and Medicaid Services; Work; black/white disparity; cost; design; disparity reduction; experience; functional status; health disparity; health service use; hip replacement arthroplasty; improved; improved functioning; innovation; knee replacement arthroplasty; metropolitan; payment; programs; racial disparity; residence

Project Summary Hip and knee replacements improve function and quality of life for people with severe arthritis, yet there have been long-standing racial disparities in the use and outcomes of these surgeries. Black Americans are about 40-50% less likely to receive hip or knee replacements (also called lower extremity joint replacements, or LEJR) than whites. Even if they receive LEJR, black patients are more likely to have complications leading to readmissions or death. Despite national awareness of this issue, this disparity persists. In April 2016, Medicare implemented the Comprehensive Care for Joint Replacement (CJR) model, a program that may substantially affect racial disparities in LEJR. The CJR, Medicare's first mandatory bundled payment program, represents an ambitious attempt to move away from the predominant fee-for-service system with the potential to serve as a model for future payment systems. Under CJR, hospitals are accountable for the cost of care for 90 days after patients with LEJR are discharged. An innovative component of CJR is that it is being implemented in 67 randomly selected metropolitan statistical areas (MSAs). This design provides a unique opportunity to estimate the causal effect of this payment reform. The CJR program may have a profound effect on racial disparities. CJR does not adjust for patients' socioeconomic status when they set target payment rates. This may lead hospitals to avoid admitting LEJR patients with more complex social service needs during recovery. Since a disproportionately high percentage of those patients may be black, existing disparities in the receipt of LEJR could be exacerbated. On the other hand, once the decision is made to provide LEJR, hospitals and post-acute care providers under CJR face new incentives to work together to improve care coordination for high-needs patients. These changes may reduce racial disparities in post-acute care following LEJR and patient outcomes of LEJR. Our proposed research makes use of the unique randomized design of the CJR program to assess its effects on black-white disparities in LEJR. Our central hypothesis is that CJR increases disparities in the receipt of LEJR, but reduces disparities in the quality of post-acute care following LEJR and patient outcomes of LEJR. Specifically, this proposal aims to assess the effect of the CJR program on black-white disparities 1) in the receipt of LEJR, 2) in post-acute care following LEJR, and 3) in patient outcomes of LEJR. To assess the effects of the CJR program, we will use Medicare claims to conduct difference-in-difference-in- differences regressions to examine the effects of CJR on racial disparities at hospitals located in MSAs affected by CJR relative to hospitals in comparable MSAs elsewhere. Accomplishing these aims will provide critical knowledge for payment reforms designed to decrease racial disparities not only in LEJR but in health care more broadly.

项目摘要 髋关节和膝关节置换术改善了严重关节炎患者的功能和生活质量， 长期以来，这些手术的使用和结果存在种族差异。美国黑人 接受髋关节或膝关节置换术（也称为下肢关节置换术或LEJR）的可能性降低40-50% 比白人。即使他们接受LEJR，黑人患者也更有可能出现并发症， 再入院或死亡尽管全国都认识到这一问题，但这种差距依然存在。 2016年4月，医疗保险实施了关节置换综合护理（CJR）模式， 这可能会严重影响LEJR中的种族差异。CJR，Medicare的第一个强制性捆绑支付 计划，代表了一个雄心勃勃的尝试，以摆脱占主导地位的收费服务系统， 这将成为未来支付系统的一种模式。在民事司法改革下，医院须负责支付 LEJR患者出院后90天的护理。CJR的一个创新组成部分是， 在67个随机选择的大都市统计区实施。这种设计提供了一种独特的 因此，我们有机会评估这一支付改革的因果影响。 CJR计划可能对种族差异产生深远的影响。CJR不调整患者的 社会经济地位时，他们设定的目标付款率。这可能会导致医院避免接收LEJR 患者在康复期间有更复杂的社会服务需求。由于不成比例的高比例 这些患者中的一部分可能是黑人，在接受LEJR方面的现有差距可能会加剧。另 另一方面，一旦决定提供LEJR，在CJR下的医院和急症后护理服务提供者将面临新的 鼓励共同努力，改善对高需求患者的护理协调。这些变化可能会减少 LEJR后急性期后护理的种族差异和LEJR的患者结局。 我们的研究利用CJR项目独特的随机设计来评估其效果 关于黑人和白人在LEJR上的差异我们的中心假设是，CJR增加了在接受 LEJR，但减少了LEJR后急性期后护理质量和LEJR患者结局的差异。 具体来说，这项建议旨在评估CJR计划对黑人和白人差距的影响1）在 接受LEJR，2）LEJR后的急性期后护理，和3）LEJR的患者结局。 为了评估CJR计划的效果，我们将使用Medicare索赔进行差异中的差异， 差异回归，以检查CJR对位于MSA的医院的种族差异的影响 与其他地区可比医疗服务协议中的医院相比，实现这些目标将提供 对旨在减少不仅在LEJR而且在健康方面的种族差异的支付改革的关键知识 照顾更广泛。