Association of the redesigned Comprehensive Care for Joint Replacement model with racial/ethnic and socioeconomic disparities in joint replacement surgeries

摘要 全髋关节和膝关节置换术（“全关节置换术”[TJR]）是非常成功的手术， 终末期关节炎患者。尽管它们具有临床益处，但种族/民族和社会经济差异仍然存在。 这些手术的使用和结果是公认的。这些差距已经持续了几十年 尽管在当地实施了善意和有效的减少差距战略。在 如果没有一个国家改革，激励减少差距，实现TJR公平的愿景可能 仍然没有实现。Medicare的2016年关节置换综合护理（CJR）模型是一个捆绑式的 支付改革旨在提高质量和减少医疗保险受益人的支出， TJR。2021年，CJR被重新设计（rCJR），以包括社会风险调整（双重资格） 医疗保险和医疗补助）和临床风险（分层条件类别评分和年龄）-可以 通过“认识到”边缘化患者的更高支出（许多 属于少数种族/族裔或社会经济地位较低的群体，健康状况较差）。这些 调整可能会减少医院避免对边缘化患者进行手术的激励， 这些患者获得高质量的医院，并增加医院之间的质量/价格竞争， 吸引这些患者;从而促进TJR使用和术后结局的公平性。理论上，新的风险 调整措施可能会将rCJR转变为国家TJR差距缩小战略。 然而，几乎没有经验证据支持我们的假设。因此，我们的目标是评估rCJR的 与TJR使用、结果和支出中的种族/民族和社会经济差异相关，重点是 安全网医院的表现。我们将使用2018-2024年的国家医疗保险数据来评估 rCJR与TJR使用差异（目标1）和临床指标（目标2）的相关性。我们还将 研究是否rCJR可能会影响边缘化患者的TJR支出（目的3）。我们的工作是 重要的是，我们将回答诸如rCJR是否有效地减少了差异， 哪些指标受rCJR影响最大，哪些机构成功地减少了差异。这些 研究结果对于理解是否以及如何利用rCJR来减少差异至关重要 在全国范围内，并实现关节炎患者TJR护理公平的难以捉摸的目标。

ABSTRACT Total hip and knee replacements (“total joint replacements” [TJRs]) are highly successful surgeries for patients with end-stage arthritis. Despite their clinical benefits, racial/ethnic and socioeconomic disparities in the use and outcomes of these surgeries are well-established. These disparities have persisted for decades despite well-intentioned and effective disparity reduction strategies that have been locally implemented. In the absence of a national reform that incentivizes disparity reduction, the vision of achieving TJR equity may remain unfulfilled. Medicare’s 2016 Comprehensive Care for Joint Replacement (CJR) model is a bundled payment reform aimed at improving quality and reducing spending for Medicare beneficiaries undergoing TJRs. In 2021, the CJR was redesigned (rCJR) to include adjustments for social risk (dual-eligibility for Medicare and Medicaid) and clinical risk (hierarchical condition category score and age) – measures that could potentially reduce TJR disparities by ‘recognizing’ the higher spending for marginalized patients (many of whom belong to racial/ethnic minority or lower socioeconomic groups, and are in poorer health). These adjustments are likely to reduce incentives for hospitals to avoid operating on marginalized patients, provide these patients access to high-quality hospitals, and increase quality/price competition between hospitals to attract these patients; thereby promoting equity in TJR use and postoperative outcomes. In theory, the new risk adjustment measures could potentially transform the rCJR into a national TJR disparity reduction strategy. However, there is little empirical evidence to support our hypothesis. Thus, our objective is to evaluate rCJR’s association with racial/ethnic and socioeconomic disparities in TJR use, outcomes, and spending, with a focus on the performance of safety-net hospitals. We will use national Medicare data from 2018-2024 to evaluate rCJR’s association with disparities in the use of TJRs (Aim 1) and in clinical metrics (Aim 2). We will also examine whether the rCJR may have influenced TJR spending for marginalized patients (Aim 3). Our work is significant because we will answer questions such as whether the rCJR was effective in reducing disparities, which metrics were most influenced by the rCJR, and which institutions successfully reduced disparities. These findings are critical for understanding whether and how the rCJR can be leveraged to reduce disparities nationally, and for realizing the elusive target of equity in TJR care for patients with arthritis.