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

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，但有 长期以来，在这些手术的使用和结果方面存在种族差异。美国黑人大约 接受髋关节或膝关节置换术(也称为下肢关节置换术，简称LEJR)的可能性降低40%-50% 而不是白人。即使接受LEJR，黑人患者也更有可能出现并发症，导致 要么重新入院，要么死亡。尽管全国都意识到了这一问题，但这种差距依然存在。 2016年4月，联邦医疗保险实施了关节置换综合护理(CJR)模式，这是一项计划 这可能会对LEJR的种族差异产生重大影响。CJR，医疗保险的第一个强制性捆绑支付 该计划代表着一种雄心勃勃的尝试，目的是摆脱以服务收费为主导的制度， 有可能成为未来支付系统的典范。根据CJR，医院对以下费用负责 LEJR患者出院后90天的护理。CJR的一个创新组成部分是它正在被 在67个随机选择的大都市统计地区(MSA)实施。这一设计提供了一种独特的 有机会评估这一支付改革的因果影响。 CJR项目可能会对种族差异产生深远影响。CJR不会根据患者的情况进行调整 当他们设定目标付款率时，他们的社会经济地位。这可能会导致医院避免接受LEJR 康复期社会服务需求较复杂的患者。因为高得不成比例的百分比 在这些患者中，可能是黑人，接受LEJR治疗的现有差异可能会加剧。另一方面 另一方面，一旦决定提供LEJR，CJR下的医院和急性后护理提供者将面临新的 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后急性护理中的种族差异和LEJR的患者结局。 我们建议的研究利用CJR计划的独特随机设计来评估其效果 关于LEJR中的黑人和白人的差异。我们的中心假设是，CJR增加了在接收 LEJR，但减少了LEJR后急性护理质量和LEJR患者结局的差异。 具体地说，这项建议旨在评估CJR计划对非洲黑人和白人差距的影响1) 接受LEJR，2)接受LEJR后的急性护理，以及3)接受LEJR的患者结局。 为了评估CJR计划的效果，我们将使用Medicare Claims来进行Difference in Difference-in- 检验CJR对位于MSA的医院种族差异影响的差异回归 受CJR影响的医院与其他地方可比MSA的医院相比。实现这些目标将提供 薪酬改革的关键知识，旨在减少种族差距，不仅在LEJR，而且在健康方面 更广泛地关心。

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.