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(“全关节置换”[TJRS])是非常成功的手术。 终末期关节炎患者。尽管他们的临床益处，种族/民族和社会经济差异 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。 尽管已经在当地实施了用心良苦和有效的缩小差距战略。在 如果缺乏激励缩小差距的国家改革，实现TJR公平的愿景可能会 仍然没有实现。Medicare的2016年关节置换综合护理(CJR)模式是捆绑的 旨在提高质量和减少医疗保险受益人支出的支付改革正在进行 TJRS。2021年，CJR进行了重新设计(RCJR)，以包括对社会风险的调整(双重资格 医疗保险和医疗补助)和临床风险(分级条件、类别、分数和年龄)--可以 潜在地减少TJR的差距，方法是“认识到”边缘化患者的较高支出(许多 他们属于种族/少数民族或较低的社会经济群体，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措施，提供 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，以 吸引这些患者；从而促进TJR使用和术后结果的公平性。理论上，新的风险 调整措施可能会将rCJR转变为国家TJR缩小差距战略。 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、结果和支出方面的种族/民族和社会经济差异的关系，重点 论安全网医院的绩效。我们将使用2018-2024年的全国医疗保险数据来评估 RCJR与TJRs使用差异(目标1)和临床指标差异(目标2)的关系。我们还将 检查rCJR是否可能影响了边缘化患者的TJR支出(目标3)。我们的工作是 意义重大，因为我们将回答诸如rCJR在缩小差距方面是否有效的问题， 哪些指标受到RCJR的影响最大，哪些机构成功地缩小了差距。这些 研究结果对于理解rcjr是否以及如何利用rcjr来减少差异至关重要。 在全国范围内，为实现关节炎患者TJR护理公平这一难以实现的目标而努力。

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.