RESUMO
BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.
Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos Hospitalares/estatística & dados numéricos , Osteoartrite/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S. , Comorbidade , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Hospitais , Humanos , Masculino , Medicare/economia , Pessoa de Meia-Idade , Osteoartrite/economia , Osteoartrite/epidemiologia , Osteoartrite/cirurgia , Pacotes de Assistência ao Paciente/economia , Estudos Retrospectivos , Cuidados Semi-Intensivos , Estados UnidosRESUMO
HYPOTHESIS: Race and insurance status are independent predictors of the choice between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) of the shoulder joint. BACKGROUND: Current literature shows that ethnic and socioeconomic status may influence access to health care. However, no study has demonstrated whether insurance status and race are independent predictors that patients with glenohumeral osteoarthritis will undergo TSA. MATERIALS AND METHODS: Patients with primary International Classification of Diseases, 9th revision, Clinical Modification, procedure codes for TSA and HA were selected from the 1988 to 2007 United States Nationwide Inpatient Sample. Primary predictors were race (Caucasian, African American, Hispanic, other) and insurance status (private, Medicare, Medicaid, other). Multiple logistic regressions were used to determine whether insurance status and race were associated with the choice of procedure for patients presenting with glenohumeral osteoarthritis. RESULTS: The study included data for 3529 patients, of whom 2369 underwent TSA (67.1%) and the remaining 1160 (32.9%) underwent HA. Of patients treated using TSA, 29% were privately insured, 63.2% had Medicare, and 2.5% had Medicaid (P < .001), and 62.1% were Caucasian, 2.5% were African American, 2.46% were Hispanic, and 30.9% had other ethnicities (P < .001). DISCUSSION: Multiple logistic regression analysis found that privately insured patients and Medicare patients did not show statistically different odds of having TSA compared with patients within the Medicaid (reference category) or "other payment" categories, after adjustment for a variety of potential confounders. Caucasian patients also did not show statistically different chances of undergoing TSA compared with African Americans. CONCLUSIONS: We were unable to support statistical evidence that race and insurance status are independent factors associated with the choice of the surgical procedure in patients with glenohumeral osteoarthritis.