Age and Frailty Influence Hip and Knee Arthroplasty Reimbursement in a Bundled Payment Care Improvement Initiative

Pepper, Andrew M; Novikov, Dmitry S.; Cizmic, Zlatan; Barrett, John T.; Collins, Michael J.; Iorio, Richard; Schwarzkopf, Ran; Long, William J.

doi:10.1016/j.arth.2019.01.050

Cited by 20 publications

(14 citation statements)

References 16 publications

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“…As this age group continues to increase in size, the current BPCI initiative in TJA is expected to result in declining profits by 2030 [6]. Pepper et al similarly demonstrated an increase in cost of care for patients aged 72 years or older at the time of their TJA [5]. In addition to age, the authors found an increasing frailty score to significantly increase costs after TJA.…”

Section: Discussionmentioning

confidence: 99%

“…Removing TJA from the inpatient-only list has created significant confusion and concern as there are no accepted parameters that can be applied to determine which patients to classify as inpatient vs outpatient status [5,9,10,12,13]. Owing to the discontinuation of TJA from the inpatient-only list, a physician has the following 3 options when a patient has already spent one night at the hospital: 1) provide appropriate documentation on why a patient requires the extra nights stay; 2) discharge the patient as an outpatient hospitalization; 3) discharge the patient as a short-stay inpatient hospitalization [20].…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, many argue that Medicare beneficiaries can undergo THA at an ambulatory center or in the outpatient hospital setting, which will subsequently result in substantial savings for the CMS [9]. However, many Medicare patients, especially the elderly and those with more comorbidities and decreased preoperative functional status, require an inpatient admission after TJA [5,9,12,13,17]. Therefore, with THA taken off the inpatient-only list, providers and hospitals have added pressure in classifying most THAs as an outpatient procedure, subsequently resulting in increased costs for physicians and health-care systems.…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, with THA taken off the inpatient-only list, providers and hospitals have added pressure in classifying most THAs as an outpatient procedure, subsequently resulting in increased costs for physicians and health-care systems. Ultimately, this may beget a bias in care toward the elderly and frail patients, who are more likely to require an inpatient admission after TJA [5,6,9,10,12,13].…”

Section: Introductionmentioning

confidence: 99%

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A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

et al. 2021

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Background: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list. This has created significant confusion regarding which patients qualify for an inpatient designation. The purpose of this study is to develop and validate a novel predictive tool for preoperatively objectively determining "outpatient" vs "inpatient" status for THA in the Medicare population. Methods: A cohort of Medicare patients undergoing primary THA between January 2017 and September 2019 was retrospectively reviewed. A machine learning model was trained using 80% of the THA patients, and the remaining 20% was used for testing the model performance in terms of accuracy and the average area under the receiver operating characteristic curve. Feature importance was obtained for each feature used in the model. Results: One thousand ninety-one patients had outpatient stays, and 318 qualified for inpatient designation. Significant associations were demonstrated between inpatient designations and the following: higher BMI, increased patient age, better preoperative functional scores, higher American Society of Anesthesiologist Physical Status Classification, higher Modified Frailty Index, higher Charlson Comorbidity Index, female gender, and numerous comorbidities. The XGBoost model for predicting an inpatient or outpatient stay was 78.7% accurate with the area under the receiver operating characteristic curve to be 81.5%. Conclusions: Using readily available key baseline characteristics, functional scores and comorbidities, this machine-learning model accurately predicts an "outpatient" or "inpatient" stay after THA in the Medicare population. BMI, age, functional scores, and American Society of Anesthesiologist Physical Status Classification had the highest influence on this predictive model.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

et al. 2021

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“…As an individual ages, comorbidities increase, as seen in the Medicare patient population of those older than 65 years [ [7] , [8] , [9] , [10] , [11] ]. In order to treat cardiac embolic events and other venous thromboembolic events, high-risk patients are often placed on oral anticoagulation [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

The Association Between Clopidogrel and Gastrointestinal Bleeding After Primary Total Joint Arthroplasty

et al. 2021

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Background: Anticoagulation after total joint arthroplasty has been demonstrated to reduce venous thromboembolism. However, anticoagulation can lead to adverse bleeding events. The purpose of this study was to assess if an association exists between specific anticoagulation modalities, such as clopidogrel, and postoperative gastrointestinal (GI) bleeding. Methods: A prospective cohort of Medicare patients undergoing total joint arthroplasty from 2017 to 2019 (3535 patients) was retrospectively reviewed. The baseline characteristics and anticoagulation methods were compared between the "GI bleed" cohort and the "non-GI bleed cohort." Independent ttests were conducted for continuous variables, while chi-squared analysis was conducted for dichotomous variables. Results: Thirteen patients (0.42%) sustained a postoperative complication of a GI bleed. The mean age for patients sustaining a GI bleed was 69.23 years compared with 72.30 years for the non-GI bleed cohort (P ¼ .11). Six patients who sustained a GI bleed (46%) were on an anticoagulation therapy other than aspirin, and this trended toward significance (P ¼ .09). Five patients who sustained a GI bleed (38%) were on clopidogrel (P < .01). Seven percent of patients on clopidogrel sustained a postoperative GI bleed (P < .01). None of the patients who sustained a postoperative GI bleed had a history of peptic ulcer disease. Conclusion: Patients on clopidogrel in the acute perioperative period demonstrated a strong association with the complication of postoperative GI bleeding. Arthroplasty surgeons should be aware of this association to educate and monitor patients on clopidogrel therapy and to work as part of interdisciplinary teams to assess the risks vs benefits of perioperative clopidogrel.

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Predictors of Success in the Bundled Payments for Care Improvement Program

et al. 2021

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BACKGROUND: Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care. OBJECTIVE: To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care. DESIGN: Retrospective cohort study. PARTICIPANTS: BPCI-participating hospitals. MAIN MEASURES: We designated hospitals that met the program goal of decreasing costs by at least 2% from baseline in average Medicare payments per 90-day episode as "savers." We used regression models to determine condition-level, patient-level, hospital-level, and marketlevel characteristics associated with savings. KEY RESULTS: In total, 421 hospitals participated in BPCI, resulting in 2974 hospital-condition combinations. Major joint replacement of the lower extremity had the highest proportion of savers (77.6%, average change in payments −$2235) and complex non-cervical spinal fusion had the lowest (22.2%, average change +$8106). Medical conditions had a higher proportion of savers than surgical conditions (11% more likely to save, P=0.001). Conditions that were mostly urgent/emergent had a higher proportion of savers than conditions that were mostly elective (6% more likely to save, P=0.007). Having higher than median costs at baseline was associated with saving (OR: 3.02, P<0.001). Hospitals with more complex patients were less likely to save (OR: 0.77, P=0.003). Savings occurred across both inpatient and post-acute care, and there were no decrements in clinical care associated with being a saver. CONCLUSIONS: Certain conditions may be more amenable than others to saving under bundled payments, and hospitals with high costs at baseline may perform well under programs which use hospitals' own baseline costs to set targets. Findings may have implications for the BPCI-Advanced program and for policymakers seeking to use payment models to drive improvements in care.

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Age and Frailty Influence Hip and Knee Arthroplasty Reimbursement in a Bundled Payment Care Improvement Initiative

Cited by 20 publications

References 16 publications

A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

A Novel Machine Learning Predictive Tool Assessing Outpatient or Inpatient Designation for Medicare Patients Undergoing Total Hip Arthroplasty

The Association Between Clopidogrel and Gastrointestinal Bleeding After Primary Total Joint Arthroplasty

Predictors of Success in the Bundled Payments for Care Improvement Program

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