Risk Adjustment Is Necessary in Value-based Outcomes Models for Infected TKA

Abstract

Background The Medicare Access and CHIP Reauthorization Act of 2015 provides the framework to link reimbursement for providers based on outcome metrics. Concerns exist that the lack of risk adjustment for patients undergoing revision TKA for an infection may cause problems with access to care. Questions/purposes (1) After controlling for confounding variables, do patients undergoing revision TKA for infection have higher 30-day readmission, reoperation, and mortality rates than those undergoing revision TKA for aseptic causes? (2) Compared with patients undergoing revision TKA who are believed not to have infections, are patients undergoing revision for infected TKAs at increased risk for complications? Methods We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing revision TKA from 2012 to 2015 identified by Current Procedural Terminology (CPT) codes 27486, 27487, and 27488. Of the 10,848 patients identified, four were excluded with a diagnosis of malignancy (International Classification of Diseases, 9th Revision code 170.7, 170.9, 171.8, or 198.5). This validated, national database records short-term outcome data for inpatient procedures and does not rely on administrative coding data. Demographic variables, comorbidities, and outcomes were Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Are Patients Who Undergo THA for Infection at Higher Risk for 30-day Complications?

“…Complications, Reoperations, and Readmissions THA revision for infection was associated with an increased risk of major complications and reoperation, which can substantially affect episode-of-care cost. These findings are consistent with previous research that showed infection was an independent risk factor associated with 30-day complication, readmission, reoperation, and mortality after revision TKA [6]. While greater numbers comorbidities may be associated with the development of PJI after primary THA [9,10], these comorbidities do not fully predict the extent of unfavorable outcomes after revision THA.…”

“…Although a recent study has found that patients undergoing revision TKA for septic causes have more complication, more frequent hospital readmissions, and higher 30-day mortality rates than patients undergoing aseptic revision TKA [6], large studies directly comparing outcomes of patients undergoing infected and aseptic revision THA have been lacking. Jafari et al [14] found that for individuals undergoing revision THA, infection was most the common cause of revision failure.…”

Low Socioeconomic Status Is Associated With Increased Complication Rates: Are Risk Adjustment Models Necessary in Cervical Spine Surgery?

“…Notably, advanced age, some comorbidities, and use of government insurance have been reported as independent risk factors for increased resource utilization for total joint arthroplasty (TJA). 8 - 10 …”

CORR Insights®: Risk Adjustment Is Necessary in Value-based Outcomes Models for Infected TKA

“…In the current study [4], Courtney and colleagues describe their experience with including the traditionally high risk and high-cost infected revision knee in their institution's knee arthroplasty bundle payment plan [3,4]. Generally, patients with a variety of risk factors-high BMI, immunocompromise, or solid-organ failure-may not be offered arthroplasty surgery because they are correctly perceived to be at greater risk for serious complications, and surgeons and healthcare systems alike tend to shy away from the financial risks associated with their care.…”

“…The authors of the current study identified patient comorbidities that result in increased financial risk should a bundled payment model be implemented for infected revision knee arthroplasty [4]. The authors searched the American College of Surgeons National Surgical Quality Improvement Program® (NSQIP) database and identified more than 10,000 revision knee arthroplasties conducted by orthopaedic surgeons in a wide range of geographic and practice settings.…”