Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

Knoedler, RN Meghan A.; Jeffery, Molly Moore; Philpot, Lindsey M.; Meier, Sarah; Almasri, Jehad; Shah, Nilay D.; Borah, Bijan J.; Murad, M Hassan; Larson, A. Noelle; Ebbert, Jon O.

doi:10.1016/j.mayocpiqo.2018.06.001

Cited by 9 publications

(6 citation statements)

References 62 publications

(89 reference statements)

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“…Our findings are consistent with previously published studies looking at LOS and complication rates in complex TKA patients. 2,4,[10][11][12][13][14] In a study of 516,745 patients from the Nationwide Inpatient Sample, Pugley et al 2 found that greater comorbidities were associated with prolonged LOS, with each additional comorbidity yielding a subsequent increase in LOS. Knoedler et al 10 evaluated 79 studies in their systematic review to find a similar association between an increased number of medical comorbidities and LOS.…”

Section: Discussionmentioning

confidence: 99%

Does Increasing Patient Complexity Have an Effect on Medical Outcomes and Lengths-of-Stay after Total Knee Arthroplasty?

et al. 2020

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A greater number of medically complex patients with multiple comorbidities are now more readily considered for total knee arthroplasty (TKA). Therefore, the purpose of this study was to determine whether comorbidity burden, measured with the Elixhauser Comorbidity Index (ECI), correlated with 90-day medical complications and longer in-hospital lengths-of-stay (LOS) in TKA patients. The PearlDiver supercomputer was queried for all primary TKA patients in the Medicare Standard Analytic Files from 2005 to 2014 using International Classification of Disease, 9th edition codes. Patients were included based on ECI scores, ranging from 1 to 5. ECI 1 patients served as the control cohort, while ECI 2, 3, 4, and 5 patients were considered study cohorts. Each study cohort was matched based on age and gender to the control cohort, resulting in a total of 715,398 patients included for analysis (ECI 1, n = 144,072; ECI 2, n = 144,072; ECI 3, n = 144,072; ECI 4, n = 144,072; ECI 5, n = 139,110). Logistic regression analyses were performed to compare 90-day medical complications and Welch's t-tests were performed to compare LOS between the cohorts. Patients with higher ECI scores were more likely to develop medical complications and have longer LOS compared with matched patients in the control cohort. Compared with matched ECI 1 patients, patients with ECI scores of 2 (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.14–1.24), 3 (OR: 1.27, 95% CI: 1.21–1.32), 4 (OR: 1.32, 95% CI: 1.27–1.38), and 5 (OR: 1.33, 95% CI: 1.27–1.39) were significantly more likely to develop 90-day medical complications. Additionally, the mean LOS of patients in the ECI 2 (2.59 ± 1.49 vs. 2.73 ± 1.52 days), ECI 3 (2.59 ± 1.49 vs. 2.88 ± 1.51 days; p < 0.001), ECI 4 (2.59 ± 1.49 vs. 3.01 ± 1.56 days; p < 0.001), and ECI 5 (2.61 ± 1.49 vs. 3.14 ± 1.61 days; p < 0.001) groups were significantly longer than the mean LOS in the control ECI 1 group. In an increasingly complex patient population, associations between comorbidities and outcomes after TKA procedures can guide providers on how to modify their pre- and postoperative care. These results demonstrate that higher ECI scores are associated with a greater likelihood of 90-day medical complications and longer in-hospital LOS.

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Section: Discussionmentioning

confidence: 99%

Does Increasing Patient Complexity Have an Effect on Medical Outcomes and Lengths-of-Stay after Total Knee Arthroplasty?

et al. 2020

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“…10 Findings from this current study is consistent with previously published literature on costs in TKA. [11][12][13][14][15][16][17][18] Cram et al 17 studied 167,186 patients from Medicare administrative databases who underwent primary TKAs in 2009 and found that mean Medicare payments for EOC increased from $19,633 for patients with 2 or fewer comorbidities to $27,578 for patients with 5 or more comorbidities (p < 0.0001). Li et al 12 also investigated Medicare payments for patients who underwent TKA in 2009.…”

Section: Discussionmentioning

confidence: 99%

“…A systematic review of healthcare utilization and costs in lower extremity joint replacement also found that patients with more comorbidities tended to incur greater costs. Knoedler et al 13 included 79 studies in their analysis and found that medical comorbidities, disease severity, and obesity were associated with increased costs. Furthermore, an increased number of medical comorbidities were also associated with a moderate increase in LOS.…”

Section: Discussionmentioning

confidence: 99%

Cost Analysis of Medicare Patients with Varying Complexities Who Underwent Total Knee Arthroplasty

et al. 2019

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The effort to reduce overall healthcare costs may affect more complex patients, as their pre- and postoperative care can be substantially involved. Therefore, the purpose of this study was to use a large nationwide insurance database to compare (1) costs, (2) reimbursements, and (3) net losses of 90-day episodes of care (EOC) for total knee arthroplasty (TKA) patients according to Elixhauser's comorbidity index (ECI) scores. All TKAs performed between 2005 and 2014 in the Medicare Standard Analytic Files were extracted from the database and stratified based on ECI scores, ranging from 1 to 5. ECI 1 patients served as the control cohort, while ECI 2, 3, 4, and 5 patients were considered study cohorts. Each study cohort and control cohort were matched based on age and sex, resulting in a total of 715,398 patients included for analysis. Total EOC costs, reimbursements, and total net losses (defined as total EOC costs minus total EOC reimbursements) were compared between the cohorts. Overall, total EOC costs increased with ECI. For example, compared with the matched ECI 1 cohorts, the total EOC costs for ECI 5 patients ($56,589.19 vs. $51,747.54) were significantly greater (p < 0.01). Although reimbursements increased with increasing ECI, so did net losses. The net losses for ECI 5 patients were greater than that for ECI 1 patients ($42,309.39 vs. $40,007.82). The bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR) are alternative payment models that might de-incentivize treatment of more complex patients. Our study found that despite increasing reimbursements, overall costs, and therefore net losses, were greater for more complex patients with higher ECI scores.

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“…Age, because older TKA and THA patients tend to have a longer rehabilitation period [ 42 , 43 ], and 3. Socioeconomic status (SES), because if the costs of care usage is reimbursed through an insurance plan (as is the case for most post-discharge TKA or THA PT care in the Netherlands), then patients with a lower SES tend to utilize more care [ 44 , 45 ]. This SES information was retrieved by merging the study sample using the four-digit postal codes of patients with the national database of Statistics Netherlands (CBS) and categorized in five groups, ranging from low to high SES.…”

Section: Methodsmentioning

confidence: 99%

The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement

Steenhuis¹,

Hofstra²,

Portrait³

et al. 2022

BMC Health Serv Res

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Background One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients. Methods This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015–2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen. Results The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller. Conclusions This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.

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Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

Cited by 9 publications

References 62 publications

Does Increasing Patient Complexity Have an Effect on Medical Outcomes and Lengths-of-Stay after Total Knee Arthroplasty?

Does Increasing Patient Complexity Have an Effect on Medical Outcomes and Lengths-of-Stay after Total Knee Arthroplasty?

Cost Analysis of Medicare Patients with Varying Complexities Who Underwent Total Knee Arthroplasty

The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement

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