Total Knee Arthroplasty Volume, Utilization, and Outcomes Among Medicare Beneficiaries, 1991-2010

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Background Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited. Questions/purposes We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained? Methods We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whetherThe institution of one of the authors (PC) has received, during the study period, funding from the National Institutes of Health (K24 AR062133 and R01 AG033035). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that the institutional review board at the University of Iowa approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at the University of Iowa, Iowa City, IA. Clinical Orthopaedics and Related Research ®A Publication of The Association of Bone and Joint Surgeons® differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors. Results There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,323

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Cram

Ravi

Vaughan-Sarrazin

et al. 2015

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“…Total joint arthroplasty (TJA) procedure volumes have risen dramatically in recent years as a result of an aging population, advances in technology, and expansion of indications to include younger, more active patients [2]. At the same time, payers, providers, and policymakers all have placed increased emphasis on strategies to control costs and improve quality associated with elective surgical procedures such as TJA.…”

Section: Introductionmentioning

confidence: 99%

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Bozic

Ward

Vail

et al. 2014

381

205

Background Understanding the type and magnitude of services that patients receive postdischarge and the financial impact of readmissions is crucial to assessing the feasibility of accepting bundled payments. Questions/purposes The purposes of this study were to (1) determine the cost and service components of a 30-day total joint arthroplasty (TJA) episode of care; (2) analyze the portion of the total payment that is used for postdischarge services, including home care; and (3) to evaluate the frequency of readmissions and their impact on total episode-of-care payments. Methods All payments to Medicare providers (hospitals, postacute care facilities, physicians, and other healthcare providers) for services beginning with the index procedure and extending 30-days postdischarge were analyzed for 250 Medicare beneficiaries undergoing primary or revision TJA from a single institution over a 12 months. Payments and services were aggregated by procedure type and categorized as index procedure, postacute care, and related hospital readmissions. Results Mean episode-of-care payments ranged from USD 25,568 for primary TJA in patients with no comorbidities to USD 50,648 for revision TJA in patients with major comorbidities or complications, with wide variability within and across procedures. Postdischarge payments accounted for 36% of total payments. A total of 49% of patients were transferred to postacute care facilities, accounting for 70% of postdischarge payments. The overall 30-day unplanned readmission rate was 10%, accounting for 11% of postdischarge payments. Conclusions Episode-of-care payments for TJAs vary widely depending on the type of procedure, patient comorbidities and complications, discharge disposition, and readmission rates. Postdischarge care accounted for more than one-third of total episode payments and varied substantially across patients and procedures.

“…There were more than 600,000 TKAs performed in the United States in 2007 with costs exceeding USD 9 billion [21]. By 2009, the use of TKA had almost doubled from a decade earlier [3], and rates of both primary and revision TKA are expected to continue to increase exponentially during the next several decades [13]. Although considered a safe and effective procedure, complications associated with TKA can lead to poor outcomes [19].…”

Section: Introductionmentioning

confidence: 99%

What Are the Rates and Causes of Hospital Readmission After Total Knee Arthroplasty?

Schairer

Vail

Bozic

2014

202

142

Background Total knee arthroplasty (TKA) and related interventions such as revision TKA and the treatment of infected TKAs are commonly performed procedures. Hospital readmission rates are used to measure hospital performance, but risk factors (both medical and surgical) for readmission after TKA, revision TKA, and treatment for the infected TKA have not been well characterized. Questions/purposes We measured (1) the unplanned hospital readmission rate in primary TKA and revision TKA, including antibiotic-spacer staged revision TKA to treat infection. We also evaluated (2) the medical and surgical causes of readmission and (3) risk factors associated with unplanned hospital readmission. Methods This retrospective cohort study included a total of 1408 patients (1032 primary TKAs, 262 revision TKAs, 113 revision of infected TKAs) from one institution. All hospital readmissions within 90 days of discharge were evaluated for timing and cause. Diagnoses at readmission were categorized as surgical or medical. Readmission risk was assessed using a Cox proportional hazards model that incorporated patient demographics and medical comorbidities. Results The unplanned readmission rate for the entire cohort was 4% at 30 days and 8% at 90 days. At 90 days postoperatively, revision of an infected TKA had the highest readmission rate, followed by revision TKA, with primary TKA having the lowest rate. Approximately threefourths of readmissions were the result of surgical causes, mostly infection, arthrofibrosis, and cellulitis, whereas the remainder of readmissions were the result of medical causes. Procedure type (primary TKA versus revision TKA or staged treatment for infected TKA), hospital stay more than 5 days, discharge destination, and a fluid/electrolyte abnormality were each associated with risk of unplanned readmission.