Nedza Susan M, Fry Donald E, DesHarnais Susan, Spencer Eric, Yep Patrick
MPA Healthcare Solutions, Chicago, IL.
Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Acad Emerg Med. 2017 Feb;24(2):236-245. doi: 10.1111/acem.13080. Epub 2017 Jan 17.
The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program.
The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day postdischarge ED claims. The claims associated with live discharge were divided into three cohorts: elective total hip replacement (THR), emergent (THR), and total knee replacement. The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the postdischarge period as well as discharge diagnosis. Visits were correlated with age, sex, joint replaced, and fracture.
There were 50,838 TJR surgeries in Texas in 2011-2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-day postdischarge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65-74 years predominated in both elective surgery categories. There were 2,370 ED visits within 90 days of 10,786 elective THRs, of which 55.5% were discharged home, 34.6% were hospitalized or transferred, and 6.9% were admitted to observation. Of the 3,438 ED visits among 8,475 emergent hip replacement cases, 22.4% were discharged home, 50.2% were hospitalized or transferred, and 5.3% were admitted to observation. Of the 6,939 visits among 31,387 knee replacement cases, 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the postdischarge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection.
ED services are frequent for Medicare TJR bundle-eligible patients within the postdischarge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing postoperative adverse outcomes.
医疗保险与医疗补助服务中心（CMS）正在积极测试捆绑支付模式。本研究旨在确定符合CMS捆绑支付计划资格的全关节置换（TJR）手术后医疗保险受益人的出院后90天内急诊室（ED）就诊的相关细节。
使用2011 - 2012年德克萨斯州的CMS研究可识别文件来确定接受TJR手术的患者。符合条件的住院索赔与出院后90天的急诊索赔相关联。与实际出院相关的索赔分为三个队列：择期全髋关节置换（THR）、急诊（THR）和全膝关节置换。确定这些急诊就诊的频率、分布、诊断和处置情况，并根据出院后时期内的时间以及出院诊断进行分层。就诊情况与年龄、性别、置换关节和骨折情况相关联。
2011 - 2012年德克萨斯州有50,838例TJR手术符合纳入CMS定义的CJR计划的条件。在出院后90天内，9,299名患者共进行了12,747次急诊就诊。85岁及以上患者因髋部骨折进行THR手术的急诊就诊最为常见。65 - 74岁患者在两个择期手术类别中占主导。在10,786例择期THR手术的90天内有2,370次急诊就诊，其中55.5%出院回家，34.6%住院或转院，6.9%接受观察。在8,475例急诊髋关节置换病例中的3,438次急诊就诊中，22.4%出院回家，50.2%住院或转院，5.3%接受观察。在31,387例膝关节置换病例中的6,939次就诊中，61.9%出院回家，30.6%再次入院或转院，7.1%接受观察。出院诊断因出院后时期的数量和时间而异。各组中最常见的诊断包括损伤/创伤、生理失代偿、心肺事件和感染。
对于符合CMS TJR捆绑支付条件的医疗保险患者，出院后急诊服务频繁。急诊利用率、出院诊断和处置情况因年龄以及择期和急诊手术而异。急诊室是识别和管理术后不良结局的重要场所。
