Knoedler Meghan A, Jeffery Molly M, Philpot Lindsey M, Meier Sarah, Almasri Jehad, Shah Nilay D, Borah Bijan J, Murad M Hassan, Larson A Noelle, Ebbert Jon O
Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
Mayo Clin Proc Innov Qual Outcomes. 2018 Jul 31;2(3):248-256. doi: 10.1016/j.mayocpiqo.2018.06.001. eCollection 2018 Sep.
The Comprehensive Care for Joint Replacement program implemented by the Centers for Medicare and Medicaid Services did not incorporate risk adjustment for lower extremity joint replacement (LEJR). Lack of adjustment places hospitals at financial risk and creates incentives for adverse patient selection.
To identify patient-level risk factors associated with health care utilization and costs of patients undergoing LEJR.
A comprehensive search of research databases from January 1, 1990, through January 31, 2016, was conducted. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and SCOPUS and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search identified 2020 studies. Eligible studies focused on primary unilateral and bilateral LEJR. Independent reviewers determined study eligibility and extracted utilization and cost data.
Seventy-nine of 330 studies (24%) were included and were abstracted for analysis. Comorbidities, age, disease severity, and obesity were associated with increased costs. Increased number of comorbidities and age, presence of specific comorbidities, lower socioeconomic status, and female sex had evidence of increased length of stay. We found no significant association between indication for surgery and the likelihood of readmission.
Developing a risk adjustment model for LEJR that incorporates clinical variables may serve to reduce the likelihood of adverse patient selection and enhance appropriate reimbursement aligned with procedural complexity.
医疗保险和医疗补助服务中心实施的关节置换综合护理计划未对下肢关节置换（LEJR）进行风险调整。缺乏调整使医院面临财务风险，并产生了不良患者选择的诱因。
确定与接受LEJR患者的医疗保健利用和费用相关的患者层面风险因素。
对1990年1月1日至2016年1月31日的研究数据库进行了全面检索。数据库包括Ovid MEDLINE在研及其他未索引引文、Ovid MEDLINE、Ovid EMBASE、Ovid考克兰对照试验中央登记册、Ovid考克兰系统评价数据库以及SCOPUS，并根据PRISMA（系统评价和荟萃分析的首选报告项目）声明进行报告。检索共识别出2020项研究。符合条件的研究聚焦于原发性单侧和双侧LEJR。独立评审员确定研究的合格性并提取利用和费用数据。
330项研究中有79项（24%）被纳入并进行摘要分析。合并症、年龄、疾病严重程度和肥胖与费用增加相关。合并症数量增加、年龄增长、特定合并症的存在、社会经济地位较低以及女性有住院时间延长的证据。我们发现手术指征与再入院可能性之间无显著关联。
开发一个纳入临床变量的LEJR风险调整模型可能有助于降低不良患者选择的可能性，并提高与手术复杂性相匹配的适当报销。
