Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Spine (Phila Pa 1976). 2019 Apr 1;44(7):488-493. doi: 10.1097/BRS.0000000000002862.
A retrospective review of Medicare claims data (2009-2014).
The aim of this study was to evaluate changes in the use of lumbar fusion procedures following the formation of Accountable Care Organizations (ACOs).
Within surgical care afforded by ACOs, savings are thought to be realized by improved care coordination as well as reductions in the use of preference-sensitive procedures such as lumbar fusion.
We queried fee-for-service claims for patients enrolled in Medicare Part A and B, identifying patients who received lumbar spine fusion, discectomy, or decompression procedures. We performed a difference-in-differences analysis comparing the use of lumbar fusion in ACOs and non-ACOs in the period before (2009-2011) and after (2012-2014) ACO formation. Propensity score adjustment was used to address differences in case-mix. Multivariable logistic regression was used to compare the likelihood of receiving a lumbar fusion in ACOs and non-ACOs in the period before and after ACO formation.
Within organizations that would form ACOs, the raw rate of lumbar fusion increased from 50% (n = 2183) in 2009 to 2011 to 54% (n = 2283) in 2012 to 2014. Among non-ACOs, the use of fusion increased from 52% (n = 110,160) to 59% (n = 109,917). Adjusted difference in differences in the use of lumbar fusion between ACOs and non-ACOs was -2.6 percentage points (P = 0.13). When limited to patients with spinal stenosis, ACOs significantly reduced the use of fusion (-5.8 percentage points; P = 0.03).
Our results indicate that ACOs may effectively curtail the use of lumbar fusion procedures, particularly among patients with spinal stenosis. As these interventions are often associated with higher complications and need for reoperation, such practices might accrue additional health care savings for Medicare beyond those realized during the index surgical period.
医疗保险索赔数据的回顾性分析（2009-2014 年）。
本研究旨在评估在问责制医疗组织（ACO）形成后，腰椎融合术的使用变化。
在 ACO 提供的外科护理中，人们认为通过改善护理协调以及减少腰椎融合等偏好敏感手术的使用，可以实现节省。
我们查询了 Medicare 第 A 部分和 B 部分参保患者的按服务收费索赔，确定了接受腰椎融合、椎间盘切除术或减压手术的患者。我们采用差异中的差异分析方法，比较了 ACO 形成前后（2009-2011 年和 2012-2014 年）ACO 内和非 ACO 内腰椎融合的使用情况。采用倾向评分调整来解决病例组合差异。多变量逻辑回归用于比较 ACO 形成前后 ACO 和非 ACO 中接受腰椎融合的可能性。
在将形成 ACO 的组织内，腰椎融合的原始比例从 2009 年至 2011 年的 50%（n=2183）增加到 2012 年至 2014 年的 54%（n=2283）。在非 ACO 中，融合的使用率从 52%（n=110160）增加到 59%（n=109917）。ACO 和非 ACO 之间腰椎融合使用差异的调整差异为-2.6 个百分点（P=0.13）。当仅限于患有椎管狭窄症的患者时，ACO 显著减少了融合的使用（-5.8 个百分点；P=0.03）。
我们的结果表明，ACO 可能有效地限制腰椎融合手术的使用，特别是在患有椎管狭窄症的患者中。由于这些干预措施通常与更高的并发症和再次手术的需求相关，因此这些做法可能会为医疗保险带来除了手术期间实现的那些之外的额外医疗保健节省。
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