Department of Orthopaedic Surgery, Duke University, Durham, NC.
J Arthroplasty. 2019 Feb;34(2):255-259. doi: 10.1016/j.arth.2018.10.011. Epub 2018 Oct 16.
With increased restraints and efforts to contain costs in total hip arthroplasty (THA), an emphasis has been placed on risk stratification. The purpose of this study was to determine whether Medicaid patients have increased resource utilization (including 90-day emergency department [ED] visits and readmissions) compared to Medicare or commercial insurance carriers. The study hypothesized that the Medicaid population would represent a high-risk cohort with increased resource utilization.
The institutional database was retrospectively queried for primary THAs from 2013 to 2017 based on Current Procedural Terminology codes and patients undergoing revision surgery were excluded. Demographic information including age, sex, and body mass index (BMI) and medical comorbidities including American Society of Anesthesiologists (ASA) scores were evaluated. Patients were stratified by insurance type and length of stay (LOS), and 90-day ED visits and 90-day readmissions were assessed in univariable and multivariable analysis.
A total of 3674 primary THA patients were included in the analysis (including 116 with Medicaid, 1713 with Medicare, and 1845 with other insurance providers). Medicaid patients had significantly higher ASA scores (P < .001) and BMI (P < .001), with corresponding increase in procedure duration (115 vs 99 vs 105 minutes; P < .001). They had a prolonged LOS (2.5 vs 2.5 vs 1.5 days; P < .001) compared with other insurances, but similar to Medicare patients. Following discharge, in multivariable analysis controlling for age, BMI, and ASA score, Medicare patients were significantly more likely to return to the ED (odds ratio, 3.15; 95% confidence interval, 1.88-5.27; P < .001) and be readmitted (odds ratio, 2.46; 95% confidence interval, 1.26-4.81; P = .009).
Medicaid patients represent a higher risk cohort with increased resource utilization perioperatively, including longer LOS, and more 90-day ED visits and readmissions. This should be considered in outcome assessments and alternative expectations for the episode of care should be set for this population.
随着髋关节置换术（THA）的限制和控制成本的努力增加，已经强调了风险分层。本研究旨在确定医疗补助患者与医疗保险或商业保险公司相比是否有更多的资源利用（包括 90 天急诊部 [ED] 就诊和再入院）。该研究假设医疗补助人群将是资源利用率增加的高风险人群。
根据当前程序术语代码，从 2013 年至 2017 年，回顾性地从机构数据库中查询原发性 THA，并排除接受翻修手术的患者。评估了包括年龄、性别和体重指数（BMI）在内的人口统计学信息以及包括美国麻醉师协会（ASA）评分在内的医疗合并症。根据保险类型和住院时间（LOS）对患者进行分层，并在单变量和多变量分析中评估 90 天 ED 就诊和 90 天再入院情况。
共纳入 3674 例原发性 THA 患者进行分析（包括 116 例医疗补助患者、1713 例医疗保险患者和 1845 例其他保险提供者）。医疗补助患者的 ASA 评分明显更高（P <.001）和 BMI（P <.001），相应的手术时间延长（115 分钟比 99 分钟比 105 分钟；P <.001）。与其他保险相比，他们的 LOS 延长（2.5 天比 2.5 天比 1.5 天；P <.001），但与医疗保险患者相似。出院后，在多变量分析中控制年龄、BMI 和 ASA 评分后，医疗保险患者返回 ED 的可能性明显更高（比值比，3.15；95%置信区间，1.88-5.27；P <.001）和再入院（比值比，2.46；95%置信区间，1.26-4.81；P =.009）。
医疗补助患者代表了一个更高风险的人群，围手术期资源利用率增加，包括更长的 LOS，以及更多的 90 天 ED 就诊和再入院。在评估结果时应考虑这一点，并应为该人群设定医疗事件的替代预期。
