Department of Orthopaedics and Sports Medicine, Emory University, Atlanta, Georgia.
Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia.
J Bone Joint Surg Am. 2018 Dec 5;100(23):2041-2049. doi: 10.2106/JBJS.17.00834.
Medicaid payer status has been shown to affect risk-adjusted outcomes and resource utilization across multiple medical specialties. The purpose of this study was to examine resource utilization via readmission rates, length of stay, and total cost specific to Medicaid payer status following primary total hip arthroplasty.
The Nationwide Readmissions Database (NRD) was utilized to identify patients who underwent total hip arthroplasty in 2013 as well as corresponding "Medicaid" or "non-Medicaid" payer status. Demographic data, 14 individual comorbidities, readmission rates, length of stay, and direct cost were evaluated. A propensity-score-based matching model was utilized to control for baseline confounding variables between payer groups. Following propensity-score matching, the chi-square test was used to compare readmission rates between the 2 payer groups. The relative risk (RR) with 95% confidence interval (CI) was estimated to quantify readmission risk. Length of stay and total cost comparisons were evaluated using the Wilcoxon signed-rank test.
A total of 5,311 Medicaid and 144,814 non-Medicaid patients managed with total hip arthroplasty were identified from the 2013 NRD. A propensity score was estimated for each patient on the basis of the available baseline demographics, and 5,311 non-Medicaid patients were matched by propensity score to the 5,311 Medicaid patients. Medicaid versus non-Medicaid payer status yielded significant differences in overall readmission rates of 28.8% versus 21.0% (p < 0.001; RR = 1.37 [95% CI, 1.28 to 1.46]) and 90-day hip-specific readmission rates of 2.5% versus 1.8% (p = 0.01; RR = 1.38 [95% CI, 1.07 to 1.78]). Mean length of stay was greater in the Medicaid group than in the non-Medicaid group at 4.5 versus 3.3 days (p < 0.0001), as was the mean total cost at $71,110 versus $65,309 (p < 0.0001).
This study demonstrates that Medicaid payer status is independently associated with increased resource utilization, including readmission rates, length of stay, and total cost following primary total hip arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status are necessary to avoid decreased access to care for this patient population and to avoid financial penalty for physicians and hospitals alike.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
医疗补助支付者身份已被证明会影响多个医学专业的风险调整后结局和资源利用。本研究的目的是检查通过再入院率、住院时间和特定于医疗补助支付者身份的总费用来评估全髋关节置换术后的资源利用情况。
利用全国再入院数据库（NRD）确定 2013 年接受全髋关节置换术的患者以及相应的“医疗补助”或“非医疗补助”支付者身份。评估人口统计学数据、14 种个体合并症、再入院率、住院时间和直接费用。利用倾向评分匹配模型控制支付组之间的基线混杂变量。在倾向评分匹配后，使用卡方检验比较两组再入院率。用 95%置信区间（CI）估计相对风险（RR）以量化再入院风险。使用 Wilcoxon 符号秩检验评估住院时间和总费用比较。
从 2013 年 NRD 中确定了 5311 例医疗补助和 144814 例非医疗补助接受全髋关节置换术的患者。根据可用的基线人口统计学数据为每位患者估算了一个倾向得分，并根据倾向得分将 5311 例非医疗补助患者与 5311 例医疗补助患者相匹配。医疗补助与非医疗补助支付者身份在总再入院率（28.8%对 21.0%，p < 0.001；RR = 1.37[95%CI，1.28 至 1.46]）和 90 天髋关节特异性再入院率（2.5%对 1.8%，p = 0.01；RR = 1.38[95%CI，1.07 至 1.78]）方面存在显著差异。医疗补助组的平均住院时间长于非医疗补助组，分别为 4.5 天和 3.3 天（p < 0.0001），总费用也高于非医疗补助组，分别为 71110 美元和 65309 美元（p < 0.0001）。
本研究表明，医疗补助支付者身份与全髋关节置换术后资源利用增加独立相关，包括再入院率、住院时间和总费用。提供者可能不愿意治疗术后需要更多资源的患者人群。需要风险调整模型来考虑医疗补助支付者身份，以避免该患者人群的医疗机会减少，并避免医生和医院受到经济处罚。
治疗性 III 级。有关证据水平的完整描述，请参见作者说明。
