Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT.
Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA.
J Arthroplasty. 2019 Jun;34(6):1072-1075. doi: 10.1016/j.arth.2019.01.069. Epub 2019 Feb 2.
Patient-reported outcomes (PROs) are gaining an important role in the assessment of quality of care. There are currently limited data on the effect of payer type on PROs in total joint arthroplasty (TJA). This study compared both disease-specific and general health PROs among patients stratified according to their payer type.
Our institutional joint registry was queried for patients who underwent primary, elective, and unilateral hip and knee arthroplasty. Patients were divided according to their insurance type at the time of surgery into 3 groups: Medicaid, Medicare, or commercial. The outcomes assessed were the net changes in PROs as well as absolute scores at 6 months and 1 year. Six of the most commonly used PROs were assessed: Short Form-12 physical and mental components, Western Ontario and McMaster Universities Osteoarthritis Index, Single Assessment Numerical Evaluation, University of Californian Los Angeles activity level rating, and Oxford Hip Score. Analysis of variance and covariance were used.
We evaluated 756 procedures (273 Medicaid, 270 Medicare, and 213 commercial insurance). Medicaid patients had significantly lower mean baseline scores across all PROs compared to either Medicare or commercial insurance patients. Medicaid patients were also more likely to be smokers, live alone, have lower educational level, African-American, and have nonprimary osteoarthritis as the indication for TJA. At 1-year follow-up, the net mean outcome gains were comparable among the 3 payer types (P > .05), but Medicaid patients continued to score lower while Medicare and commercial insurance patients continued to score higher (P < .01). When adjusting for all baseline differences among Medicaid patients, the negative effects of payer type resolved except for Oxford Hip Score which remained lower in the Medicaid group (P = .006).
When using PROs to assess the value of care, the preoperative to postoperative changes are a better indicator of surgical success than comparing absolute values, especially in Medicaid patients. While TJA imparts similar net improvements to patients of all payer types, Medicaid coverage is a predictor of lower absolute outcome scores at any given time as result of increased baseline health burden (eg, depression, tobacco smoking, and poor overall well-being). Arthroplasty surgeons should be aware of these factors when counseling patients and seek optimization when necessary. The findings should be taken into account by stakeholders when constructing value-based payment models. Further research is needed to better understand the barriers leading to higher prevalence of increased health disparities among Medicaid beneficiaries and how to effectively address them.
患者报告的结局（PROs）在评估医疗质量方面发挥着重要作用。目前，关于支付类型对全膝关节置换术（TJA）中 PRO 的影响的数据有限。本研究比较了根据支付类型分层的患者的疾病特异性和一般健康 PRO。
我们机构的关节登记处查询了接受初次、择期、单侧髋关节和膝关节置换术的患者。根据手术时的保险类型，患者分为 3 组：医疗补助、医疗保险或商业保险。评估的结果是 PRO 的净变化以及 6 个月和 1 年时的绝对评分。评估了 6 种最常用的 PRO：简短形式-12 个身体和心理成分、安大略西部和麦克马斯特大学骨关节炎指数、单一评估数值评估、加利福尼亚大学洛杉矶活动水平评分和牛津髋关节评分。使用方差分析和协方差分析。
我们评估了 756 例手术（273 例医疗补助，270 例医疗保险，213 例商业保险）。与医疗保险或商业保险患者相比，医疗补助患者在所有 PRO 中的基线评分均显著较低。医疗补助患者也更有可能是吸烟者、独居、教育水平较低、非裔美国人，并且 TJA 的指征是非原发性骨关节炎。在 1 年随访时，3 种支付类型的净平均结局获益相当（P>0.05），但医疗补助患者的评分继续较低，而医疗保险和商业保险患者的评分继续较高（P<0.01）。在调整医疗补助患者所有基线差异后，支付类型的负面影响得到解决，但牛津髋关节评分仍较低（P=0.006）。
在使用 PRO 评估护理价值时，与比较绝对值相比，术前到术后的变化是手术成功的更好指标，尤其是在医疗补助患者中。虽然 TJA 为所有支付类型的患者带来了相似的净改善，但医疗补助覆盖是任何给定时间绝对结果评分较低的预测因素，这是由于基线健康负担增加（例如，抑郁、吸烟和整体健康状况不佳）所致。关节置换外科医生在为患者提供咨询时应注意这些因素，并在必要时寻求优化。利益相关者在构建基于价值的支付模型时应考虑这些发现。需要进一步研究以更好地了解导致医疗补助受益人中健康差异增加的障碍以及如何有效解决这些障碍。
