Johnson Joshua K, Erickson Jill A, Miller Caitlin J, Fritz Julie M, Marcus Robin L, Pelt Christopher E
Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA.
Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA.
Arthroplast Today. 2019 Feb 7;5(1):119-125. doi: 10.1016/j.artd.2018.12.003. eCollection 2019 Mar.
Bundled payment models for lower extremity total joint arthroplasty (TJA) aim to improve value by decreasing costs via efficient care pathways. It is unclear how such models affect patient-centered outcomes such as functional recovery. We aimed to determine whether participation in bundled payment for TJA negatively affects patients' functional recovery.
All patients, regardless of payer, undergoing elective TJA between July 2014 and December 2016 were identified retrospectively and categorized into prebundle (n = 680) and postbundle (n = 1216) cohorts. Mixed-effects linear regression and Wald postests were used to test for differences in patients' functional recovery during the hospital period and over 12 months after TJA between cohorts. We also used multivariate regression to test for differences in hospital length of stay (LOS) and postacute care (PAC) facility use between cohorts.
Compared with the prebundle cohort, patients in the postbundle cohort demonstrated a small and nonmeaningful difference in the trajectory of functional recovery in the hospital [χ(3) = 31.3, < .01] and no difference in the 12 months after TJA [χ(3) = 3.9, = .28]. They had a 0.4-day shorter hospital LOS (95% confidence interval: -0.5, -0.3) and decreased odds for PAC facility use (adjusted odds ratio = 0.3; 95% confidence interval: 0.2, 0.4).
Participation in bundled payment for TJA was not associated with significant changes in patients' functional recovery, an important patient-centered outcome. For the postbundle cohort, hospital LOS and PAC facility use were decreased, consistent with previous studies describing cost-saving strategies in bundled payment. These findings support the need for an ongoing study of the long-term sustainability of these value-based payment models.
下肢全关节置换术（TJA）的捆绑支付模式旨在通过高效的护理途径降低成本，从而提高价值。目前尚不清楚此类模式如何影响以患者为中心的结局，如功能恢复。我们旨在确定参与TJA捆绑支付是否会对患者的功能恢复产生负面影响。
对2014年7月至2016年12月期间接受择期TJA的所有患者（无论付款人如何）进行回顾性识别，并分为捆绑支付前队列（n = 680）和捆绑支付后队列（n = 1216）。采用混合效应线性回归和Wald检验来检验队列之间患者在住院期间以及TJA后12个月内功能恢复的差异。我们还使用多变量回归来检验队列之间住院时间（LOS）和急性后期护理（PAC）设施使用情况的差异。
与捆绑支付前队列相比，捆绑支付后队列的患者在住院期间功能恢复轨迹上存在微小且无意义的差异[χ(3) = 31.3，P <.01]，在TJA后12个月内无差异[χ(3) = 3.9，P =.28]。他们的住院LOS缩短了0.4天（95%置信区间：-0.5，-0.3），且使用PAC设施的几率降低（调整后的优势比 = 0.3；95%置信区间：
0.2，0.4）。
参与TJA捆绑支付与患者功能恢复这一重要的以患者为中心的结局的显著变化无关。对于捆绑支付后队列，住院LOS和PAC设施使用有所减少，这与之前描述捆绑支付中成本节约策略的研究一致。这些发现支持对这些基于价值的支付模式的长期可持续性进行持续研究的必要性
