Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
J Arthroplasty. 2019 Dec;34(12):2855-2860. doi: 10.1016/j.arth.2019.06.059. Epub 2019 Jul 2.
Alternative payment models have been viewed as successfully decreasing costs following primary total knee arthroplasty (TKA) while maintaining quality. Concerns exist regarding access to care for patients who may utilize more resources in a bundled payment arrangement. The purpose of this study is to determine if patients undergoing conversion of prior surgery to TKA have increased costs compared to primary TKA patients.
Claims from Medicare and a single private insurer were queried for all primary TKA patients at our institution from 2015 to 2016. Ninety-day post-acute care costs were compared between primary and conversion TKA. Secondary endpoints included discharge disposition, complications, and readmissions. A multivariate regression analysis was performed to identify independent risk factors for increased post-acute care costs and short-term outcome metrics.
Of 3999 primary TKA procedures, 948 patients (23%) underwent conversion TKA. Conversion TKA was associated with greater post-acute care costs in patients with commercial insurance ($4714 vs $3759, P = .034). Among Medicare beneficiaries, prior ligament reconstruction was associated with increased post-acute care costs ($1917 increase, P = .036), while prior fracture fixation approached statistical significance ($2402 increase, P = .055). Conversion TKA was an independent risk factor for readmissions (odds ratio 1.46, 95% confidence interval 1.00-2.17, P = .050), while patients with a prior open knee procedure had higher rates of complications (odds ratio 2.41, 95% confidence interval 1.004-5.778, P = .049).
Our data suggest that conversion from prior knee surgery to TKA is associated with increased 90-day post-acute care costs and resource utilization, particularly prior open procedures. Without appropriate risk adjustment in alternative payment models, surgeons may be financially deterred from providing quality arthroplasty care given the reduced net payment and surgical complexity of such cases.
在初次全膝关节置换术（TKA）后，替代支付模式被认为成功降低了成本，同时保持了质量。对于可能在捆绑支付安排中使用更多资源的患者，人们对获得护理的机会存在担忧。本研究的目的是确定先前手术转为 TKA 的患者与初次 TKA 患者相比是否增加了成本。
从我们机构的 Medicare 和单一私人保险公司的索赔中查询了 2015 年至 2016 年所有初次 TKA 患者的数据。比较了初次和转换 TKA 患者的 90 天急性后护理成本。次要终点包括出院处置、并发症和再入院。进行了多变量回归分析，以确定增加急性后护理成本和短期结果指标的独立危险因素。
在 3999 例初次 TKA 手术中，948 例（23%）患者接受了转换 TKA。在商业保险患者中，转换 TKA 与较高的急性后护理成本相关（4714 美元比 3759 美元，P =.034）。在 Medicare 受益人中，先前的韧带重建与较高的急性后护理成本相关（增加 1917 美元，P =.036），而先前的骨折固定则接近统计学意义（增加 2402 美元，P =.055）。转换 TKA 是再入院的独立危险因素（优势比 1.46，95%置信区间 1.00-2.17，P =.050），而先前有开放膝关节手术的患者并发症发生率较高（优势比 2.41，95%置信区间 1.004-5.778，P =.049）。
我们的数据表明，从先前的膝关节手术转为 TKA 与增加 90 天急性后护理成本和资源利用相关，特别是先前的开放性手术。如果在替代支付模式中没有适当的风险调整，由于这种情况下的净付款减少和手术复杂性，外科医生可能会因经济上的阻碍而不愿提供优质的关节置换护理。
