Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA.
J Arthroplasty. 2020 Jul;35(7):1756-1760. doi: 10.1016/j.arth.2020.02.038. Epub 2020 Feb 21.
With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA.
At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites.
Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient.
Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.
随着全髋关节置换术（THA）和膝关节置换术（TKA）后替代支付模式的日益普及，人们致力于降低急性后期护理（PAC）成本，特别是将患者出院到熟练护理设施（SNF）的成本。本研究旨在确定是否优先将患者出院到高质量的 SNF 可以降低主要 THA 和 TKA 的捆绑支付成本。
在我们的机构，一项针对 SNF 的质量改进计划于 2017 年初实施，优先将患者出院到内部认证的设施，这些设施由几个质量措施指定。从医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services）查询索赔数据，以确定在初次全关节置换术后出院到 SNF 的患者。我们比较了出院到认证 SNF 地点的患者和出院到其他地点的患者的成本和结果。
在 2015 年至 2018 年期间，连续 8778 例初次 THA 和 TKA 患者中，有 1284 例（14.6%）出院到 SNF。在计划启动后，有 498 名患者出院到 SNF，其中 301 名（60.4%）被送往认证设施。在认证设施的患者的 SNF 费用（$11,184 比 $8198，P <.0001）、PAC 费用（$18,952 比 $15,148，P <.0001）和治疗期费用（$34,557 比 $30,831，P <.0001）显著较低，而再入院率（10%比 12%，P =.33）或并发症率（8%比 6%，P =.15）没有差异。控制混杂变量后，出院到认证设施可使 SNF 费用降低 1961 美元（P =.0020），PAC 费用降低 3126 美元（P =.0031）。
通过与选择性 SNF 合作进行质量改进努力，可以显著降低初次 THA 和 TKA 患者的 PAC 成本。
