Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY.
J Arthroplasty. 2020 Jun;35(6S):S73-S78. doi: 10.1016/j.arth.2020.02.056. Epub 2020 Feb 28.
Bundled payment models may lead to selection of healthier total joint arthroplasty (TJA) candidates resulting in comorbid patients being taken care of in fewer hospitals. We aimed to (1) evaluate hospital-specific TJA comorbidity burden ("casemix") over time and (2) associations with resource utilization.
This retrospective cohort study used 2011 and 2016 New York State data (n = 36,078 hip/knee arthroplasties). Comorbidity burden was estimated by the Charlson-Deyo Index; main outcomes were hospitalization cost and nonhome discharge. Hospitals were categorized into those with a decreased, stable (with a 5% buffer), or increased percentage of comorbidity-free patients (Charlson-Deyo = 0) between 2011 and 2016. Mixed-effects models measured the association between Charlson-Deyo Index category and outcomes, by hospital casemix categorization. Odds ratios and 95% confidence intervals (CIs) are reported.
Overall, 29 (n = 8810), 37 (n = 16,297), and 46 (n = 10,971) hospitals were categorized into the decreased, stable, and increased Charlson-Deyo = 0 categories, respectively, with median annual TJA volumes of 499, 814, and 393 (P < .0001). Multivariable models demonstrated that-in hospitals with a stable patient casemix-increased patient comorbidity was associated with increased hospitalization costs (maximum 21.8%, CI 18.9-24.9, P < .0001). However, this effect was moderated (maximum 11.1%, CI 8.0-14.2) in hospitals that took on a more comorbid patient casemix. Similar patterns were observed for nonhome discharge.
Most studied hospitals show an increase in comorbidity-free TJA patients, suggestive of patient selection. This redistribution of comorbid patients to select hospitals may not necessarily be a negative development as our results suggest more efficient resource utilization for comorbid patients in such hospitals.
打包付费模式可能导致更健康的全关节置换术（TJA）患者的选择，从而导致合并症患者在较少的医院接受治疗。我们的目的是：（1）评估医院特有的 TJA 合并症负担（“病例组合”）随时间的变化；（2）与资源利用的关联。
这项回顾性队列研究使用了 2011 年和 2016 年纽约州的数据（n=36078 髋/膝关节置换术）。通过 Charlson-Deyo 指数评估合并症负担；主要结果是住院费用和非家庭出院。根据 2011 年至 2016 年期间合并症患者比例（Charlson-Deyo=0），将医院分为减少、稳定（缓冲 5%）或增加（Charlson-Deyo=0）的医院。混合效应模型通过医院病例组合分类，测量 Charlson-Deyo 指数类别与结果之间的关联。报告比值比和 95%置信区间（CI）。
总体而言，29 家（n=8810）、37 家（n=16297）和 46 家（n=10971）医院分别归入减少、稳定和增加 Charlson-Deyo=0 类别，其年度 TJA 量中位数分别为 499、814 和 393（P<0.0001）。多变量模型表明，在患者病例组合稳定的医院中，患者合并症增加与住院费用增加相关（最大增加 21.8%，95%CI 18.9-24.9，P<0.0001）。然而，在接受更多合并症患者的医院中，这种影响（最大 11.1%，95%CI 8.0-14.2）有所缓和。非家庭出院也观察到类似的模式。
大多数研究医院的 TJA 无合并症患者比例增加，提示存在患者选择。将合并症患者重新分配到选择医院可能不一定是负面的发展，因为我们的结果表明，在这些医院中，合并症患者的资源利用效率更高。
