Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA.
Center for Musculoskeletal Research, Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA.
Clin Orthop Relat Res. 2022 Jun 1;480(6):1033-1045. doi: 10.1097/CORR.0000000000002072. Epub 2021 Dec 21.
Higher hospital volume is associated with lower rates of adverse outcomes after revision total joint arthroplasty (TJA). Centralizing revision TJA care to higher-volume hospitals might reduce early complication and readmission rates after revision TJA; however, the effect of centralizing revision TJA care on patient populations who are more likely to experience challenges with access to care is unknown.
QUESTIONS/PURPOSES: (1) Does a hypothetical policy of transferring patients undergoing revision TJA from lower-to higher-volume hospitals increase patient travel distance and time? (2) Does a hypothetical policy of transferring patients undergoing revision TJA from lower- to higher-volume hospitals disproportionately affect travel distance or time in low income, rural, or racial/ethnic minority populations?
Using the Medicare Severity Diagnosis Related Groups 466-468, we identified 37,147 patients with inpatient stays undergoing revision TJA from 2008 to 2016 in the Statewide Planning and Research Cooperative System administrative database for New York State. Revisions with missing or out-of-state patient identifiers (3474 of 37,147) or those associated with closed or merged facilities (180 of 37,147) were excluded. We chose this database for our study because of relative advantages to other available databases: comprehensive catchment of all surgical procedures in New York State, regardless of payer; each patient can be followed across episodes of care and hospitals in New York State; and New York State has an excellent cross-section of hospital types for TJA, including rural and urban hospitals, critical access hospitals, and some of the highest-volume centers for TJA in the United States. We divided hospitals into quartiles based on the mean revision TJA volume. Overall, 80% (118 of 147) of hospitals were not for profit, 18% (26 of 147) were government owned, 78% (115 of 147) were located in urban areas, and 48% (70 of 147) had fewer than 200 beds. The mean patient age was 66 years old, 59% (19,888 of 33,493) of patients were females, 79% (26,376 of 33,493) were white, 82% (27,410 of 33,493) were elective admissions, and 56% (18,656 of 33,493) of admissions were from government insurance. Three policy scenarios were evaluated: transferring patients from the lowest 25% by volume hospitals, transferring patients in the lowest 50% by volume hospitals, and transferring patients in the lowest 75% by volume hospitals to the nearest higher-volume institution by distance. Patients who changed hospitals and travelled more than 60 miles or longer than 60 minutes with consideration for average traffic patterns after the policy was enacted were considered adversely affected. The secondary outcome of interest was the impact of the three centralization policies, as defined above, on lower-income, nonwhite, rural versus urban counties, and Hispanic ethnicity.
Transferring patients from the lowest 25% by volume hospitals resulted in only one patient stay that was affected by an increase in travel distance and travel time. Transferring patients from the lowest 50% by volume hospitals resulted in 9% (3050 of 33,493) of patients being transferred, with only 1% (312 of 33,493) of patients affected by either an increased travel distance or travel time. Transferring patients from the lowest 75% by volume hospitals resulted in 28% (9323 of 33,493) of patients being transferred, with 2% (814 of 33,493) of patients affected by either an increased travel distance or travel time. Nonwhite patients were less likely to encounter an increased travel distance or time after being transferred from the lowest 50% by volume hospitals (odds ratio 0.31 [95% CI 0.15 to 0.65]; p = 0.002) or being transferred from the lowest 75% by volume hospitals (OR 0.10 [95% CI 0.07 to 0.15]; p < 0.001) than white patients were. Hispanic patients were more likely to experience increased travel distance or time after being transferred from the lowest 50% by volume hospitals (OR 12.3 [95% CI 5.04 to 30.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.24 [95% CI 2.24 to 4.68]; p < 0.001) than non-Hispanic patients were. Patients from a county with a lower median income were more likely to experience increased travel distances or time after being transferred from the lowest 50% by volume hospitals (OR 69.5 [95% CI 17.0 to 283]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.86 [95% CI 3.21 to 4.64]; p < 0.001) than patients from counties with a higher median income. Patients from rural counties were more likely to be affected after being transferred from the lowest 50% by volume hospitals (OR 98 [95% CI 49.6 to 192.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 11.7 [95% CI 9.89 to 14.0]; p < 0.001) than patients from urban counties.
Although centralizing revision TJA care to higher-volume institutions in New York State did not appear to increase the travel burden for most patients, policies that centralize revision TJA care will need to be carefully designed to minimize the disproportionate impact on patient populations that already face challenges with access to healthcare. Further studies should examine the feasibility of establishing centers of excellence designations for revision TJA, the effect of best practices adoption by lower volume institutions to improve revision TJA care, and the potential role of care-extending technology such as telemedicine to improve access to care to reduce the effects of travel distances on affected patient populations.
Level III, prognostic study.
更高的医院容量与翻修全膝关节置换术（TJA）后不良结局的发生率较低相关。将翻修 TJA 护理集中到更高容量的医院可能会降低翻修 TJA 后的早期并发症和再入院率；然而，将翻修 TJA 护理集中到更有可能面临获得护理挑战的患者人群的效果尚不清楚。
问题/目的：（1）假设将接受翻修 TJA 的患者从低容量医院转移到高容量医院的政策是否会增加患者的旅行距离和时间？（2）假设将接受翻修 TJA 的患者从低容量医院转移到高容量医院的政策是否会不成比例地影响低收入、农村或少数族裔人群的旅行距离或时间？
使用 Medicare 严重程度诊断相关组 466-468，我们从纽约州全州规划和研究合作系统行政数据库中确定了 2008 年至 2016 年期间接受住院翻修 TJA 的 37,147 名患者。对有缺失或州外患者标识符的手术（37,147 例中的 3474 例）或与关闭或合并设施相关的手术（37,147 例中的 180 例）进行了排除。我们选择这个数据库进行研究，是因为它相对于其他可用数据库具有相对优势：全面涵盖了纽约州所有类型的手术，无论支付方式如何；每位患者都可以在纽约州的医院和多个住院期间进行跟踪；并且纽约州拥有各种类型的 TJA 医院，包括农村和城市医院、关键接入医院以及美国一些最高容量的 TJA 中心。我们根据翻修 TJA 量的平均值将医院分为四分之一。总体而言，80%（118/147）的医院是非营利性的，18%（26/147）的医院是政府所有的，78%（115/147）的医院位于城市地区，48%（70/147）的医院床位少于 200 张。患者的平均年龄为 66 岁，59%（19,888/33,493）的患者为女性，79%（26,376/33,493）为白人，82%（27,410/33,493）为择期入院，56%（18,656/33,493）的入院患者来自政府保险。评估了三种政策方案：将来自最低 25%体积医院的患者转移、将来自最低 50%体积医院的患者转移，以及将来自最低 75%体积医院的患者转移到距离最近的高容量机构。如果患者改变了医院并在政策实施后考虑到平均交通模式旅行超过 60 英里或超过 60 分钟，则认为他们受到了不利影响。上述三个集中化政策对低收入、非白人、农村与城市县以及西班牙裔的影响是我们关注的次要结果。
将来自最低 25%体积医院的患者转移仅导致一名患者的旅行距离和时间增加。将来自最低 50%体积医院的患者转移导致 9%（3050/33,493）的患者被转移，只有 1%（312/33,493）的患者受到旅行距离或时间增加的影响。将来自最低 75%体积医院的患者转移导致 28%（9323/33,493）的患者被转移，只有 2%（814/33,493）的患者受到旅行距离或时间增加的影响。与白人患者相比，非白人患者在从最低 50%体积医院转移（比值比 0.31[95%置信区间 0.15 至 0.65]；p=0.002）或从最低 75%体积医院转移（比值比 0.10[95%置信区间 0.07 至 0.15]；p<0.001）后，不太可能出现旅行距离或时间增加的情况。与非西班牙裔患者相比，西班牙裔患者在从最低 50%体积医院转移（比值比 12.3[95%置信区间 5.04 至 30.2]；p<0.001）和从最低 75%体积医院转移（比值比 3.24[95%置信区间 2.24 至 4.68]；p<0.001）后更有可能出现旅行距离或时间增加的情况。收入中位数较低的县的患者在从最低 50%体积医院转移（比值比 69.5[95%置信区间 17.0 至 283]；p<0.001）和从最低 75%体积医院转移（比值比 3.86[95%置信区间 3.21 至 4.64]；p<0.001）后更有可能出现旅行距离或时间增加的情况。与收入中位数较高的县的患者相比，来自农村县的患者在从最低 50%体积医院转移（比值比 98[95%置信区间 49.6 至 192.2]；p<0.001）和从最低 75%体积医院转移（比值比 11.7[95%置信区间 9.89 至 14.0]；p<0.001）后更有可能受到影响。
尽管将翻修 TJA 护理集中到纽约州更高容量的医院似乎并没有增加大多数患者的旅行负担，但集中化政策将需要精心设计，以尽量减少对已经面临获得医疗保健挑战的患者群体的不成比例影响。进一步的研究应探讨为翻修 TJA 建立卓越中心指定的可行性、低容量机构采用最佳实践以改善翻修 TJA 护理的效果，以及远程医疗等扩大护理范围的技术在减少受旅行距离影响的患者群体方面的潜在作用。
III 级，预后研究。
