Wang Jennifer C, Piple Amit S, Chen Xiao T, Bedard Nicholas A, Callaghan John J, Berry Daniel J, Christ Alexander B, Heckmann Nathanael D
Keck School of Medicine of USC, Los Angeles, California.
Mayo Clinic, Rochester, Minnesota.
J Bone Joint Surg Am. 2022 Dec 21;104(24):2145-2152. doi: 10.2106/JBJS.22.00254. Epub 2022 Oct 26.
Medicare Advantage (MA) plans are popular among Medicare-eligible patients, but little is known about MA in lower-extremity total joint arthroplasty (TJA). The purpose of this study was to describe trends in MA utilization and analyze differences in patient characteristics and postoperative outcomes between patients undergoing primary TJA using traditional Medicare (TM) or MA plans.
Patients ≥65 years of age who underwent primary total knee or total hip arthroplasty were identified using the Premier Healthcare Database. Patients were categorized into TM and MA cohorts. Data from 2004 to 2020 were used to describe trends in insurance coverage. Data from 2015 to 2020 were used to identify differences in patient characteristics and postoperative complications using ICD-10 codes. Multivariate analyses were performed using 2015 to 2020 data to account for potential confounders.
From 2004 to 2020, the proportion of patients with MA increased from 7.9% to 34.4%, while those with TM decreased from 83.7% to 54.0%. Of the 697,317 patients who underwent primary elective TJA from 2015 to 2020, 471,439 (67.6%) had TM coverage and 225,878 (32.4%) had MA coverage. The cohorts were similar in terms of age and sex. However, a higher proportion of Black patients (8.29% compared with 4.62%; p < 0.001) and a lower proportion of White patients (84.0% compared with 89.2%; p < 0.001) were enrolled in MA compared with TM. After controlling for confounders, patients with MA had higher odds of surgical site infection (adjusted odds ratio [aOR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.47; p = 0.031), periprosthetic joint infection (aOR: 1.10; 95% CI: 1.03 to 1.18; p = 0.006), stroke (aOR: 1.15; 95% CI: 1.02 to 1.31; p = 0.026), and acute kidney injury (aOR: 1.08; 95% CI: 1.04 to 1.11; p < 0.001), but lower odds of urinary tract infection (aOR: 0.94; 95% CI: 0.90 to 0.98; p = 0.003).
From 2004 to 2020, the number of patients utilizing MA increased markedly such that 1 in 3 were covered by MA in 2020. From 2015 to 2020, patients who were non-White were more likely to have MA than TM, and the MA group had a higher rate of several postoperative complications compared with the TM group. As TM claims data inform health-care policy and clinical decisions, this change portends future challenges, including limitations in arthroplasty registry research, an increase in the administrative burden of surgeons, and a potential worsening of social disparities in health care.
医疗保险优势（MA）计划在符合医疗保险资格的患者中很受欢迎，但对于下肢全关节置换术（TJA）中的MA计划了解甚少。本研究的目的是描述MA计划的使用趋势，并分析使用传统医疗保险（TM）或MA计划进行初次TJA的患者在特征和术后结果方面的差异。
使用Premier医疗数据库识别年龄≥65岁且接受初次全膝关节或全髋关节置换术的患者。将患者分为TM组和MA组。使用2004年至2020年的数据描述保险覆盖趋势。使用2015年至2020年的数据，通过ICD-10编码识别患者特征和术后并发症的差异。使用2015年至2020年的数据进行多变量分析，以考虑潜在的混杂因素。
从2004年到2020年，MA患者的比例从7.9%增加到34.4%，而TM患者的比例从83.7%下降到54.0%。在2015年至2020年接受初次择期TJA的697317例患者中，471439例（67.6%）有TM保险，225878例（32.4%）有MA保险。两组在年龄和性别方面相似。然而，与TM组相比，MA组中黑人患者的比例更高（8.29%对4.62%；p<0.001），白人患者的比例更低（84.0%对89.2%；p<0.001）。在控制混杂因素后，MA患者发生手术部位感染的几率更高（调整后的优势比[aOR]：1.15；95%置信区间[CI]：1.04至1.47；p=0.031）、假体周围感染（aOR：1.10；95%CI：1.03至1.18；p=0.006）、中风（aOR：1.15；95%CI：1.02至1.31；p=0.026）和急性肾损伤（aOR：1.08；95%CI：1.04至1.11；p<0.001），但发生尿路感染的几率更低（aOR：0.94；95%CI：0.90至0.98；p=0.003）。
从2004年到2020年，使用MA计划的患者数量显著增加，以至于2020年三分之一的患者由MA计划承保。从2015年到2020年，非白人患者比白人患者更有可能拥有MA计划，并且与TM组相比，MA组的几种术后并发症发生率更高。由于TM理赔数据为医疗保健政策和临床决策提供依据，这种变化预示着未来的挑战，包括关节置换登记研究的局限性、外科医生行政负担的增加以及医疗保健社会差距的潜在恶化。
