Department of Orthopaedic Surgery, Rush University, Chicago, Illinois.
Department of Orthopedic Surgery, Columbia University, New York, New York.
J Arthroplasty. 2023 Jun;38(6):992-997. doi: 10.1016/j.arth.2022.12.029. Epub 2022 Dec 16.
In 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates.
Using a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions.
In 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001).
Over half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA.
2018 年，医疗保险和医疗补助服务中心（Centers for Medicare & Medicaid Services）将全膝关节置换术（TKA）从仅限住院治疗的清单中删除，引发了许多意想不到的后果。本研究的目的是确定 TKA 移除对门诊 TKA 患者数量的影响、哪些患者被归类为门诊患者以及门诊分类如何影响出院地点和再入院率。
使用大型行政索赔数据库，我们回顾了 2015 年至 2020 年期间连续 216365 例初次 TKA 医疗保险患者。根据人口统计学、合并症、出院情况和再入院情况，将 2018 年至 2020 年期间有住院（n=63356）和门诊（n=38510）状态的患者进行比较。
2015 年，只有 1.8%的 TKA 患者被指定为门诊患者，但到 2020 年，57.2%的 Medicare TKA 患者被归类为门诊患者。大多数（72%）有门诊指定的患者在医院停留时间超过 24 小时（平均住院时间为 2.7 天）。有门诊状态的患者比有住院状态的患者更频繁地出院到熟练护理设施（3.1%比 2.0%，P<.001），急诊就诊率更高（5.1%比 3.9%，P<.001），90 天再入院率更高（2.2%比 0.9%，P<.001）。
在将 TKA 从仅限住院治疗的清单中删除的政策实施 3 年后，超过一半的 Medicare TKA 患者被归类为门诊患者。被指定为门诊患者的患者比被指定为住院患者的患者再入院率更高。在未能证明接受 TKA 的 Medicare 患者更安全出院的情况下，应重新评估该政策。
