Department of Orthopedic Surgery, Hanyang University Seoul Hospital, Seoul, Korea.
Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Korea.
Clin Orthop Surg. 2023 Apr;15(2):241-248. doi: 10.4055/cios21214. Epub 2022 Nov 22.
We evaluated and compared South Korea's total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases.
Two TKA appropriateness criteria and HIRA's reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee joint-specific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group.
Data on 448 cases that underwent TKA were examined. According to the HIRA's reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA's reimbursement criteria.
In terms of insurance coverage, HIRA's reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.
我们评估并比较了健康保险审查与评估服务（HIRA）制定的韩国全膝关节置换术（TKA）报销标准与其他 TKA 适宜性标准，以通过审查 TKA 不适宜病例找到改善其适宜性的额外标准。
从 2017 年 12 月至 2020 年 4 月，我们在一家医院将两种 TKA 适宜性标准和 HIRA 的 TKA 报销标准适用于接受 TKA 的患者。使用了包括 9 个膝关节特异性参数、年龄和影像学的验证问卷在内的术前数据。我们将病例分为适宜、不确定、不适宜组，并对每组进行了分析。
共检查了 448 例接受 TKA 的病例。根据 HIRA 的报销标准，434 例（96.9%）为适宜，14 例（3.1%）为不适宜；优于其他 TKA 适宜性标准。不适宜组的膝关节损伤和骨关节炎结果评分（KOOS）疼痛、KOOS 症状、西安大略和麦克马斯特大学骨关节炎指数（WOMAC）总分以及韩国膝关节评分总分的症状比 HIRA 报销标准分类的适宜组更差。
在保险覆盖方面，与其他 TKA 适宜性标准相比，HIRA 的报销标准更有效地为最迫切需要 TKA 的患者提供医疗保健。然而，我们发现其他标准的较低年龄限制和患者报告的结果测量是改善当前报销标准适宜性的有用工具。
