Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
J Arthroplasty. 2023 Jul;38(7 Suppl 2):S150-S155. doi: 10.1016/j.arth.2022.08.039. Epub 2022 Nov 8.
While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers are requiring preoperative PROMs when determining eligibility for total knee arthroplasty (TKA). Concerns exist that these data may be used to deny TKA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate TKA outcomes based on theoretical PROM thresholds.
We retrospectively analyzed 25,246 consecutive primary TKA patients from 2016 to 2019. Hypothesized preoperative knee injury and osteoarthritis outcome score for joint replacement cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. One-year minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.
For "denied" patients below thresholds 40, 50, 60, and 70 points, 1-year MCID achievement was 88.3%, 85.9%, 79.6%, and 77%, respectively. In-hospital complication rates for approved patients were 2.2%, 2.3%, 2.1%, and 2.1%, while 90-day readmission rates were 4.6%, 4.5%, 4.3%, and 4.3%, respectively. Approved patients had higher MCID achievement rates (P < .001) for all thresholds but higher nonhome discharge rates than denied patients for thresholds 40 (P < .001), 50 (P = .002), and 60 (P = .024). Approved and denied patients had similar in-hospital complication and 90-day readmission rates.
Most patients achieved MCID at all theoretical PROMs thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for TKA eligibility can help optimize patient improvement, but such a policy can create access to care barriers for some patients who would otherwise benefit from a TKA.
尽管医疗保险要求许多质量计划的患者报告结局测量（PROMs），但一些商业保险公司在确定全膝关节置换术（TKA）的资格时，也要求术前 PROMs。有人担心，这些数据可能会被用来拒绝特定 PROM 评分以上的 TKA 患者，但最佳阈值尚不清楚。我们旨在根据理论 PROM 阈值评估 TKA 结果。
我们回顾性分析了 2016 年至 2019 年的 25246 例连续原发性 TKA 患者。假设术前膝关节损伤和骨关节炎结局评分的关节置换截止值为 40、50、60 和 70 分。每个阈值以下的术前评分被认为是“批准”手术。每个阈值以上的术前评分被认为是“拒绝”手术。评估了住院期间的并发症、90 天再入院率和出院去向。使用以前验证过的基于锚的方法计算了 1 年的最小临床重要差异（MCID）实现。
对于低于 40、50、60 和 70 点阈值的“拒绝”患者，1 年 MCID 实现率分别为 88.3%、85.9%、79.6%和 77%。批准患者的住院期间并发症发生率分别为 2.2%、2.3%、2.1%和 2.1%，90 天再入院率分别为 4.6%、4.5%、4.3%和 4.3%。所有阈值下，批准患者的 MCID 实现率均较高（P<.001），但对于 40（P<.001）、50（P=.002）和 60（P=.024）的阈值，非家庭出院率高于拒绝患者。批准和拒绝患者的住院期间并发症和 90 天再入院率相似。
大多数患者在所有理论 PROM 阈值下都达到了 MCID，并发症和再入院率较低。设定 TKA 资格的术前 PROM 阈值可以帮助优化患者的改善，但对于那些本可以从 TKA 中受益的患者来说，这样的政策可能会造成获得医疗服务的障碍。
