Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California.
Department of Health Policy, Stanford University, Stanford, California.
JAMA Netw Open. 2023 Aug 1;6(8):e2328343. doi: 10.1001/jamanetworkopen.2023.28343.
In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown.
To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs.
DESIGN, SETTING, AND PARTICIPANTS: This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022.
Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared.
A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001).
This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.
重要性：2018 年，医疗保险将全膝关节置换术从仅限住院治疗的手术清单中移除，从而产生了新的可接受门诊全膝关节置换术的患者群体。这种变化与在医院所有的手术中心（HOSC）与独立的门诊手术中心（FASC）接受门诊膝关节置换术的患者特征之间的关联尚不清楚。
目的：描述 2017 年和 2018 年接受门诊、择期全膝关节和部分膝关节置换术的患者的特征，并比较在 FASC 和 HOSC 接受治疗的患者队列。
设计、地点和参与者：这项观察性回顾性队列研究纳入了 2017 年和 2018 年在佛罗里达州和威斯康星州州立门诊手术数据库中接受择期门诊部分和全膝关节置换术的 5657 名患者。先前的入院记录可在州立住院数据库中查到。统计分析于 2022 年 3 月至 6 月进行。
主要结果和措施：比较了 2017 年和 2018 年在 FASC 和 HOSC 接受手术的患者的特征。
结果：共纳入 5657 名患者（平均[标准差]年龄，64.2[9.9]岁；2907 名女性[51.4%]）。门诊膝关节置换术从 2017 年的 1910 例增加到 2018 年的 3747 例，并且与全膝关节置换术的增加有关（2017 年 474 例，2018 年 2065 例）。接受门诊膝关节置换术的患者增加，加剧了在 FASC 和 HOSC 接受治疗的患者之间的差异。在 FASC 就诊的私人支付保险患者比例从 2017 年的 63.4%（867 例中的 550 例）增加到 2018 年的 72.7%（1749 例中的 1272 例）（P<0.001），而在 HOSC 就诊的私人支付保险患者比例增加，但程度较小（2017 年为 41.6%（1027 例中的 427 例），2018 年为 46.4%（1346 例中的 625 例）；P<0.001）。2017 年，FASC 和 HOSC 就诊的白人患者比例相似（分别为 85.0%[737 例中的 867 例]和 88.2%[906 例中的 1027 例]）；2018 年，FASC 就诊的白人患者比例增加，与 HOSC 就诊的白人患者比例有显著差异（90.6%[1585 例中的 1749 例]和 87.9%[1183 例中的 1346 例]；P=0.01）。这两种类型的医疗机构在 2017 年至 2018 年期间，来自社会脆弱性低的社区的患者比例都有所增加，但 FASC 的增幅更大（FASC：2017 年为 6.7%（867 例中的 58 例），2018 年为 33.9%（1749 例中的 593 例）；HOSC：2017 年为 7.6%（1027 例中的 78 例），2018 年为 21.2%（1346 例中的 285 例））。最后，尽管 2017 年 FASC 和 HOSC 为有既往住院史的患者提供的医疗服务比例相似（分别为 7.8%[867 例中的 68 例]和 9.4%[1027 例中的 97 例]；P=0.25），但 2018 年 FASC 为有既往住院史的患者提供的医疗服务比例低于 HOSC（4.0%[1749 例中的 70 例]和 8.1%[1346 例中的 109 例]；P<0.001）。
结论：这项研究表明，2018 年接受门诊膝关节置换术的患者数量增加，与 FASC 治疗更多白人、私人支付保险和更健康的患者有关。这些发现令人担忧，因为随着更多手术过渡到门诊环境，FASC 获得的机会可能会增加，使医院所有的中心承担更多照顾更脆弱、病情更严重的患者的负担。
