Reddy Akshay, Miley Emilie N, Parvataneni Hari K, Prieto Hernan A, Gray Chancellor F
College of Medicine, University of Florida, Gainesville, FL, USA.
Department of Orthopaedic Surgery, College of Medicine, University of Florida, Gainesville, FL.
Arthroplast Today. 2024 Jul 20;28:101466. doi: 10.1016/j.artd.2024.101466. eCollection 2024 Aug.
The downstream regional effect of the Comprehensive Care for Joint Replacement (CJR) program on care pathway-adjacent patients, including revision arthroplasty patients, is poorly understood. Prior studies have demonstrated that care pathways targeting primary total joint arthroplasty may produce a halo effect, impacting more complex patients with parallel care pathways. However, neither the effect of regional referral changes from CJR nor the durability of these positive changes with prolonged bundle participation has been assessed.
Blinded data were pulled from electronic medical records. Primary analyses focused on the effect of CJR participation from 2015 (baseline) to 2020 (final participation year) at a tertiary care safety-net hospital. Patient demographics were evaluated using multivariate analysis of variance and chi-square calculations between procedure types over time.
Patients who underwent revision total knee arthroplasty (N = 376) and revision total hip arthroplasty (N = 482) were included. More patients moved through the revision-care pathway over the participation period, with volume increasing by 42% over time. Patients became more medically complex: the Charlson comorbidity index increased from 3.91 to 4.65 ( = .01). The mean length of stay decreased from 5.14 days to 4.50 days ( = .03), but the all-cause complication (8.3%-15.2%; = .02) and readmission rates (13.6%-16.6%; = .19) increased over time.
Despite care pathway improvements over 5 years of CJR participation, revision patients did not display clear benefits in quality metrics but demonstrated a considerable increase in volume and medical complexity over time. The care of these patients may supersede even thoughtfully implemented care pathways, especially when referral burden increases, as may be prone to happen in regional, financial risk-conferring value-based programs. Understanding the impact of mandatory bundled payment programs like CJR on the care of arthroplasty patients regionally will be essential as value-based programs evolve.
关节置换综合护理（CJR）计划对护理路径相邻患者（包括翻修关节成形术患者）的下游区域影响了解甚少。先前的研究表明，针对初次全关节置换术的护理路径可能会产生光环效应，影响具有平行护理路径的更复杂患者。然而，既未评估CJR导致的区域转诊变化的影响，也未评估随着长期参与捆绑式服务这些积极变化的持续性。
从电子病历中提取盲态数据。主要分析聚焦于2015年（基线）至2020年（最终参与年份）在一家三级医疗安全网医院参与CJR的影响。使用多变量方差分析和不同手术类型随时间变化的卡方计算来评估患者人口统计学特征。
纳入了接受全膝关节翻修术（N = 376）和全髋关节翻修术（N = 482）的患者。在参与期间，更多患者通过了翻修护理路径，数量随时间增加了42%。患者的医疗复杂性增加：查尔森合并症指数从3.91增至4.65（P = .01）。平均住院时间从5.14天降至4.50天（P = .03），但全因并发症发生率（8.3%-15.2%；P = .02）和再入院率（13.6%-16.6%；P = .19）随时间增加。
尽管参与CJR的5年中护理路径有所改善，但翻修患者在质量指标方面未显示出明显益处，不过随着时间推移数量和医疗复杂性显著增加。这些患者的护理可能会超越精心实施的护理路径，尤其是当转诊负担增加时，在基于区域、赋予财务风险的价值导向项目中可能容易出现这种情况。随着价值导向项目的发展，了解像CJR这样的强制性捆绑支付项目对区域关节成形术患者护理的影响至关重要。
