ElNemer William, Sharma Sribava, Avendano John P, Cha Myung-Jin, Marrache Majd, Harris Andrew B, Srikumaran Umasuthan, Best Matthew J
School of Medicine, The Johns Hopkins University, 733 N. Broadway, Baltimore, MD, 21205, USA.
Department of Orthopaedic Surgery, 601 N Caroline Street, Baltimore, MD, 21287, USA.
J Orthop. 2024 Nov 8;59:137-143. doi: 10.1016/j.jor.2024.10.040. eCollection 2025 Jan.
AIMS & OBJECTIVES: This study characterized the independent association between insurance type and healthcare outcomes in patients undergoing total joint arthroplasty (TJA).
MATERIALS &METHODS: National data identified patients who underwent total hip, knee, shoulder, elbow, ankle or wrist joint arthroplasty surgery from 2012 to 2020 for osteoarthritis. Medicaid, Medicare≥65 years old, Medicare<65 years old, and uninsured patients were matched to privately insured patients based on age, sex, and comorbidities. Multivariable analysis, controlled for various characteristics, was conducted to quantify various outcome measures by payer status.
Medicaid patients had greater odds of cardiac, genitourinary, hematoma/hemorrhage/seroma, respiratory, and wound dehiscence complications than privately insured (odds ratio [OR]: 1.5, 1.2, 1.6, 1.3, 1.5, respectively; p < 0.01). Medicare patients ≥65 years old had greater odds of cardiac and wound dehiscence complications but fewer central nervous system and genitourinary complications and post-operative infections than privately insured (OR:1.2, 1.2, 0.3, 0.8, 0.7, respectively; p < 0.01). Medicare<65 years old patients had greater odds of cardiac, gastrointestinal, genitourinary, hematoma/hemorrhage/seroma, post-operative anemia, respiratory, and wound dehiscence complications than privately insured (OR: 1.2, 1.4, 1.2, 1.4, 1.2, 1.7, 1.6, respectively; p < 0.01). Medicare≥65, Medicare<65, and Medicaid patients had $2,243, $3,849, and $1170 more total charges, respectively (p < 0.01).
Despite Medicaid expansion through the 2014 Affordable Care Act, marked disparities in complications after TJA between individuals with and without private insurance still exist. Medicare<65 and Medicaid cohorts demonstrated higher complication rates than private payers, possibly attributable to barriers in healthcare such as patient education, access to healthcare, and social determinants of health.
本研究描述了全关节置换术（TJA）患者的保险类型与医疗结果之间的独立关联。
国家数据确定了2012年至2020年因骨关节炎接受全髋关节、膝关节、肩关节、肘关节、踝关节或腕关节置换手术的患者。根据年龄、性别和合并症，将医疗补助计划患者、65岁及以上的医疗保险患者、65岁以下的医疗保险患者和未参保患者与私人保险患者进行匹配。通过多变量分析，控制各种特征，按付款人状态量化各种结果指标。
与私人保险患者相比，医疗补助计划患者发生心脏、泌尿生殖系统、血肿/出血/血清肿、呼吸系统和伤口裂开并发症的几率更高（优势比[OR]分别为：1.5、1.2、1.6、1.3、1.5；p<0.01）。65岁及以上的医疗保险患者发生心脏和伤口裂开并发症的几率更高，但中枢神经系统和泌尿生殖系统并发症以及术后感染比私人保险患者少（OR分别为：1.2、1.2、0.3、0.8、0.7；p<0.01）。65岁以下的医疗保险患者发生心脏、胃肠道、泌尿生殖系统、血肿/出血/血清肿、术后贫血、呼吸系统和伤口裂开并发症的几率比私人保险患者更高（OR分别为：1.2、1.4、1.2、1.4、1.2、1.7、1.6；p<0.01）。65岁及以上、65岁以下的医疗保险患者和医疗补助计划患者的总费用分别多出2243美元、3849美元和1170美元（p<0.01）。
尽管通过2014年《平价医疗法案》扩大了医疗补助计划，但有私人保险和无私人保险的个体在TJA术后并发症方面仍存在显著差异。65岁以下的医疗保险患者和医疗补助计划人群的并发症发生率高于私人付费者，这可能归因于医疗保健方面的障碍，如患者教育、医疗保健可及性以及健康的社会决定因素。
