Association of the redesigned Comprehensive Care for Joint Replacement model with racial/ethnic and socioeconomic disparities in joint replacement surgeries

重新设计的关节置换综合护理模式与关节置换手术中种族/民族和社会经济差异的关联

• 批准号: 10711959
• 负责人: Caroline Pinto Thirukumaran
• 金额: $ 35.76万
• 依托单位: UNIVERSITY OF ROCHESTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-13 至 2027-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10711959
• 关键词: Acute; Adverse event; Age; Area; Arthritis; Black race; Caring; Categories; Clinical; Comprehensive Health Care; Data; Disparity; Eligibility Determination; Emergency department visit; Enrollment; Equity; Funding; Goals; Health; Hispanic; Hospitals; Incentives; Inpatients; Institution; Intervention; Measures; Medicare; Medicare/Medicaid; Methods; Modeling; National Institute on Minority Health and Health Disparities; Not Hispanic or Latino; Operative Surgical Procedures; Outcome; Outpatients; Pain; Patient Care; Patients; Performance; Policy Analysis; Postoperative Period; Prevalence; Price; Relaxation; Replacement Arthroplasty; Research; Rewards; Risk; Risk Adjustment; Social Adjustment; Total Hip Replacement; Vision; Work; beneficiary; bundled payment; clinical risk; comorbidity; design; disparity reduction; dual eligible; ethnic disparity; ethnic minority; hip replacement arthroplasty; hospital care; hospital readmission; improved; knee replacement arthroplasty; low socioeconomic status; marginalization; payment; racial disparity; racial minority; response; safety net; social disparities; social factors; socioeconomic disparity; socioeconomics; surgery outcome; theories

ABSTRACT Total hip and knee replacements (“total joint replacements” [TJRs]) are highly successful surgeries for patients with end-stage arthritis. Despite their clinical benefits, racial/ethnic and socioeconomic disparities in the use and outcomes of these surgeries are well-established. These disparities have persisted for decades despite well-intentioned and effective disparity reduction strategies that have been locally implemented. In the absence of a national reform that incentivizes disparity reduction, the vision of achieving TJR equity may remain unfulfilled. Medicare’s 2016 Comprehensive Care for Joint Replacement (CJR) model is a bundled payment reform aimed at improving quality and reducing spending for Medicare beneficiaries undergoing TJRs. In 2021, the CJR was redesigned (rCJR) to include adjustments for social risk (dual-eligibility for Medicare and Medicaid) and clinical risk (hierarchical condition category score and age) – measures that could potentially reduce TJR disparities by ‘recognizing’ the higher spending for marginalized patients (many of whom belong to racial/ethnic minority or lower socioeconomic groups, and are in poorer health). These adjustments are likely to reduce incentives for hospitals to avoid operating on marginalized patients, provide these patients access to high-quality hospitals, and increase quality/price competition between hospitals to attract these patients; thereby promoting equity in TJR use and postoperative outcomes. In theory, the new risk adjustment measures could potentially transform the rCJR into a national TJR disparity reduction strategy. However, there is little empirical evidence to support our hypothesis. Thus, our objective is to evaluate rCJR’s association with racial/ethnic and socioeconomic disparities in TJR use, outcomes, and spending, with a focus on the performance of safety-net hospitals. We will use national Medicare data from 2018-2024 to evaluate rCJR’s association with disparities in the use of TJRs (Aim 1) and in clinical metrics (Aim 2). We will also examine whether the rCJR may have influenced TJR spending for marginalized patients (Aim 3). Our work is significant because we will answer questions such as whether the rCJR was effective in reducing disparities, which metrics were most influenced by the rCJR, and which institutions successfully reduced disparities. These findings are critical for understanding whether and how the rCJR can be leveraged to reduce disparities nationally, and for realizing the elusive target of equity in TJR care for patients with arthritis.

抽象的 全髋关节和膝关节置换术（“全关节置换术”[TJRs]）是非常成功的手术 终末期关节炎患者尽管具有临床益处，但种族/民族和社会经济差异 这些手术的使用和结果已明确存在了数十年。 尽管当地实施了善意且有效的缩小差距战略。 如果缺乏激励缩小差距的国家改革，实现 TJR 公平的愿景可能会 医疗保险 2016 年关节置换综合护理 (CJR) 模式仍然未实现。 支付改革旨在提高医疗保险受益人的质量并减少支出 2021 年，CJR 进行了重新设计 (rCJR)，纳入了社会风险调整（双重资格） 医疗保险和医疗补助）和临床风险（分层病情类别评分和年龄）——可以采取的措施 通过“认识到”失去患者的更高支出（许多 属于少数种族/族裔或社会经济地位较低的群体，并且健康状况较差）。 调整可能会减少医院避免对边缘化患者进行手术的动机，提供 这些患者可以进入优质医院，并增加医院之间的质量/价格竞争 吸引这些患者；从而促进 TJR 使用和术后结果的公平性。 调整措施有可能将 rCJR 转变为国家 TJR 差距缩小战略。 然而，几乎没有经验证据支持我们的假设，因此，我们的目标是评估 rCJR 的效果。 TJR 使用、结果和支出与种族/民族和社会经济差异的关联，重点是 我们将使用 2018 年至 2024 年的国家医疗保险数据来评估安全网医院的绩效。 rCJR 与 TJR 使用差异（目标 1）和临床指标（目标 2）的关联。 检查 rCJR 是否可能影响边缘化患者的 TJR 支出（目标 3）。 意义重大，因为我们将回答诸如 rCJR 是否有效减少差距等问题， 哪些指标受 rCJR 影响最大，哪些机构成功缩小了差距。 研究结果对于了解是否以及如何利用 rCJR 来减少差距至关重要 在全国范围内，并实现关节炎患者 TJR 护理公平这一难以捉摸的目标。