Comprehensive care program reduced racial disparities in readmission rates for THA, TKA
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Results showed the Comprehensive Care for Joint Replacement program reduced racial disparities in readmission rates and Medicare payments for patients undergoing total joint arthroplasty; but, racial disparities in other outcomes persisted.
To analyze trends in racial differences and the impact of the CMS-initiated Comprehensive Care for Joint Replacement (CJR) bundled payment model on the TJA continuum of care, Calin S. Moucha, MD, and Jashvant Poeran, MD, PhD, retrospectively reviewed data on 1,483,221 TJAs from 2013 to 2018. Researchers compared several preoperative, perioperative and postoperative outcomes between 74,390 Black patients (5%) and 1,408,831 white patients (95%) including Deyo-Charlson comorbidity index scores, blood transfusions, length of stay, readmission, combined complications, institutional post-acute care, as well as median Medicare payments for skilled nursing facility care, readmissions and outpatient care. Okewunmi and colleagues also performed a “difference-in-differences” analysis to analyze the effect of the CJR program on racial differences in the continuum of care.
According to the study, racial differences persisted across the TJA continuum of care in 2013 and 2018, as Black patients were more likely to have a higher Deyo-Charlson comorbidity index, to require more transfusions, to be discharged to institutional post-acute care and to be readmitted within 90 days. Difference-in-differences analysis determined the CJR program led to reductions in racial disparities for 90-day readmission, 180-day readmission and Medicare payments related to outpatient care.
“While the CJR program coincided with a reduction in racial differences in terms of readmission rates and Medicare payments related to outpatient care, differences in other outcomes persisted,” Moucha told Healio. “It is this latter finding that we need to focus our attention on and, without doubt, this will continue to be a challenge. Moving forward, the key to minimizing differences in outcomes will be creating an ethical balance between preoperatively optimizing patients with multiple comorbidities and offering them alternative nonoperative treatments,” Moucha said.
“These results are exciting, as they suggest a potential role of bundled payments to reduce racial disparities in musculoskeletal care,” Poeran told Healio. “We studied a bundled payment program that was not specifically geared toward reducing disparities, but our results open up the discussion on designing bundled payment programs with that specific goal in mind. It sets the stage for exciting future studies focusing on improving equitable access to musculoskeletal care,” he added.
Editor’s Note: This article was updated on June 3, 2022, with additional comments from the authors.
Perspective
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Racial differences not attributable to clinical factors or appropriateness of intervention have received significant interest given the longstanding disparity in total joint replacement utilization and outcomes present in communities of color when compared with white patients. With the shift from fee-for-service to a Comprehensive Care for Joint Replacement (CJR) bundled payment model and emphasis on “value-based care” focusing on maximizing value and reduction of health care costs, the effect on vulnerable populations must be evaluated to explore its full impact and potential unintended consequences.
Increased rates of readmission for patients of color and those from lower socioeconomic status has been well documented. Okewunmi and colleagues, in a review of a large cohort of patients undergoing total joint replacement between 2013 and 2018, demonstrated a reduction in 90-day and 180-day readmission and hospital payments related to outpatient care. It is encouraging to see the program resulted in improved readmission statistics for Black patients but, as the authors note, it is important to establish whether the reduction in discharge to institutional post-acute care represents underutilization of post-acute care or transition to a more effective discharge model.
Standardizing care certainly should offer the benefits of potentially improved access. Health care disparities are a multifactorial problem which requires interventions at the patient, provider and systemic levels. While it is encouraging to see a reduction in total cost and disparity in discharge destination in a large cohort of patients enrolled in the CJR program, one should not ignore the significant impact of the social determinants of health in differential outcomes between Black and white patients. Poverty and where patients live have been shown to have a clear deleterious effect on outcomes and cannot be eliminated by simply standardizing care and fitting one payment to all patients, especially when a segment of the bundle comes with additional comorbidities and often present with more advanced clinical symptoms. While the authors found no evidence of post-CJR selection in their data or difference in comorbidity burden, further study is needed to determine how patients in communities of color burdened with tremendous comorbidities of obesity, diabetes and heart disease are impacted with new payment methodology, and the current work is an important step in gaining this knowledge.
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