Bundled payment programs may reduce sex disparities in TJR
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Key takeaways:
- The Comprehensive Care for Joint Replacement program reduced sex disparities in post-acute care discharge for total joint replacement.
- More work is needed to reduce sex disparities in joint replacement.
Published results showed implementation of the Comprehensive Care for Joint Replacement bundled payment program may reduce sex disparities in total joint replacement.
“There seems to be hope in terms of policies that incentivize standardization of care, such as the [Comprehensive Care for Joint Replacement] CJR program, in terms of reducing [sex] disparities,” Jashvant Poeran, MD, PhD, associate professor and senior researcher in the department of orthopedics at the Ichan School of Medicine at Mount Sinai, told Healio.
Poeran, Calin S. Moucha, MD, and colleagues assessed sex disparities for care and outcomes in total hip (n=259,673; 61.7% women) and knee (n=506,311; 64% women) arthroplasty related to the period before surgery, during hospitalization and after discharge. Researchers reported disparities as women:men ratios and used difference-in-differences analyses to estimate the impact of the CJR program on preexisting sex disparities.
For both total hip arthroplasty and total knee arthroplasty, results showed women had a lower comorbidity burden but were more likely to require blood transfusions perioperatively, have a longer hospital length of stay and be discharged to institutional post-acute care postoperatively, including skilled nursing facilities. Women were also less likely to be discharged home and had higher 90-day skilled nursing facility payments, according to researchers.
Researchers found a significant reduction in preexisting sex disparities in institutional post-acute care discharge when comparing the impact of the CJR program between men and women undergoing THA. Women experienced significantly lower discharges to institutional post-acute care, 90-day readmissions and 90-day skilled nursing facility Medicare payments, while men had reductions for institutional post-acute care discharge and 90-day skilled nursing facility payments with implementation of the CJR program.
Preexisting sex disparities in institutional post-acute care discharge were also significantly reduced when comparing the impact of the CJR program between women and men undergoing TKA, according to researchers. Although the CJR program significantly lowered discharge to institutional post-acute care, 90-day readmissions and 90-day skilled nursing facility Medicare payments among women, researchers found CJR hospitals had significantly increased 90-day outpatient and readmission payments for women. Results showed reductions in age, institutional post-acute care discharge, 90-day readmissions and 90-day skilled nursing facility payments for men.
“This is just a precursor of a lot of additional work that needs to be done if you want to equalize care for men and women and outcomes for men and women undergoing hip and knee replacement surgery,” Poeran said. “This gives us an indication that there could be something positive, but we need to know more about mechanisms and truly understand the mechanisms that can, in turn, help us design an intervention that will reduce disparities.”
Perspective
Back to TopThe current study authored by Meredith Mihalopoulos, MD, Calin S. Moucha, MD, and colleagues examines the impact of the CJR bundled payment program on sex disparities in THA and TKA. The program is designed to incentivize quality and efficiency of care with enhanced coordination by providing a single payment for all the care delivered during an arthroplasty episode, that includes the hospitalization and the 90 days after surgery.
They analyzed data from 2013 to 2017 to examine the differences in preoperative patient characteristics, hospitalization characteristics and post-discharge characteristics of men and women before and after the initiation of the CJR program. The authors compared data from January 2013 through September 2017, prior to the initiation of the CJR program to data, from Oct. 1, 2016, through Dec. 31, 2017, when the program was in place. These results were then stratified by sex to evaluate the impact of the CJR program on disparities in this population.
The authors found that sex disparities did exist in the population studied, both before and after the implementation of CJR. Specifically, prior to the start of CJR, women presented with fewer comorbidities and were more likely to require blood transfusion and to be discharged to an institution for post-acute care than men. However, these differences were decreased when comparing the patients in the CJR program to those having surgery prior to the start of the program. The most substantial difference in the change for women compared to men with the initiation of CJR was in the decreased rate of discharge to an institution for post-acute care, with a greater reduction in 90-day readmissions for women compared to men in the THA group as well.
These changes after the implementation of the CJR program are certainly encouraging. They may reflect improved optimization and appropriateness of care due to the incentives created by the CJR bundled payment design. However, as the authors note, the study has some limitations. These include the use of a historical comparison group for baseline data, which can lead to improvements being attributed solely to the CJR program that may have occurred without the program through increased education and further evolution in the care of these patients, with changes occurring more rapidly at CJR hospitals for unknown reasons. In addition, data regarding other factors that may impact the most appropriate rate of use of post-acute care facilities and readmissions for both men and women, such as home support, is lacking. Nonetheless, elimination of sex disparities in care is of paramount importance to our profession, and the results of this study are positive. Further work is needed to determine the precise impact of the CJR program on sex disparities and to identify the best approaches to achieve optimal outcomes for all hip and knee arthroplasty patients, regardless of sex.
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