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The University of Missouri Health Care approach to Comprehensive Care for Joint Replacement.

ABSTRACT: The University of Missouri Health Care is a 5-hospital academic medical center with 595 beds, located in the central United States. Our system was selected for mandatory participation in the Comprehensive Care for Joint Replacement bundled payment model and participated from April 2016 through December 2017. Using an established improvement model, we implemented several key strategies which resulted in improved quality and lower overall costs.

SUBMITTER: Schelp G

PROVIDER: S-EPMC6588682 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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The University of Missouri Health Care approach to Comprehensive Care for Joint Replacement.

Schelp Ginger G

Arthroplasty today 20181130 2

The University of Missouri Health Care is a 5-hospital academic medical center with 595 beds, located in the central United States. Our system was selected for mandatory participation in the Comprehensive Care for Joint Replacement bundled payment model and participated from April 2016 through December 2017. Using an established improvement model, we implemented several key strategies which resulted in improved quality and lower overall costs. ...[more]

PMID: 31286035

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Project description:ImportancePrior research concluded that institutional postacute care spending decreased under the Comprehensive Care for Joint Replacement (CJR) model. Less is known about how changes in institutional postacute care spending varied across different types of hospitals.ObjectiveTo measure hospital-level heterogeneity in the association of the CJR model with changes in institutional postacute care spending and to identify hospital characteristics associated with this variation.Design setting and participantsUsing 100% Medicare claims data, this cross-sectional study assessed institutional postacute care spending from 2016 to 2017 among US hospitals randomly selected to participate in the CJR model and control group hospitals that were eligible but not selected for the participation in the CJR model. A causal forest was used to estimate the treatment effect of the CJR model conditional on hospital characteristics. Analysis was conducted between October 2019 and October 2021.Main outcomes and measuresThe unit of analysis was each hospital; the outcome was the average per-episode Medicare spending for institutional postacute care within 90 days after hospital discharge for hip or knee joint replacement.ResultsThis study included 531 CJR participating hospitals and 658 control group hospitals from 2016 to 2017. The CJR model was associated with a $761 reduction in institutional postacute care spending (95% CI, -$1172 to -$351). The reduction in spending under the CJR model did not vary across conditional on hospital characteristics. Limited evidence was found for greater savings among hospitals with higher pre-CJR spending. However, this finding did not hold for hospitals in the highest quintile of pre-CJR spending.Conclusions and relevanceIn this cross-sectional study of 1189 hospitals, findings did not show strong evidence for significant heterogeneity in how the CJR model was associated with reductions in institutional postacute care spending across a range of hospital characteristics. Savings were not concentrated in hospitals with specific characteristics, such as hospitals with high-volume joint replacement or hospitals serving less medically or socially complex patients. Findings suggest that the CJR model created opportunities for savings across a spectrum of different hospitals.

Project description:Resection of the odontoid process and anterior arch of the atlas results in atlantoaxial instability, which if left uncorrected may lead to severe neurological complications. Currently, such atlantoaxial instability is corrected by anterior and/or posterior C1-C2 fusion. However, this results in considerable loss of rotation function of the atlantoaxial complex. From the viewpoint of retaining the rotation function and providing stability, we designed an artificial atlanto-odontoid joint based on anatomical measurements of 50 pairs of dry atlantoaxial specimens by digital calipers and 10 fresh cadaveric specimens by microsurgical techniques. The metal-on-metal titanium alloy joint has an arc-shaped atlas component, and a hollow cylindrical bushing into which fits a rotation axle of an inverted v-shaped axis component and is implanted through a transoral approach. After the joint was implanted onto specimens with anterior decompression, biomechanical tests were performed to compare the stability parameters in the intact state, after decompression, after artificial joint replacement, and after fatigue test. Compared to the intact state, artificial joint replacement resulted in a significant decrease in the range of motion (ROM) and neutral zone (NZ) during flexion, extension, and lateral bending (P < 0.001); however, with regard to axial rotation, there was no significant difference in ROM (P = 0.405), a significant increase in NZ (P = 0.008), and a significant decrease in stiffness (P = 0.003). Compared to the decompressed state, artificial joint replacement resulted in a significantly decreased ROM (P B 0.021) and NZ (P B 0.002) and a significantly increased stiffness (P \ 0.001) in all directions. Following artificial joint replacement, there was no significant difference in ROM (P C 0.719), NZ (P C 0.580), and stiffness (P C 0.602) in all directions before and after the fatigue test. The artificial joint showed no signs of wear and tear after the fatigue test. This artificial atlanto-odontoid joint may be useful in cases of odontoid resection due to malunion or nonunion of odontoid fracture, atraumatic odontoid fracture, irreducible atlas dislocation, posterior atlantoaxial subluxation, or congenital skull base abnormalities.

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The University of Missouri Health Care approach to Comprehensive Care for Joint Replacement.

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The University of Missouri Health Care approach to Comprehensive Care for Joint Replacement.

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