The Predictive Accuracy of the CareMOSAIC Risk Assessment for Discharge Disposition in Medicare Bundle Patients After Total Joint Arthroplasty.
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ABSTRACT: Background
This article evaluates the predictive accuracy of the CareMOSAIC Risk Assessment for discharge disposition in Medicare patients undergoing total joint arthroplasty.Methods
Retrospectively collected data from a single institution on 499 consecutive Medicare patients who underwent primary total hip arthroplasty or total knee arthroplasty were reviewed. The CareMOSAIC Risk Assessment was completed by each patient during the preoperative period. The CareMOSAIC Risk Assessment scores were calculated via the CareMOSAIC software, and the scores indicate a risk category for each patient as it relates to post-acute care discharge needs.Results
The CareMOSAIC Risk Assessment with a binary logistic regression area under the receiver operating characteristic curve of 0.798 appears to be a reliable tool for predicting discharge disposition. The assessment had a positive predictive value of 90.0% and negative predictive value of 76.3% for discharge disposition.Conclusions
The CareMOSAIC Risk Assessment effectively predicts the discharge disposition for Medicare patients undergoing total hip or total knee arthroplasty.
SUBMITTER: Anderson C
PROVIDER: S-EPMC8783109 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background:Predicting discharge destination following total joint arthroplasty (TJA) is important, as discharge destination has major implications for post-operative costs, clinical outcomes, and readmissions. Few studies have looked at factors affecting discharge destination for patients following primary simultaneous bilateral total joint arthroplasty. Questions/Purposes:The purpose of this study was to describe clinical and social factors that relate to a discharge to home versus rehabilitation facility (RF) for patients after primary simultaneous bilateral total hip arthroplasty (PSBTHA) or primary simultaneous bilateral total knee arthroplasty (PSBTKA). Methods:The inclusion criteria for this retrospective cohort study were all patients after PSBTHA or PSBTKA at a metropolitan orthopedic specialty hospital between February 1, 2016, and March 31, 2018. Exclusion criteria were revisions, differing weight-bearing status, bed-rest orders, and non-standard hip precautions. Social and clinical demographic data were collected. Multiple regression analysis was conducted to determine which factors related most to discharge plan. Results:Of 253 PSBTHA patients, 153 were discharged home and 100 to an RF. Regression analysis found a posterolateral approach to be the only significant factor associated with an RF discharge. Of 619 PSBTKA patients, 136 were discharged home and 483 to RF. Increased body mass index and older age increased the likelihood of discharge to an RF. Patients with an adductor-only nerve block were more likely to be sent to RF. Conclusion:These findings shed light on the variables that contribute to discharge destination after PSBTHA and PSBTKA. Such information allows for safe pre-operative discharge planning and assists with discharge to the appropriate level of patient care. Future studies might investigate the effect of surgeon experience, surgical technique, and pre-operative discussion with a physical therapist on the discharge disposition of patients undergoing bilateral total joint arthroplasty.
| S-EPMC6778168 | biostudies-literature
Project description:Background:Over 1 million total joint arthroplasties (TJAs) are performed every year in the United States, creating Medicare cost concerns for policy makers. The purpose of this study is to evaluate recent trends in Medicare utilization and reimbursements to hospitals/surgeons for TJAs between 2012 and 2017. Methods:We tracked annual Medicare claims and payments to TJA surgeons using publicly available Medicare databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization (per 10,000 Medicare beneficiaries), and reimbursement rates and to examine associations between county-specific variables and TJA utilization and reimbursements. Results:Between 2012 and 2017, there was an 18.9% increase in annual primary TJA volume (357,500 cases in 2012 to 425,028 cases in 2017) and a 2.0% increase in annual primary TJA per capita utilization (73.4 cases per 10,000 Medicare beneficiaries in 2012 to 74.8 in 2017). The Midwest and the South had higher utilization rates compared with the Northeast and West (P < .001). Utilization rates for primary TJA procedures also had a significant negative association with the poverty rate (P < .001). Medicare Part B payments to surgeons fell by 7.5%, equivalent to a 14.9% inflation-adjusted decline, whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively, during the study period. Conclusions:Despite increasing TJA volume and utilization, surgeon reimbursements have continued to decline, whereas hospital payments and hospital charges have increased significantly more than surgeon charges. Cost containment efforts will need to address other expenditures such as hospital costs and implant costs to better align financial risks and incentives for TJA surgeons.
| S-EPMC7320234 | biostudies-literature
Project description:ImportanceTotal knee arthroplasty (TKA) is one of the most common elective procedures performed in adults with end-stage arthritis. Racial disparities in TKA outcomes have been described in the literature.ObjectivesTo assess the association of race/ethnicity with discharge disposition and hospital readmission after elective primary TKA and to assess the association of nonhome discharge disposition with hospital readmission risk.Design, setting, and participantsThis retrospective cohort study used data from the Pennsylvania Health Care Cost Containment Council Database, a large regional database that included demographic data from all discharges of patients who underwent elective primary TKA in 170 nongovernmental acute care hospitals in Pennsylvania from April 1, 2012, to September 30, 2015. Data analyses were conducted from September 29, 2017, to November 29, 2017.ExposuresPatient race/ethnicity and discharge disposition.Main outcomes and measuresDischarge disposition and 90-day hospital readmission.ResultsAmong 107?768 patients, 7287 (6.8%) were African American, 68?372 (63.4%) were women, 46?420 (43.1%) were younger than 65 years, and 60?636 (56.3%) were insured by Medicare. In multivariable logistic regression, among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) (adjusted relative risk ratio [aRRR], 2.49 [95% CI, 1.42-4.36]; P?=?.001) or a skilled nursing facility (SNF) (aRRR, 3.91 [95% CI, 2.17-7.06]; P?<?.001) and had higher odds of 90-day hospital readmission (adjusted odds ratio [aOR], 1.30 [95% CI, 1.02-1.67]; P?=?.04). Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF (aRRR, 3.30 [95% CI, 1.81-6.02]; P?<?.001). In both age groups, discharge to an IRF (age <65 years: aOR, 3.62 [95% CI, 2.33-5.64]; P?<?.001; age ?65 years: aOR, 2.85 [95% CI, 2.25-3.61]; P?<?.001) or SNF (age <65 years: aOR, 1.91 [95% CI, 1.37-2.65]; P?<?.001; age ?65 years: aOR, 1.55 [95% CI, 1.27-1.89]; P?<?.001) was associated with higher odds of 90-day readmission.Conclusions and relevanceThis cohort study found that race/ethnicity was associated with higher odds of discharge to an IRF or SNF for postoperative care after primary TKA. Among patients younger than 65 years, African American patients were more likely than white patients to be readmitted to the hospital within 90 days. Discharge to an IRF or SNF for postoperative care and rehabilitation was also associated with a higher risk of readmission to an acute care hospital.
| S-EPMC6824220 | biostudies-literature
Project description:Background: Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA.Methods: 1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions.Results: 759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention.Conclusion: Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.
| S-EPMC7364149 | biostudies-literature
Project description:The purpose of this study was to investigate the association between insurance type and length of stay (LOS) in primary total joint arthroplasty. A retrospective review of 848 patients was performed. Patients were divided into 3 groups based on their insurance type: Medicare, Medicaid, or commercial coverage. Medicare patients had a significantly higher rate of LOS > 2 days than the Medicaid and commercial groups (P < .0001). The effect of Medicare coverage on LOS remained significant even after controlling for baseline differences among the study groups. There were no differences in the rates of 90-day emergency room visits and readmissions between the 3 groups (P > .05). Arthroplasty surgeons not experienced with outpatient surgery should not be pressured to default to outpatient admission in Medicare patients.
| S-EPMC6920717 | biostudies-literature
Project description:BackgroundDetermining discharge disposition after total joint arthroplasty (TJA) has been a challenge. Advances in machine learning (ML) have produced computer models that learn by example to generate predictions on future events. We hypothesized a trained ML algorithm's diagnostic accuracy will be better than that of current predictive tools to predict discharge disposition after primary TJA.MethodsThis study was a retrospective cohort study from a single, tertiary referral center for primary TJA. We trained and validated an artificial neural network (ANN) based on 4368 distinct surgical encounters between 1/1/2013 and 6/28/2016. The ANN's ability to identify discharge disposition was then tested on 1452 distinct surgical encounters between 1/3/17 and 11/30/17.ResultsThe area under the curve and accuracy achieved during model validation were 0.973 and 91.7%, respectively, with 25% of patients being discharged to skilled nursing facilities (SNFs). Within our testing data set, 6.7% of patients went to SNFs. The performance in the testing set included an area under the curve of 0.804, accuracy of 61.3%, sensitivity of 28.9%, and specificity of 93.8%.ConclusionsThis is the first prediction tool using an electronic medical record-integrated ANN to predict discharge disposition after TJA based on locally generated data. Dramatically reduced numbers of patients discharged to SNFs due to implementation of a bundled payment model lead to poor recall in the testing model. This model serves as a proof of concept for developing an ML prediction tool using a relatively small data set and subsequent integration into the electronic medical record.
| S-EPMC7567055 | biostudies-literature
Project description:Background:Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature. Purposes:We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care. Methods:This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models. Results:The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care. Conclusions:Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.
| S-EPMC6778171 | biostudies-literature
Project description:BackgroundWith hospital inpatient capacity increasingly limited and primary total joint arthroplasty (TJA) rapidly transitioning to outpatient settings, the feasibility of outpatient aseptic revision and conversion TJA (rTJA) has been considered. Before the widespread adoption of outpatient rTJA, guidelines must be established to prevent patient harm. To this end, this study describes our initial experience with same-day-discharge (SDD) aseptic rTJA.MethodsAll aseptic rTJAs performed between May 8, 2015, and December 30, 2021, were retrospectively reviewed. Revision indications, patient selection criteria, and outcomes including SDD success rate, predischarge complications, all-cause emergency department visits, inpatient readmissions, and unplanned clinic encounters within 90 days of surgery were recorded.ResultsThirty-five SDD aseptic rTJAs were performed. Conversion total hip arthroplasty (55.0%) and instability (27.3%) were the most common indications for hip revision. Instability (50%) and conversion total knee arthroplasty (20.8%) were most common for knee revision. SDD was achieved in 97% (34/35) of cases. One hip patient failed SDD due to persistent hypoxia requiring an overnight hospital stay and also underwent closed reduction for dislocation in the emergency department within 90 days of discharge. Two additional patients had unplanned clinic encounters within 90 days of the index procedure. There were no hospital readmissions or reoperations within 90 days.ConclusionsOur initial experience suggests SDD aseptic rTJA can be safe and effective when modern perioperative outpatient protocols and surgical techniques are implemented. Future studies should further define patient selection criteria to optimize outcomes and minimize complications in this population.
| S-EPMC9493283 | biostudies-literature
Project description:BackgroundThere has been a shift toward same-day discharge (SDD) in total joint arthroplasty (TJA) in recent years. Our clinical standard had been next-day discharge, but the COVID pandemic led to a hospital bed shortage, causing us to shift to SDD directly from the Post-Anesthesia Care Unit (PACU). The aim of our project was to investigate if the SDD protocol was successful and if it changed complications or 90-day readmission rates. Our secondary aim was to investigate if the protocol created disparities in patient selection.MethodsA retrospective review compared the first 100 patients intended to discharge from PACU to the 100 patients prior to the SDD protocol undergoing elective primary TJA procedures at our academic institution from September 1, 2020, to March 23, 2021. The SDD protocol started on November 19, 2020.ResultsDuring this SDD period, 98% (98/100) of patients were successfully discharged from the PACU. The 90-day readmission rate changed from 0% to 2% (P = .4975), and the overall complication rate changed from 2% to 5% (P = .4448). Most complications were manipulation under anesthesia to improve range of motion. Manipulations under anesthesia changed from 1% to 4% (P = .3687).ConclusionsThe transition to same SDD in TJA at our academic institution was successfully implemented without markedly increasing complications, readmissions, or changing patient selection. The COVID-19 pandemic likely influenced the recovery of patients before and after the protocol. Future studies are needed to validate this data during the post-COVID era.
| S-EPMC10958211 | biostudies-literature
Project description:BackgroundAs a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.MethodsA nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.ResultsFollowing bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.ConclusionThe results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.
| S-EPMC6884960 | biostudies-literature