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Determinants of Cost Variation in Total Hip and Knee Arthroplasty: Implications for Alternative Payment Models.

全髋和膝关节置换术成本变化的决定因素: 对替代支付模式的影响。

  • 影响因子:0
  • DOI:10.5435/JAAOS-D-18-00718
  • 作者列表:"Rudy MD","Bentley J","Ahuja N","Rohatgi N
  • 发表时间:2020-03-15
Abstract

BACKGROUND:Alternative payment models have been proposed to deliver high-quality, cost-effective care. Under these models, payments may be shared between the hospital and the post-acute care services. Post-acute care services may account for one-third of the episode costs for total hip or knee arthroplasty (THA/TKA). Because hospitals or episode initiators bear notable financial risks in these payment models with minimal risk adjustment for complexity, it has been suggested these models may lead to prospective selection of healthier and younger patients. Studies evaluating the effect of patient demographics, medical complexity, and surgical characteristics on the cost of index hospitalization have been limited. We aimed to (1) quantify the impact of patient demographics, medical complexity, and surgical characteristics (type of anesthesia and operating time) on variation in direct cost of index hospitalization and (2) examine the association of these characteristics with discharge with home health services or to rehabilitation facility. METHODS:Retrospective study of 3,542 patients admitted to our hospital for elective THA/TKA between 2012 and 2017. Multivariable generalized estimating equations were used for analysis. RESULTS:Patient demographics and medical complexity accounted for 6.2% (THA) and 5.6% (TKA) of variation in direct cost of index hospitalization. Surgical characteristics accounted for 37.1% (THA) and 35.3% (TKA) of the cost variation. One thousand one hundred eighty-three (53.4%) patients were discharged with home health services, and 1,237 (29.4%) were discharged to rehabilitation facility. Patient demographics and higher medical complexity were markedly associated with discharge with home health services or to rehabilitation facility after THA/TKA. DISCUSSION:Patient demographics and medical complexity had minimal impact on variation in direct cost of index hospitalization for elective THA/TKA compared with surgical characteristics but were markedly associated with discharge with home health services or to rehabilitation facility. Having additional risk adjustment in these payment models could mitigate concerns about access to care for higher risk, higher cost patients.

摘要

背景: 已经提出了替代支付模式来提供高质量、成本效益高的护理。在这些模式下,支付可以在医院和急性后护理服务之间共享。急性后护理服务可能占全髋关节或膝关节置换术 (THA/TKA) 的发作费用的3分之1。由于医院或发病发起者在这些支付模型中承担着显著的财务风险,并且对复杂性进行了最小的风险调整,因此有人认为这些模型可能会导致更健康和更年轻患者的前瞻性选择。评估患者人口统计学、医疗复杂性和手术特征对指数住院成本影响的研究有限。我们的目的是 (1) 量化患者人口统计学、医疗复杂性和手术特征 (麻醉类型和手术时间) 对指数住院直接成本变化的影响,以及 (2) 检查这些特征与出院、家庭保健服务或康复机构的关联。 方法: 对我院2012年至3,542年间收治的2017例择期THA/TKA患者进行回顾性研究。使用多变量广义估计方程进行分析。 结果: 患者人口统计学和医疗复杂性占指数住院直接成本变化的6.2% (THA) 和5.6% (TKA)。手术特点占费用变动的37.1% (THA) 和35.3% (TKA)。100名83名 (53.4%) 患者出院时接受家庭保健服务,1,237名 (29.4%) 患者出院时接受康复治疗。患者人口统计学特征和更高的医疗复杂性与出院后的家庭健康服务或THA/TKA后的康复机构显著相关。 讨论: 与手术特征相比,患者人口统计学和医疗复杂性对择期THA/TKA指数住院直接费用变化的影响最小,但与家庭保健服务或康复机构的出院显著相关。在这些支付模式中进行额外的风险调整可以减轻对高风险、高成本患者获得护理的担忧。

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DOI:10.1213/ANE.0000000000003945
作者列表:["Winterberg AV","Ding L","Hill LM","Stubbeman BL","Varughese AM"]

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影响因子:2.27
发表时间:2020-01-01
DOI:10.1213/ANE.0000000000003975
作者列表:["Uppal V","Retter S","Casey M","Sancheti S","Matheson K","McKeen DM"]

METHODS:BACKGROUND:Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS:Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS:Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS:Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

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影响因子:2.27
发表时间:2020-05-01
DOI:10.1213/ANE.0000000000004012
作者列表:["Jean YK","Kam D","Gayer S","Palte HD","Stein ALS"]

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用药物或其他方法使患者整体或局部暂时失去感觉,以达到无痛的目的进行手术治疗。

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