Published 6/1/2020
Kaitlyn D’Onofrio

Value of Bundled TJR: A Perspectives Analysis

Editor’s note: The following content was published in the AAOS Now Special Edition and distributed in June 2020. The content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage.

A study that was presented as part of the Annual Meeting Virtual Experience assessed how the value of bundled total joint replacement (TJR) differs among patients, payers/employers, and hospitals/providers.

“With all of the buzz surrounding ‘high-value care’ and the recent transition in TJRs from fee-for-service to more value-based models of payment (such as the bundled payment program), it’s important to first define what ‘value’ means before we can determine the effectiveness of these payment models in promoting high-value care,” study author Amy Ahn, BS, MD candidate at Icahn School of Medicine, told AAOS Now. “We also wanted to provide distinct definitions of value for each of the three stakeholders involved in a TJR bundle—patient, provider, and payer.

The researchers evaluated data spanning 2017 through 2018 on elective TJRs performed at a multi-hospital academic health system. They collected demographic, psychosocial, clinical, financial, and patient-reported outcome (PRO) data. The value of TJR for patients was defined as improvements in PROs from preoperatively to one-year postoperatively; for payers/employers, it was improvements in PROs per $1,000 of bundle cost; and for hospitals/providers, it was the normalized sum of PRO improvements and hospital bundle margin. Multivariate analyses were performed to determine predictors of low value for each group.

Of 280 patients with eligible PRO data, 71 also had Medicare claims data available. Among patients, diabetes was a predictor of low value (odds ratio [OR], 0.45; P = 0.02). For payers/employers, low-value predictors were female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and discharge to a skilled nursing facility (SNF) (OR, 0.17) (P ≤ 0.03 for all). For hospitals/providers, predictors were pulmonary disease (OR, 0.16) and SNF discharge (OR, 0.19) (P ≤ 0.04 for both).

The study authors were surprised and pleased to observe that several predictors of low value overlapped among the groups, “as [this] aligns the goals of insurance companies and hospitals, incentivizing collaboration in trying to address them,” Ms. Ahn explained.

“The study highlights specific opportunities for improvement within bundled payment programs in terms of providing high-value care, as well as an incentive for both hospitals and providers to work together to address them,” she continued. “For example, patients who are high risk for SNF discharge should be identified earlier to allow for more efficient discharge planning, preoperative risk modification, and removal of potential barriers to home discharge. Hospitals and payers should also ensure a network of known, high-performing SNFs for patients to be discharged to in order to avoid both the negative clinical and financial outcomes commonly associated with SNF discharge. For pulmonary disease, care pathways can be redesigned based on evidence-based protocols around smoking cessation, incentive spirometry, asthma/chronic obstructive pulmonary disease pharmacotherapy planning, and tailoring of anesthesia in order to optimize the outcomes.”

Limitations of the study are that it included patients from only two urban academic institutions and that it had a small sample size. The study also did not include socioeconomic differences, which may have affected baseline and postoperative outcomes.

Ms. Ahn’s coauthors of Poster 245, “Defining and Optimizing Value in Total Joint Replacements from the Patient, Payer, and Provider Perspectives,” are Christopher E. Ferrer, Christopher Park, Daniel Snyder, Samuel Zev Maron, Christopher Mina Mikhail, Aakash Keswani, Ilda B. Molloy, Michael J. Bronson, Wayne E. Moschetti, David S. Jevsevar, Jashvant Poeran, Leesa M. Galatz, and Calin Stefan Moucha.

Kaitlyn D’Onofrio is the associate editor for AAOS Now. She can be reached at kdonofrio@aaos.org.