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In-Bundle Surgeons More Likely Select Cemented Femoral Fixation in Total Hip Arthroplasty for At-Risk Patients: The
Adam I Edelstein1, Eric L Hume2, Liliana E Pezzin1
1Department of Orthopaedic Surgery (A.I.E.), the Institute for Health and Equity (L.E.P.), and the Center for Advancing Population Science (E.L.M.), Medical College of Wisconsin, Milwaukee, Wisconsin.
Insights
Surgeons in the Comprehensive Care for Joint Replacement (CJR) bundled payment model were more likely to use cemented femoral fixation for elderly female hip arthroplasty patients. This shift may reflect increased risk aversion within bundled payment environments.
Area of Science:
- Orthopedic surgery
- Health economics
- Healthcare policy
Background:
- Bundled payment models for lower-extremity arthroplasty aim to reduce costs but have not consistently improved quality.
- The impact of bundled payments on surgeon decision-making in arthroplasty care remains unclear.
- This study investigates how the Comprehensive Care for Joint Replacement (CJR) model influences femoral component fixation choices in total hip arthroplasty (THA).
Purpose of the Study:
- To compare the utilization of cemented versus cementless femoral fixation in primary total hip arthroplasties (THAs) among at-risk elderly patients.
- To assess differences in fixation mode selection between surgeons participating in the Medicare CJR bundled payment model and those in exempt areas.
- To analyze surgeon decision-making regarding femoral fixation in the context of bundled payment reform.
Main Methods:
- Retrospective analysis of Medicare claims data for elective, primary THAs performed in 2017-2018.
- Comparison of cemented and cementless femoral fixation utilization.
- Multivariable regression models stratified by sex, adjusting for patient demographics, comorbidity burden, and hospital geographic factors.
- Assessment of the association between CJR bundle participation and femoral fixation mode.
Main Results:
- Of 118,676 THAs, 9.1% used cemented femoral components, with significant regional variation.
- Cemented fixation was associated with older age, higher likelihood of being White, and greater comorbidity burden in both sexes.
- Female patients in the CJR model were more likely to receive cemented fixation (OR, 1.11; 95% CI, 1.05-1.16), while male patients were less likely (OR, 0.91; 95% CI, 0.83-0.99).
Conclusions:
- Surgeons in the CJR bundled payment environment were more inclined to select cemented femoral fixation for elderly female patients undergoing THA.
- This trend may indicate increased surgeon risk aversion, potentially avoiding cementless fixation in higher-risk patients within bundled payment structures.
- Further research is warranted to directly elucidate the influence of bundled payment models on surgeon decision-making processes in arthroplasty.
Background:
Bundled payment models for lower-extremity arthroplasty have been shown to lower costs but have not reliably improved quality. It is unknown how the bundled payment model may affect surgeons' decisions that impact the quality of arthroplasty care. The purpose of this study was to compare the utilization of femoral component fixation modes by surgeons performing total hip arthroplasties (THAs) in at-risk patients in areas subject to Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment model compared with patients treated by surgeons in areas exempt from the policy.
Methods:
Elective, primary THAs among elderly persons were identified from Medicare claims during 2017 and 2018, including the use of cemented or cementless femoral fixation. Multivariable regression models, applied to samples stratified by sex, were used to assess the association between CJR bundle participation and the use of femoral fixation mode. Analyses were adjusted for patient age, race or ethnicity, comorbidity burden, low-income status, and Census division of the hospital.
Results:
Of 118,676 Medicare patients who underwent THA, 9.1% received cemented femoral components, and use of cement varied significantly by geographic region (p < 0.001). Patients who received cemented fixation, compared with patients who received cementless fixation, had significant differences in mean age (and standard deviation) at 78.3 ± 6.9 years compared with 74.5 ± 6.1 years (p < 0.001) for female patients and 77.3 ± 6.8 years and 74.2 ± 5.9 years (p < 0.001) for male patients; were more likely to be White at 94.0% compared with 92.7% (p < 0.001) for female patients and 95.1% compared with 93.8% (p = 0.046) for male patients; and had higher mean Elixhauser comorbidity index at 2.6 ± 2.2 compared with 2.3 ± 2.0 (p < 0.001) for female patients and 2.8 ± 2.4 compared with 2.4 ± 2.1 (p < 0.001) for male patients. In adjusted analyses, female patients in the CJR bundled payment model were more likely to have cemented fixation compared with female patients not in the CJR model (odds ratio [OR], 1.11 [95% confidence interval (CI), 1.05 to 1.16]; p < 0.001), whereas male patients in the CJR bundled payment model were less likely to have cemented fixation compared with male patients not in the CJR model (OR, 0.91 [95% CI, 0.83 to 0.99]; p = 0.029).
Conclusions:
In the bundled environment, surgeons were more likely to choose cemented femoral fixation for elderly female patients. This may be due to in-bundle surgeons being more risk-averse and avoiding cementless fixation in patients at risk for fracture or implant-related complications. Further research is needed to directly examine the impact of the bundle on surgeon decision-making.
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