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Reverse Total Shoulder Arthroplasty
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Reversal of the Halo Effect: Prolonged Participation in Comprehensive Care for Joint Replacement Negatively Impacts
Akshay Reddy1, Emilie N Miley2, Hari K Parvataneni3
1College of Medicine, University of Florida, Gainesville, FL, USA.
Insights
The Comprehensive Care for Joint Replacement (CJR) program increased revision arthroplasty patient volume and complexity. Quality metrics showed no clear benefits, with rising complications despite pathway improvements.
Area of Science:
- Orthopedic surgery
- Health services research
- Value-based healthcare
Background:
- The regional impact of the Comprehensive Care for Joint Replacement (CJR) program on revision arthroplasty patients is not well understood.
- Prior research suggests care pathways for primary joint replacements may affect adjacent complex patient pathways.
- The effects of CJR-driven regional referral changes and long-term bundle participation durability remain unassessed.
Purpose of the Study:
- To evaluate the downstream regional effects of the CJR program on revision arthroplasty patients.
- To assess changes in patient volume, complexity, and quality metrics over five years of CJR participation.
Main Methods:
- Retrospective analysis of blinded electronic medical record data from 2015 to 2020.
- Inclusion of patients undergoing revision total knee arthroplasty (N=376) and revision total hip arthroplasty (N=482).
- Multivariate analysis of variance and chi-square tests for demographic and outcome comparisons over time.
Main Results:
- Revision arthroplasty patient volume increased by 42% during the study period.
- Patient medical complexity, measured by the Charlson comorbidity index, significantly increased (3.91 to 4.65, P=.01).
- Mean length of stay decreased (5.14 to 4.50 days, P=.03), but all-cause complication rates rose (8.3% to 15.2%, P=.02).
Conclusions:
- Despite care pathway enhancements over five years of CJR participation, revision patients did not show improved quality metrics.
- Increased patient volume and medical complexity were observed, potentially overwhelming implemented care pathways.
- Understanding CJR's impact on regional arthroplasty care is crucial as value-based programs evolve.
Background:
The downstream regional effect of the Comprehensive Care for Joint Replacement (CJR) program on care pathway-adjacent patients, including revision arthroplasty patients, is poorly understood. Prior studies have demonstrated that care pathways targeting primary total joint arthroplasty may produce a halo effect, impacting more complex patients with parallel care pathways. However, neither the effect of regional referral changes from CJR nor the durability of these positive changes with prolonged bundle participation has been assessed.
Methods:
Blinded data were pulled from electronic medical records. Primary analyses focused on the effect of CJR participation from 2015 (baseline) to 2020 (final participation year) at a tertiary care safety-net hospital. Patient demographics were evaluated using multivariate analysis of variance and chi-square calculations between procedure types over time.
Results:
Patients who underwent revision total knee arthroplasty (N = 376) and revision total hip arthroplasty (N = 482) were included. More patients moved through the revision-care pathway over the participation period, with volume increasing by 42% over time. Patients became more medically complex: the Charlson comorbidity index increased from 3.91 to 4.65 (P = .01). The mean length of stay decreased from 5.14 days to 4.50 days (P = .03), but the all-cause complication (8.3%-15.2%; P = .02) and readmission rates (13.6%-16.6%; P = .19) increased over time.
Conclusions:
Despite care pathway improvements over 5 years of CJR participation, revision patients did not display clear benefits in quality metrics but demonstrated a considerable increase in volume and medical complexity over time. The care of these patients may supersede even thoughtfully implemented care pathways, especially when referral burden increases, as may be prone to happen in regional, financial risk-conferring value-based programs. Understanding the impact of mandatory bundled payment programs like CJR on the care of arthroplasty patients regionally will be essential as value-based programs evolve.
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