Testing the Feasibility of a Cross-Setting Measure to Address the Rising Trend in Hospital Outpatient TJA Procedures

Area of Science:

• Orthopedic Surgery
• Health Services Research
• Quality Measurement

Background:

• Total joint arthroplasties (TJAs) like hip and knee replacements are common procedures for pain relief and function improvement.
• While generally safe, TJAs can have complications, and care is increasingly shifting from inpatient to outpatient settings.
• A need exists for a unified measure to evaluate TJA quality across both inpatient and outpatient settings.

Purpose of the Study:

• To respecify the Centers for Medicare & Medicaid Services (CMS) inpatient-only risk-standardized TJA complications measure for cross-setting evaluation.
• To assess complication rates for elective primary TJAs performed in either inpatient or outpatient settings.

Main Methods:

• Utilized Medicare administrative claims and enrollment data for TJA patients.
• Aligned inpatient and outpatient coding practices.
• Employed hierarchical logistic regression to calculate hospital-specific, risk-standardized complication rates (RSCRs).
• Tested measure reliability and incorporated patient and provider input.

Main Results:

• A combined model including procedure setting demonstrated superior discrimination (C-statistic: 0.664) compared to inpatient-only (0.651) or outpatient-only (0.638) models.
• Among 2,747 hospitals, the mean RSCR was 2.91% (median 2.85%).
• A median odds ratio of 1.33 indicated higher complication risk at higher-risk hospitals.

Conclusions:

• A reliable and valid measure was developed to assess hospital TJA performance across inpatient and outpatient settings.
• Significant variation in hospital-level complication rates was observed between settings.
• This measure enables a more representative evaluation of hospital performance using a broader patient population.