Does Bundling TJA Reduce Racial Disparities?

Are individuals of different races getting different treatment throughout their episode of care for total hip and knee arthroplasties and does Medicare’s bundling program affect those disparities?

A team of researchers from the Icahn School of Medicine at Mount Sinai in New York City, set out to determine and quantify what differences might exist and whether bundling has an effect. Their study, “Racial Differences in Care and Outcomes After Total Hip and Knee Arthroplasties: Did the Comprehensive Care for Joint Replacement Program Make a Difference?” appears in the June 1, 2022, edition of The Journal of Bone and Joint Surgery.

Co-author Jashvant Poeran, M.D., Ph.D. an epidemiologist and director of the Center for Clinical and Outcomes Research told OTW, “We know that disparities in care and outcomes are—unfortunately—pervasive in medicine; this has become ever more clear again during the COVID-19 pandemic with certain patient subgroups more heavily impacted.”

“The same is true for care and outcomes in orthopedic surgery, specifically for patients undergoing hip and knee replacement surgery. Various studies have described the presence of these disparities, but much less data exist on ways to reduce these disparities.”

“Given the unsustainable level of spending in U.S. healthcare, the Centers for Medicare and Medicaid Services (incentivized by the Affordable Care Act) has implemented various policies aimed at reducing spending while maintaining or improving care quality.”

“One such initiative was the CJR [care for joint replacement] bundled payment program—specific to hip and knee replacement surgery—in which health care organizations receive a single lump sum payment for care associated with the procedure for up to 90 days after hospital discharge, called an ‘episode of care.’ This theoretically incentivizes standardization of care and as a result could reduce disparities in care (the assumption here is that if care is standardized, there is less room for patient subgroup-specific differences in care and outcomes).”

“With these two developments in mind, we tested whether the CJR program had an impact on disparities in care and outcomes after hip and knee replacement surgery.”

Using Medicare claims data on 1,483,221 total joint arthroplasties, the researchers collected data for both Black and white patients looking, specifically at the following variables:

• preoperative characteristics (Deyo-Charlson comorbidity index, patient sex, and age),
• characteristics during hospitalization (length of stay, blood transfusions, and combined complications), and
• postoperative characteristics (90 and 180-day readmission rates and institutional post-acute care).

Study Results and Conclusions

“We did see that racial differences in measures of care and outcomes persist among these patients,” said Dr. Poeran to OTW.

“However, we also found that the CJR program coincided with reductions in racial differences in terms of some of the outcomes we looked at—for example, readmissions within 90 days after surgery.”

“In other words, the gap between Black and White patients in terms of this specific outcome was reduced after the CJR program was implemented. We saw this result only for a few of our studied outcomes, but we believe that this is promising in the sense that it has identified a potential way for us to reduce disparities.”

“More research is needed,” says Dr. Poeran, “specifically on what specific elements of the CJR program may have impacted our results. Another important avenue of future research could focus on if reductions in this racial gap in outcome truly represents an improvement or potential underutilization of care.”

“The paper’s impact will be probably more on the health policy level in terms of increased understanding of the potential of bundled payment programs to reduce disparities in care. Another impact is probably the implication for future research on:

• validation of our findings, and
• see what aspects of bundled payment programs may result in reducing disparities.”

Calin Moucha, M.D., professor of Orthopedics and chief of Joint Replacement Surgery at Mount Sinai Health System, also a co-author on the study, told OTW, “While the CJR program coincided with a reduction in racial differences in terms of readmission rates and Medicare payments related to outpatient care, differences in other outcomes persisted.”

“It is this latter finding that we need to focus our attention on, and without doubt, this will continue to be a challenge. Moving forward, the key to minimizing differences in outcomes will be creating an ethical balance between preoperatively optimizing patients with multiple comorbidities and offering them alternative non-operative treatments.”