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CJR Outcomes Vary Widely, Driven by 2 Factors

News  |  By Christopher Cheney  
   January 11, 2017

Low-performing hospitals must focus on reducing complications and readmissions to close the gap on high-performing organizations, researchers say.

Clinical outcomes for hip and knee replacement surgery vary widely from hospital to hospital, and there are significant opportunities to boost patient care and to lower costs.

Two factors—inpatient complications of care and readmissions following discharge—are prime drivers of clinical performance levels for hip and knee replacement procedures, according to research published in The Journal of Bone & Joint Surgery.

The findings show the need for improvement among poor-performing hospitals, stated Donald Fry, MD, lead author of the research and executive vice president for clinical outcomes at MPA Healthcare Solutions. He made his remarks in a media release.

Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment model requires mandatory hospital participation in 67 geographic areas of the country.

Under CJR, Medicare bundles payments for hip and knee replacement procedures for hospital, professional, and other patient services through 90 days post-discharge.

Hospitals And Surgery Centers Play Tug-Of-War Over America's Ailing Knees

CJR has established a powerful financial incentive for low-performing hospitals to curtail complications and readmissions, the researchers wrote.

Under the CJR, it is imperative that organizations understand the "excess costs" of total patient care. "Because most hospitals have already improved inpatient efficiency, reductions in complications and readmissions must become the focus of attention," they wrote.

The research is based on Medicare Limited Data Set information collected from 2010 to 2012. The data set features clinical outcome information from 253,978 total hip replacement patients and 672,515 total knee replacement patients.

For hip replacements, the researchers examined data from 1,483 hospitals. For knee replacements, the researchers examined data from 2,349 hospitals.

The data were risk-adjusted for several factors including patient comorbidities. Adverse-outcome rates were based on factors such as patient death and prolonged lengths of stay.

The Outcome Gap
The risk-adjusted data found a wide gap in the adverse-outcome rates at the top 10% of high-performing hospitals compared to the bottom 10% of low-performing hospitals.

For hip replacement procedures, the top 10% of high-performing hospitals posted a 6.6% adverse-outcome rate compared to a 19.8% adverse-outcome rate for the bottom 10% of low-performing hospitals.

For knee replacement procedures, the top 10% of high-performing hospitals posted a 6.4% adverse-outcome rate compared to a 19.3% adverse-outcome rate at the bottom 10% of low-performing hospitals.

Medicare Bundle Backlash is Brewing

Closing the gap between high-performing and low-performing hospitals would generate significant clinical benefits for patients and cost savings for taxpayers, the authors wrote.

"Improvement of suboptimally performing hospitals to the mean level would have a dramatic impact on patient morbidity and costs," they wrote.

The trend toward shorter inpatient stays for hip and knee replacement is having a significant impact on complication and readmission rates, the researchers stated.

"The trend to shorter lengths of stay and early transfer of frail patients to skilled nursing and rehabilitation facilities means that many complications of care are not identified until after discharge," they wrote.

To achieve clinical and financial success in bundled payment programs such as CJR, hospitals must have a firm grasp on what happens to their patients in postacute care settings such as skilled nursing facilities.

Majority of Hospitals Eye Losses in CJR

"Too often, hospitals don't know their own outcomes," Fry said.

Often, neither the hospital nor the surgeons are aware of post-discharge deaths without readmissions, or readmissions that occurred in facilities other than where the original operation was performed, he stated.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

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