Background 

Higher hospital volume is associated with lower rates of adverse outcomes after revision total joint arthroplasty (TJA). Centralizing revision TJA care to higher-volume hospitals might reduce early complication and readmission rates after revision TJA; however, the effect of centralizing revision TJA care on patient populations who are more likely to experience challenges with access to care is unknown.

Questions/purposes 

(1) Does a hypothetical policy of transferring patients undergoing revision TJA from lower-to higher-volume hospitals increase patient travel distance and time? (2) Does a hypothetical policy of transferring patients undergoing revision TJA from lower- to higher-volume hospitals disproportionately affect travel distance or time in low income, rural, or racial/ethnic minority populations?

Methods 

Using the Medicare Severity Diagnosis Related Groups 466-468, we identified 37,147 patients with inpatient stays undergoing revision TJA from 2008 to 2016 in the Statewide Planning and Research Cooperative System administrative database for New York State. Revisions with missing or out-of-state patient identifiers (3474 of 37,147) or those associated with closed or merged facilities (180 of 37,147) were excluded. We chose this database for our study because of relative advantages to other available databases: comprehensive catchment of all surgical procedures in New York State, regardless of payer; each patient can be followed across episodes of care and hospitals in New York State; and New York State has an excellent cross-section of hospital types for TJA, including rural and urban hospitals, critical access hospitals, and some of the highest-volume centers for TJA in the United States. We divided hospitals into quartiles based on the mean revision TJA volume. Overall, 80% (118 of 147) of hospitals were not for profit, 18% (26 of 147) were government owned, 78% (115 of 147) were located in urban areas, and 48% (70 of 147) had fewer than 200 beds. The mean patient age was 66 years old, 59% (19,888 of 33,493) of patients were females, 79% (26,376 of 33,493) were white, 82% (27,410 of 33,493) were elective admissions, and 56% (18,656 of 33,493) of admissions were from government insurance. Three policy scenarios were evaluated: transferring patients from the lowest 25% by volume hospitals, transferring patients in the lowest 50% by volume hospitals, and transferring patients in the lowest 75% by volume hospitals to the nearest higher-volume institution by distance. Patients who changed hospitals and travelled more than 60 miles or longer than 60 minutes with consideration for average traffic patterns after the policy was enacted were considered adversely affected. The secondary outcome of interest was the impact of the three centralization policies, as defined above, on lower-income, nonwhite, rural versus urban counties, and Hispanic ethnicity.

Results 

Transferring patients from the lowest 25% by volume hospitals resulted in only one patient stay that was affected by an increase in travel distance and travel time. Transferring patients from the lowest 50% by volume hospitals resulted in 9% (3050 of 33,493) of patients being transferred, with only 1% (312 of 33,493) of patients affected by either an increased travel distance or travel time. Transferring patients from the lowest 75% by volume hospitals resulted in 28% (9323 of 33,493) of patients being transferred, with 2% (814 of 33,493) of patients affected by either an increased travel distance or travel time. Nonwhite patients were less likely to encounter an increased travel distance or time after being transferred from the lowest 50% by volume hospitals (odds ratio 0.31 [95% CI 0.15 to 0.65]; p = 0.002) or being transferred from the lowest 75% by volume hospitals (OR 0.10 [95% CI 0.07 to 0.15]; p < 0.001) than white patients were. Hispanic patients were more likely to experience increased travel distance or time after being transferred from the lowest 50% by volume hospitals (OR 12.3 [95% CI 5.04 to 30.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.24 [95% CI 2.24 to 4.68]; p < 0.001) than non-Hispanic patients were. Patients from a county with a lower median income were more likely to experience increased travel distances or time after being transferred from the lowest 50% by volume hospitals (OR 69.5 [95% CI 17.0 to 283]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.86 [95% CI 3.21 to 4.64]; p < 0.001) than patients from counties with a higher median income. Patients from rural counties were more likely to be affected after being transferred from the lowest 50% by volume hospitals (OR 98 [95% CI 49.6 to 192.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 11.7 [95% CI 9.89 to 14.0]; p < 0.001) than patients from urban counties.

Conclusion 

Although centralizing revision TJA care to higher-volume institutions in New York State did not appear to increase the travel burden for most patients, policies that centralize revision TJA care will need to be carefully designed to minimize the disproportionate impact on patient populations that already face challenges with access to healthcare. Further studies should examine the feasibility of establishing centers of excellence designations for revision TJA, the effect of best practices adoption by lower volume institutions to improve revision TJA care, and the potential role of care-extending technology such as telemedicine to improve access to care to reduce the effects of travel distances on affected patient populations.

Level of Evidence 

Level III, prognostic study.

中文翻译：

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假定的 THA 和 TKA 翻修集中化是否会因患者出行距离或时间的增加而加剧获得护理方面现有的地理或人口差异？大型数据库研究

背景 

较高的住院量与翻修全关节置换术 (TJA) 后不良后果发生率较低相关。将翻修 TJA 护理集中到规模较大的医院可能会减少翻修 TJA 后的早期并发症和再入院率；然而，集中翻修 TJA 护理对更有可能在获得护理方面遇到挑战的患者群体的影响尚不清楚。

问题/目的 

(1) 将接受 TJA 翻修的患者从业务量较低的医院转移到业务量较大的医院的假设政策是否会增加患者的出行距离和时间？(2) 将接受 TJA 翻修的患者从流量较小的医院转移到流量较大的医院的假设政策是否会不成比例地影响低收入、农村或少数种族/族裔人群的出行距离或时间？

方法 

使用 Medicare 严重程度诊断相关组 466-468，我们在纽约州全州规划和研究合作系统管理数据库中确定了 2008 年至 2016 年期间住院接受修订 TJA 的 37,147 名患者。排除了缺失或州外患者标识符的修订（37,147 例中的 3474 例）或与关闭或合并设施相关的修订（37,147 例中的 180 例）。我们选择该数据库进行研究是因为与其他可用数据库相比具有相对优势：全面涵盖纽约州的所有外科手术，无论付款人是谁；可以在纽约州的各个护理和医院中跟踪每位患者；纽约州拥有多种 TJA 医院类型，包括农村和城市医院、重症医院以及美国一些 TJA 治疗量最大的中心。我们根据平均 TJA 修订量将医院分为四分位数。总体而言，80%（147 家中的 118 家）医院是非营利性的，18%（147 家中的 26 家）为政府所有，78%（147 家中的 115 家）位于城市地区，48%（147 家中的 70 家）医院数量较少床位200余张。患者平均年龄为 66 岁，59%（33,493 例中的 19,888 例）患者为女性，79%（33,493 例中的 26,376 例）为白人，82%（33,493 例中的 27,410 例）为择期入院，56%（33,493 例中的 18,656 例）为择期入院的录取来自政府保险。评估了三种政策情景：从就诊量最低的 25% 医院转移患者、将就诊量最低的 50% 医院的患者转移以及将就诊量最低的 75% 医院的患者转移到距离最近的较高诊治机构。政策颁布后，考虑到平均交通模式，更换医院并出行超过 60 英里或超过 60 分钟的患者被视为受到不利影响。次要的兴趣结果是如上所述的三项集权政策对低收入、非白人、农村与城市县以及西班牙裔的影响。

结果 

从数量最低的 25% 医院转移患者仅导致一名患者因出行距离和出行时间增加而住院。从数量最低的 50% 医院转移患者导致 9%（33,493 名患者中的 3050 名）患者被转移，只有 1%（33,493 名患者中的 312 名）患者受到出行距离或出行时间增加的影响。从数量最低的 75% 医院转移患者导致 28%（33,493 名患者中的 9323 名）患者被转移，其中 2%（33,493 名患者中的 814 名）患者受到出行距离或出行时间增加的影响。非白人患者从数量最低的 50% 医院转院后，旅行距离或时间增加的可能性较小（比值比 0.31 [95% CI 0.15 至 0.65]；p = 0.002）或从数量最低 75% 的医院转院后，旅行距离或时间增加的可能性较小。数量医院（OR 0.10 [95% CI 0.07 至 0.15]；p < 0.001）高于白人患者。西班牙裔患者从就诊量最低的 50% 医院转院后，旅行距离或时间更有可能增加（OR 12.3 [95% CI 5.04 至 30.2]；p < 0.001）以及从就诊量最低 75% 的医院转院后，旅行距离或时间更有可能增加（OR 3.24 [95% CI 2.24 至 4.68]；p < 0.001）高于非西班牙裔患者。来自中位收入较低县的患者从数量最低的 50% 医院转院后更有可能经历更长的出行距离或时间（OR 69.5 [95% CI 17.0 至 283]；p < 0.001）并从其他医院转院与中位收入较高县的患者相比，医院数量最低的 75%（OR 3.86 [95% CI 3.21 至 4.64]；p < 0.001）。来自农村县的患者从就诊量最低的 50% 医院转院（OR 98 [95% CI 49.6 至 192.2]；p < 0.001）和从就诊量最低 75% 的医院转院（OR 98 [95% CI 49.6 to 192.2]；p < 0.001）后更有可能受到影响。 11.7 [95% CI 9.89 至 14.0]；p < 0.001）比来自城市县的患者高。

结论 

尽管将 TJA 翻修护理集中到纽约州的大容量机构似乎不会增加大多数患者的出行负担，但需要仔细设计集中 TJA 翻修护理的政策，以最大程度地减少对已经面临挑战的患者群体的不成比例的影响获得医疗保健。进一步的研究应探讨建立 TJA 翻修卓越中心的可行性、规模较小的机构采用最佳实践对改善 TJA 翻修护理的效果，以及远程医疗等护理延伸技术在改善患者获得护理机会方面的潜在作用。减少旅行距离对受影响患者群体的影响。

证据水平 

III级，预后研究。