Patient‐Reported Outcomes from the Comprehensive Care for Joint Replacement Evaluation

Abstract

Research ObjectiveThe Comprehensive Care for Joint Replacement (CJR) model is intended to encourage participant hospitals to reduce Medicare payments by coordinating care with the physicians, post‐acute care (PAC) providers, and other providers involved in an episode of care for a lower extremity joint replacement (LEJR), which comprises the surgery plus the services provided in the 90 days after hospital discharge. Previous studies have documented reductions in institutional PAC attributable to the model.1 The shift towards less intensive PAC could affect patient experiences and recovery. We surveyed Medicare fee‐for‐service (FFS) beneficiaries after LEJR surgery to document their self‐reported functional status, pain, satisfaction with care management and overall recovery, care transitions, and dependence on caregivers for help with activities of daily living. These patient‐reported outcomes are important indicators of quality that cannot be measured using secondary data.Study DesignIn 2018, participation in CJR was mandatory for hospitals that that did not meet rural or low‐volume exemptions, and were located in 34 randomly‐selected, historically high‐payment metropolitan statistical areas (MSAs). We surveyed a census of Medicare FFS beneficiaries who had LEJR surgery in mandatory CJR hospitals, and those who had LEJR surgery in hospitals within 47 high‐payment MSAs randomly assigned to the control group. Patients received the survey approximately 90 to 120 days after hospital discharge. We estimated risk‐adjusted differences between CJR and control respondents.Population StudiedWe sampled beneficiaries who had LEJR surgery in March, April, August or September 2018 from the CJR group (12,478 beneficiaries) and the control group (13,137 beneficiaries). Response rates for the survey were similar for the CJR and control groups (67.6% and 68.6%, respectively).Principal FindingsThe CJR model did not have a significant impact on patient‐reported functional status, pain, satisfaction with care management or satisfaction with overall recovery. However, CJR respondents were 1.2 percentage points less likely to report that they received the right amount of care in the two weeks after hospital discharge than control respondents (p < 0.01), and CJR respondents required more caregiver help at home than control respondents (a difference of 1.9 points on a 100‐point scale, p < 0.01).ConclusionsThe CJR model resulted in a small increase in the number of respondents who reported that they needed caregiver help after returning home. This is consistent with previous findings that CJR patients were less likely to use institutional PAC and were more likely to go directly home after surgery than control respondents. However, this did not result in decreased functional status or satisfaction with care management and recovery. This suggests that greater dependence on caregivers did not translate to lower satisfaction or worse functional recovery.Implications for Policy or PracticeResults show that CJR reduced Medicare payments by reducing institutional PAC.1 Despite decreasing the use of institutional PAC, the model generally did not affect patient‐reported functional recovery or satisfaction. However, more research is needed to assess the possible impact of the model on caregivers and on patients with physical or social risk factors who may be more vulnerable to changes in care. 1https://innovation.cms.gov/Files/reports/cjr‐secondannrpt.pdf Primary Funding SourceCenters for Medicare and Medicaid Services.