title: Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost.
abstract: There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program.
  
  
  
  Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions.
  
  
  
  Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%.
  
  
  
  The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.
authors.affiliation: Signature Medical Group, St Louis, Missouri.
authors.forename: Jon E
authors.initials: JE
authors.lastname: Tessier
authors.affiliation: Signature Medical Group, St Louis, Missouri.
authors.forename: Gerald
authors.initials: G
authors.lastname: Rupp
authors.affiliation: Signature Medical Group, St Louis, Missouri.
authors.forename: Jim T
authors.initials: JT
authors.lastname: Gera
authors.affiliation: Orthopedic Institute, Providence Health & Services, Portland, Oregon.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: DeHart
authors.affiliation: Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon.
authors.forename: Tom D
authors.initials: TD
authors.lastname: Kowalik
authors.affiliation: Orthopedic + Fracture Specialists, Portland, Oregon.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Duwelius
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000191:economics / Q000592:standards*; D019645:Arthroplasty, Replacement, Knee / Q000191:economics / Q000592:standards*; D015331:Cohort Studies; D003365:Costs and Cost Analysis; D019091:Critical Pathways; D005260:Female; D017048:Health Care Costs; D005102:Health Expenditures; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics; D009985:Orthopedics / Q000592:standards*; D010351:Patient Discharge; D010820:Physicians; D012866:Skilled Nursing Facilities; D019467:Subacute Care / Q000592:standards*; D014481:United States
keywords: bundled payment; care pathway; discharge disposition; primary hip arthroplasty; primary knee arthroplasty; total joint arthroplasty