The CCJR® Gerard A. Engh, MD Excellence in Knee Research Award: Patient Factors Associated with Achieving Substantial Clinical Benefit After Total Knee Arthroplasty.

Abstract

The Centers for Medicare and Medicaid Services (CMS) now require the collection of pre- and postoperative patient-reported outcome measures (PROMs) for elective inpatient Medicare total joint arthroplasty procedures. There are concerns CMS will utilize the percentage of patients meeting the substantial clinical benefit (SCB) threshold in determining hospital reimbursement. However, understanding of what drives SCB achievement remains limited. Using a prospectively collected registry of total knee arthroplasty (TKA) patients between January 2020 and June 2023, eligible patients were categorized into two groups, designated "improvement" and "non-improvement," based on their attainment or lack of attainment of the established SCB threshold. Cohort demographics and preoperative/postoperative PROMs were compared. Cluster analyses were performed to evaluate for patient characteristics impacting SCB achievement status. In total, 1,240 of 1,860 patients (66.7%) completed pre- and postoperative PROMs data and met inclusion criteria for this study. Patients achieving SCB represented 66.1% of included patients (820 of 1,240). There were very few demographic differences between "improvement" and "non-improvement" groups; the improvement group was notable for more women (66.6 versus 58.3%, P = 0.02). Cluster analyses revealed characteristics associated with likely SCB achievement included younger age, non-White race, Hispanic/Latino ethnicity, lower level of education, and worse preoperative pain and functioning scores. The implication of PROMs and SCB in reimbursement within the CMS patient population has far-reaching consequences across the field of arthroplasty. We found that Medicaid insurance and lower education level (factors associated with lower socioeconomic status) were not associated with failure to achieve SCB. Additionally, non-White race and Hispanic/Latino ethnicity were associated with SCB achievement, indicating that these policies may not be exacerbating existing inequities in arthroplasty care. Further work is necessary to maximize PROMs collection and SCB achievement while prioritizing patient outcomes.