Do Patient Point of Entry and Medicaid Status Affect Quality Outcomes Following Total Knee Arthroplasty?
BACKGROUND
The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA.


METHODS
The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers.


RESULTS
There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of "other' ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026).


CONCLUSION
Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS.


LEVEL OF EVIDENCE
III, retrospective observational analysis.
['Feng|James E|JE|', 'Roof|Mackenzie A|MA|', 'Adnan|Mohamed|M|', 'Anoushiravani|Afshin A|AA|', 'Friedlander|Scott|S|', 'Lajam|Claudette M|CM|', 'Vigdorchik|Jonathan|J|', 'Slover|James D|JD|', 'Schwarzkopf|Ran|R|']
D019645:Arthroplasty, Replacement, Knee D006801:Humans D007902:Length of Stay D008484:Medicaid D010351:Patient Discharge D012189:Retrospective Studies D014481:United States
Medicaid outcomes total knee arthroplasty insurance type primary payer