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Value measurements: the impending barrier to orthopaedic surgery for obese patients

“Chick Yates, Adolph J. Jr. MD

doi: 10.1097/BCO.0000000000000330
SPECIAL FOCUS: Orthopaedics and Comorbidities

Obese patients needing total joint arthroplasty (TJA) face inherent elements of discrimination due to exposure, operating time, and perceptions of higher complication rates. An expanding literature supports that perception, which is now juxtaposed on newly introduced Centers for Medicare and Medicaid Services (CMS) risk adjusted performance measures. If those performance measures are not adequately risk adjusted, obese patients face a higher likelihood of discrimination. The performance measures were reviewed for their quality of risk adjustment and their potential impact. A literature review was performed to help define the risk of an elevated body mass index (BMI). The risk adjustment model for both National Quality Forum (NQF) 1550 (TJA Complications) and NQF 1551 (TJA 30 Day Readmissions) have a C-statistic of 0.65. Combined they represent hospital exposure for repayment of up to 5% of Medicare reimbursement. Although literature supports an association of obesity with increased risk for complications, more recent literature demonstrates that BMI itself might not be a reliable independent predictor of risk if other associated comorbidities are used. The C-statistic for both current CMS total joint performance measures is low. Hospitals face increased jeopardy for penalties because of patients with higher risk if risk adjustment does not protect them for providing their care. It is predictable that they will shed risk by avoiding patients with higher risk, including those with high BMI. This is occurring nationally with the setting of threshold BMI by groups, hospitals, and health care systems despite the evidence that the BMI itself may not be as predictive as perceived.

UPMC Shadyside Hospital, Pittsburgh, PA

Financial Disclosures: The author has no disclosures and reports no conflicts of interest.

Correspondence to Adolph J. “Chick” Yates, Jr., MD, Chief of Orthopaedic Surgery, UPMC Shadyside Hospital, Associate Professor, Vice Chairman of Quality Management, UPMC Department of Orthopaedic Surgery, Shadyside Medical Building, Suite 415, 5200 Centre Avenue, Pittsburgh, PA 15232 Tel: +412-802-4105; fax: +412-802-4120; e-mail:

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