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What Are the Migration Patterns for U.S. Primary Total Joint Arthroplasty Patients?

Etkin, Caryn D., PhD, MPH; Lau, Edmund C., MS; Watson, Heather N., PhD; Kurtz, Steven M., PhD; Gioe, Terrence J., MD; Springer, Bryan D., MD; Lewallen, David G., MD; Bozic, Kevin J., MD, MBA

Clinical Orthopaedics and Related Research®: June 2019 - Volume 477 - Issue 6 - p 1424–1431
doi: 10.1097/CORR.0000000000000693
SELECTED PROCEEDINGS FROM THE 7TH INTERNATIONAL CONGRESS OF ARTHROPLASTY REGISTRIES
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Background Evaluation of total joint arthroplasty (TJA) patient-reported outcomes and survivorship requires that records of the index and potential revision arthroplasty procedure are reliably captured. Until the goal of the American Joint Replacement Registry (AJRR) of more-complete nationwide capture is reached, one must assume that patient migration from hospitals enrolled in the AJRR to nonAJRR hospitals occurs. Since such migration might result in loss to followup and erroneous conclusions on survivorship and other outcomes of interest, we sought to quantify the level of migration and identify factors that might be associated with migration in a specific AJRR population.

Questions/Purposes (1) What are the out-of-state and within-state migration patterns of U.S. Medicare TJA patients over time? (2) What patient demographic and institutional factors are associated with these patterns?

Methods Hospital records of Medicare fee-for-service beneficiaries enrolled from January 1, 2004 to December 31, 2015, were queried to identify primary TJA procedures. Because of the nationwide nature of the Medicare program, low rates of loss to followup among Medicare beneficiaries, as well as long-established enrollment and claims processing procedures, this database is ideal for examining patient migration after TJA. We identified an initial cohort of 5.33 million TJA records from 2004 to 2016; after excluding patients younger than 65 years of age, those enrolled solely due to disability, those enrolled in a Medicare HMO, or residing outside the United States, the final analytical dataset consisted of 1.38 million THAs and 3.03 million TKAs. The rate of change in state or county of residence, based on Medicare annual enrollment data, was calculated as a function of patient demographic and institutional factors. A multivariate Cox model with competing risk adjustment was used to evaluate the association of patient demographic and institutional factors with risk of out-of-state or out-of-county (within-state) migration.

Results One year after the primary arthroplasty, 0.61% (95% confidence interval [CI], 0.60–0.61; p < 0.001 for this and all comparisons in this Results section) of Medicare patients moved out of state and another 0.62% (95% CI, 0.60–0.63) moved to a different county within the same state. Five years after the primary arthroplasty, approximately 5.41% (95% CI, 5.39–5.44) of patients moved out of state and another 5.50% (95% CI, 5.46–5.54) Medicare patients moved to a different county within the same state. Among numerous factors of interest, women were more likely to migrate out of state compared with men (hazard ratios [HR], 1.06), whereas black patients were less likely (HR, 0.82). Patients in the Midwest were less likely to migrate compared with patients in the South (HR, 0.74). Patients aged 80 and older were more likely to migrate compared with 65- to 69-year-old patients (HR, 1.19). Patients with higher Charlson Comorbidity Index scores compared with 0 were more likely to migrate (index of 5+; HR, 1.19).

Conclusions Capturing detailed information on patients who migrate out of county or state, with associated changes in medical facility, requires a nationwide network of participating registry hospitals. At 5 years from primary arthroplasty, more than 10% of Medicare patients were found to migrate out of county or out of state, and the rate increases to 18% after 10 years. Since it must be assumed that younger patients might exhibit even higher migration levels, these findings may help inform public policy as a “best-case” estimate of loss to followup under the current AJRR capture area. Our study reinforces the need to continue aggressive hospital recruitment to the AJRR, while future research using an increasingly robust AJRR database may help establish the migration patterns of nonMedicare patients.

Level of Evidence Level III, therapeutic study.

C. D. Etkin, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

T. J. Gioe, University of Minnesota Medical School, Minneapolis, MN, USA

E. C. Lau, H. N. Watson, Exponent Inc, Menlo Park, CA USA

B. D. Springer, OrthoCarolina Hip and Knee Center, Charlotte, NC, USA

B. D. Springer, Carolinas Medical Center, Charlotte, NC, USA

D. G. Lewallen, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

S. M. Kurtz, Exponent Inc, Philadelphia, PA, USA

K. J. Bozic, Dell Medical School, The University of Texas at Austin, Austin, TX, USA

K. J. Bozic Dell Medical School, The University of Texas at Austin, 1500 Red River St., Austin, TX 78701 USA, Email: kevin.bozic@austin.utexas.edu

The institution of one or more of the authors (ECL, HNW, SMK) has received, during the study period, funding from the American Joint Replacement Registry (Rosemont, IL, USA) for their work on the project.

The institution of one or more of the authors (HNW) has received, during the study period, funding from Pacira Pharmaceuticals (Parsippany-Troy Hills, NJ, USA) and Swiftpath LLC (Kirkland, WA, USA) outside the submitted work.

The institutions of one or more of the authors certifies that they (KJB, DGL) have received funding from the Agency for Healthcare Research and Quality (Rockville, MD, USA) (KJB received research funding for The University of Texas for $10,000-$100,000), California Public Employees' Retirement System (Sacramento, CA, USA) (KJB received research funding for University of California San Francisco), and NIH (Bethesda, MD, USA) (KJB received research funding to University of California San Francisco).

One of the authors certifies that he (SMK), or a member of his or her immediate family, received institutional support from Invibio (West Conshohocken, PA, USA); Smith & Nephew (Memphis, TN, USA); Stryker Orthopedics (Mahwah, NJ, USA); Zimmer Biomet (Warsaw, IN, USA); DePuy Synthes (Warsaw, IN, USA); Medtronic (Memphis, TN, USA); Stelkast (McMurray, PA, USA); Formae (Paoli, PA, USA); Kyocera Medical (Kyoto, Japan); Wright Medical Technology (Memphis, TN, USA); Ceramtec (Plochingen, Germany); DJO (Vista, CA, USA); Celanese (Florence, KY, USA); Aesculap (Tuttlingen, Germany); Spinal Motion (Mountain View, CA, USA); Active Implants (Memphis, TN, USA); and Ferring Pharmaceuticals (Parsippany, NJ, USA), outside the submitted work.

One of the authors certifies that he (KJB), or a member of his or her immediate family, has received or may receive payments or benefits, the Agency for Healthcare Research and Quality (Rockville, MD, USA); nonfinancial support from the Harvard Business School (Boston, MA, USA); personal fees, in an amount of USD 10,000 to USD 100,000 from the Centers for Medicare and Medicaid Services (Baltimore, MD, USA); other from AJRR (Rosemont, IL, USA); other from American Academy of Orthopaedic Surgeons (Rosemont, IL, USA) other from American Association of Hip and Knee Surgeons (Rosemont, IL, USA), other from the Knee Society (Rosemont, IL, USA); other from Carrum Health (South San Francisco, CA, USA); other from Cardinal Analytx (Palo Alto, CA, USA); personal fees in an amount of less than USD 10,000 from Institute for Healthcare Improvement (Boston, MA, USA); other from the Hip Society (Rosemont, IL, USA); other from the California Public Employees' Retirement System (CalPERS) (Sacramento, CA, USA); other from the National Institutes for Health (NIH) (Rockville, MD, USA); other from the Orthopaedic Research and Education Foundation (OREF) (Rosemont, IL, USA); outside the submitted work.

One of the authors certifies that he (TJG), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, in an amount of USD 10,000 to USD 100,000 from the AJRR; in an amount of USD 10,000 to USD 100,000 from DePuy (Warsaw, IN, USA); personal fees, nonfinancial support and other including stock with mutual funds in an amount less 10,000 from A Johnson & Johnson Company (New Brunswick, NJ, USA) and from Eli Lilly (Indianapolis, IN, USA), outside the submitted work.

One of the authors certifies that he (DGL), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, in an amount of USD 10,000 to USD 100,000 from the AJRR (annual) (Rosemont, IL, USA) and USD 100,000 to 1 million (all time); in an amount of USD 10,000 to USD 100,000 (all time) from Link (Hamburg, Germany); in an amount of USD 10,000 to USD 100,000 from Stryker (Mahwah, NJ, USA) (last year and all time); in an amount of USD 100,000 to USD 1 million (last year) and > USD 1 million (all time) from Zimmer Biomet (Warsaw, IN, USA), related to this work.

One of the authors certifies that he (BDS), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount of USD > 100,000 from Mako/Stryker (Mahwah, NJ, USA), related to this work.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the American Joint Replacement Registry, Rosemont, IL, USA.

Received October 23, 2018

Accepted February 04, 2019

© 2019 Lippincott Williams & Wilkins LWW
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