Services & Data Requests - PHC4 Data Users Series

Effects of Payment Reform on Post-Acute Care After Lower Extremity Joint Replacement

Value-based payment models that have been implemented over the years have changed the delivery of patient care. For example, patients undergoing elective lower extremity total joint replacement (LEJR) are increasingly discharged home than to institutional post-acute care settings (such as skilled nursing facilities). Dr. Robert E. Burke, MD, MS from the University of Pennsylvania Perelman School of Medicine used inpatient discharge data to study the effects of payment reform on discharge patterns and patient outcomes. The study entitled, Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement, compared patients discharged to institutional post-acute care settings to patients discharged home, to evaluate the effect of financial incentives (i.e., hospital participation in bundled payments) on patient readmissions, surgical complications, and mortality. Dr. Burke’s research team used Pennsylvania Health Care Cost Containment Council’s (PHC4) inpatient discharge data to examine changes in patient outcomes after lower extremity joint replacement surgery over a period when substantial financial payment incentives were implemented. Variations were also studied across payers and by hospital participation in bundled payments (Bundled Payments for Care Improvement or Comprehensive Care for Joint Replacement models).

Patient and hospital characteristics in the discharge dataset allowed for adjustment. Regardless of where the procedure was performed, all lower extremity joint replacements for all payers were included in the analysis. Results of the study revealed that the decrease in higher-intensity institutional post-acute care was associated with fewer hospital readmissions. Furthermore, although bundled payments are used for Medicare fee-for-service beneficiaries, the change in use of post-acute care was similar across all payers. Dr. Burke stated, “Our results suggest that adults discharged home in 2016 to 2018 who were clinically similar to adults discharged to institutional forms of post-acute care were not more likely to sustain potentially adverse outcomes, such as hospital readmissions, surgical complications, or mortality.”

Dr. Burke shared some of the findings from his study saying, “We found that neither the change in post-acute care use nor any changes in outcomes (readmissions, complications, or mortality) were different in hospitals participating in bundled payments. We did not find any signal of worsened outcomes even in high-risk groups, and even with a large total shift from facility-based to home-based care after surgery.”

The study was published in JAMA Network Open.1 Dr. Burke stated, “Using PHC4 comprehensive contemporary data is a huge advantage, to be able to present results that are useful to policymakers and health systems’ leaders.” According to Dr. Burke, one benefit of using PHC4 data was that it could be easily linked with mortality data and information about hospital participation in bundled payments, which allowed for tracking patient complication and readmission outcomes.

Dr. Burke expressed working with the PHC4 team was a smooth process for someone doing it for the first time, and assistance provided by the PHC4 team in linking discharge data with Pennsylvania mortality data made it easier than trying to connect with widely disparate entities. He found the PHC4 team’s knowledge and support especially helpful to develop the proper dataset for his research needs.


1 Burke RE, Canamucio A, Medvedeva E, Hume EL, Navathe AS. Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement. JAMA Netw Open. 2020;3(10)


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Robert E. Burke

Robert E. Burke, MD, MS, FHM
Associate Division Chief for Research, Division of General Internal Medicine
Assistant Professor of Medicine, Perelman School of Medicine, University of Pennsylvania

Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania

Core Investigator, Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA

Robert E. Burke, MD, MS, FHM is the Associate Chief for Research in the Division of General Internal Medicine and Assistant Professor of Medicine at the University of Pennsylvania’s Perelman School of Medicine. He is also a Core Investigator at the Center for Health Equity Research and Promotion at the Corporal Crescenz VA Medical Center in Philadelphia. Dr. Burke’s research seeks to reduce unnecessary hospitalizations and long-term nursing home care for frail older adults. He leads a VA implementation science program center (the SAGE QUERI), which seeks to implement evidence-based practices aligned with the “Age-Friendly Health System” model. He also leads projects involving health policy and payment reform, including an AHRQ-funded study evaluating differences in post-acute care use between Medicare Advantage and fee-for-service beneficiaries, an NIA-funded study evaluating value-based purchasing in skilled nursing facilities, as well as a VA-funded project intended to help the VA build a high-value post-acute care network of skilled nursing facilities.

Dr. Burke was selected as a 2017-2018 Health and Aging Policy fellow working with the Centers for Medicare and Medicaid Services on programs for dual-eligible populations. He is a graduate of the Stanford University School of Medicine and completed residency training in internal medicine at Brigham and Women’s Hospital in Boston. From 2011-2018, he served as an Assistant Professor at the University of Colorado and as a hospitalist at the Denver VA Medical Center, completing a Master of Science degree in Clinical Sciences at the University of Colorado in 2015.

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