Evaluation of Appropriateness of the Reimbursement Criteria of Korean Health Insurance Review and Assessment Service for Total Knee Arthroplasty.
Appropriateness review
Health insurance reimbursement
Total knee arthroplasty
Journal
Clinics in orthopedic surgery
ISSN: 2005-4408
Titre abrégé: Clin Orthop Surg
Pays: Korea (South)
ID NLM: 101505087
Informations de publication
Date de publication:
Apr 2023
Apr 2023
Historique:
received:
19
11
2021
revised:
02
03
2022
accepted:
14
03
2022
medline:
4
4
2023
entrez:
3
4
2023
pubmed:
4
4
2023
Statut:
ppublish
Résumé
We evaluated and compared South Korea's total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases. Two TKA appropriateness criteria and HIRA's reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee joint-specific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group. Data on 448 cases that underwent TKA were examined. According to the HIRA's reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA's reimbursement criteria. In terms of insurance coverage, HIRA's reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.
Sections du résumé
Background
UNASSIGNED
We evaluated and compared South Korea's total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases.
Methods
UNASSIGNED
Two TKA appropriateness criteria and HIRA's reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee joint-specific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group.
Results
UNASSIGNED
Data on 448 cases that underwent TKA were examined. According to the HIRA's reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA's reimbursement criteria.
Conclusions
UNASSIGNED
In terms of insurance coverage, HIRA's reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.
Identifiants
pubmed: 37008978
doi: 10.4055/cios21214
pmc: PMC10060769
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
241-248Informations de copyright
Copyright © 2023 by The Korean Orthopaedic Association.
Déclaration de conflit d'intérêts
CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.
Références
J Bone Joint Surg Am. 2020 Sep 2;102(17):1495-1500
pubmed: 32898378
Qual Health Care. 1996 Mar;5(1):20-30
pubmed: 10157268
J Clin Epidemiol. 2008 Sep;61(9):907-18
pubmed: 18687289
Arthritis Care Res (Hoboken). 2015 Mar;67(3):349-57
pubmed: 25132662
Knee Surg Relat Res. 2020 Nov 17;32(1):61
pubmed: 33203479
Arthritis Rheum. 2013 May;65(5):1243-52
pubmed: 23459843
Knee Surg Relat Res. 2015 Mar;27(1):10-6
pubmed: 25750889
Ann Rheum Dis. 1957 Dec;16(4):494-502
pubmed: 13498604
Clin Orthop Relat Res. 2007 Nov;464:190-5
pubmed: 18062051
N Engl J Med. 2000 Apr 6;342(14):1016-22
pubmed: 10749964
Knee Surg Relat Res. 2020 Nov 16;32(1):60
pubmed: 33198817
Int J Technol Assess Health Care. 2003 Winter;19(1):57-70
pubmed: 12701939
Arthritis Rheumatol. 2014 Aug;66(8):2134-43
pubmed: 24974958
J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):100-2
pubmed: 23118394
J Eval Clin Pract. 2011 Apr;17(2):251-60
pubmed: 20860582
PLoS One. 2016 Jul 21;11(7):e0159204
pubmed: 27441381
Clin Orthop Surg. 2020 Dec;12(4):456-463
pubmed: 33274022
J Bone Joint Surg Am. 2004 Oct;86(10):2179-86
pubmed: 15466726
Clin Orthop Surg. 2021 Jun;13(2):175-184
pubmed: 34094008
Health Qual Life Outcomes. 2003 Nov 03;1:64
pubmed: 14613558
J Bone Joint Surg Am. 2012 Oct 17;94(20):1839-44
pubmed: 23079875
Arthritis Rheum. 2012 Feb;64(2):339-41
pubmed: 22252374