Use of Rehabilitation and Other Health Care Services by Patients With Joint Replacement After Discharge From Skilled Nursing and Inpatient Rehabilitation Facilities

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Step descent strategy is altered bilaterally despite unilateral muscle strength impairment after total knee arthroplasty

PURPOSE

Muscle weakness and difficulty descending stairs are common after unilateral total knee arthroplasty (TKA), but the relationship between each is unclear. The purpose of this study was to compare lower extremity muscle strength, lower extremity support moments during step descent, and assess relationships between each.

METHODS

The study included 40 subjects (20 post-TKA, 20 control). Knee extensor, hip abductor, and hip external rotator strength were measured and biomechanical analyses of step descent performed. Patients with TKA were assessed 3 and 6 months post-surgery.

RESULTS

At 3 and 6 months post-TKA, operated limb hip external rotator and knee extensor strength were impaired compared to the non-operated limb (p < 0.01); however, no between-limb differences were observed during step descent. Compared to the control group, hip external rotator and knee extensor strength, total lower extremity support moment, and knee support moment during step descent were impaired post-TKA (p < 0.05). At 6 months post-TKA, knee extensor and hip external rotator strength correlated with total support moment during step descent (r_s = 0.40, 0.41, p < 0.02). Hip abductor and external rotator strength negatively correlated with knee support moment during step descent (r_s = - 0.35, - 0.39, p < 0.03).

CONCLUSIONS

Persistent operative limb knee extensor and hip external rotator muscle weakness are noted following unilateral TKA. Despite unilateral weakness, bilateral alterations in step descent strategy occur following TKA. Patients with TKA utilize hip musculature to reduce knee muscle demand during step descent, possibly contributing to limitations in long-term step descent performance.

Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

BACKGROUND

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.

METHODS

A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.

RESULTS

Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.

CONCLUSION

The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty

BACKGROUND

Home-health-care utilization after total knee arthroplasty (TKA) is increasing. Recent publications have suggested that supervised rehabilitation is not needed to optimize functional recovery after TKA; however, few studies have evaluated patients in home-health-care settings. The objectives of this study were to (1) determine whether physical therapy (PT) utilization is associated with functional improvements for patients in home-health-care settings after TKA and (2) determine which factors are related to utilization of PT.

METHODS

This study was an analysis of Medicare home-health-care claims data for patients treated with a TKA in 2012 who received home-health-care services for postoperative rehabilitation. Multivariable linear regression models were used to evaluate relationships between PT utilization and recovery in activities of daily living (ADLs). Negative binomial regression models were used to determine factors associated with PT utilization.

RESULTS

Records from 5,967 Medicare beneficiaries were evaluated. Low home-health-care PT utilization (≤5 visits) was associated with less improvement in ADLs compared with 6 to 9 visits, 10 to 13 visits, or ≥14 visits. Compared with low home-health-care utilization, utilization of 6 to 9 visits was associated with a 25% greater improvement in ADLs over the home-health-care episode (p < 0.0001); 10 to 13 visits, with a 40% greater improvement (p < 0.0001); and ≥14 visits, with a 50% greater improvement (p < 0.0001). The findings remained robust following adjustments for medical complexity, baseline functional status, and home-health-care episode duration. After adjustment, lower PT utilization was observed for patients receiving home health care from rural agencies (10.7% fewer visits, 95% confidence interval [CI] = 7.9% to 13.7%), those with depressive symptoms (4.8% fewer visits, 95% CI = 1.3% to 8.3%), and those with any baseline dyspnea (5.3% fewer visits, 95% CI = 3.1% to 7.5%).

CONCLUSIONS

Low home-health-care PT utilization was significantly associated with worse recovery in ADLs after TKA for Medicare beneficiaries, after controlling for medical complexity, baseline function, and home-health-care episode duration. Patients who are served by rural agencies or who have higher medical complexity receive fewer PT visits after TKA and may need closer monitoring to ensure optimal functional recovery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Skilled Nursing Facility Star Rating, Patient Outcomes, and Readmission Risk After Total Joint Arthroplasty

BACKGROUND

This study examined the correlation between publicly reported indicators of skilled nursing facility (SNF) quality and clinical outcomes after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

This retrospective analysis used Medicare claims from the Centers for Medicare and Medicaid Services 100% Standard Analytic File (2014-2015) that were linked to SNF quality star ratings from the Centers for Medicare and Medicaid Services Nursing Home Compare database. Overall SNF rating and subcomponents of the rating were evaluated for correlation to 30-day and 90-day risk of readmission. Ratings were based upon a 5-star rating system (1 representing the lowest quality). Cox proportional hazards regressions controlled for age, race, census division, hospital location, comorbidities, and SNF length of stay.

RESULTS

A total of 9418 SNFs, 58,064 TKA patients, and 26,837 THA patients met criteria. As SNF overall star rating increased from 1 to 5, incidence of all-cause 30-day readmission decreased from 6.4% to 5.0% for TKA (relative reduction [RR] 22%; P < .001) and from 9.1% to 6.2% for THA (RR 32%; P < .001). As nurse staffing rating increased, incidence of all-cause readmission decreased from 6.8% to 4.7% for the TKA cohort (30.9% RR; P < .001), and from 7.7% to 6.0% for the THA cohort (22.1% RR; P = .003). Regression analysis demonstrated that a higher star rating was associated with decreased risk of readmission (both cohorts P < .05).

CONCLUSIONS

For patients undergoing TKA or THA, the overall SNF star rating, nurse staffing ratios, and physical therapy intensity were significantly correlated with risk of readmission within 30 days of SNF admission.

Implementation of the comprehensive care for joint replacement model: A post-acute physical therapy case report

Background: The Centers for Medicare and Medicaid services has specifically targeted total joint replacements with a retrospective bundled payment program called the Comprehensive Care for Joint Replacement (CJR) model to improve collaboration between providers and decrease costs associated with the surgery and subsequent rehabilitation. The purpose of this report is to describe the physical therapy post-acute episode of care of a patient receiving services under the CJR model and illustrate the impact of facility policy changes on physical therapy service delivery, length of stay, cost of care, and patient outcomes in a post-acute environment. Case Description: The patient was a 78-year-old woman who underwent an elective total knee arthroplasty (TKA). She had moderate mobility impairments (total activities of daily living [ADL] score of 6) and was a high fall risk as scored by the Physical Mobility Scale and Tinetti Mobility Test, respectively. Physical therapy interventions focused on exercises to decrease activity limitations and participation restrictions. Outcomes: The patient demonstrated significant improvements in physical function after 22 total physical therapy visits spanning her Skilled Nursing Facility and subsequent outpatient treatment resulting in an intrafacility cost reduction of 52%. Compared with the average number of visits and costs for post-acute care following a TKA, this patient's care, under the CJR model, involved less cost and required fewer visits. Conclusions: This case report supports some of the proposed benefits of the CJR model for Medicare beneficiaries undergoing TKA.

The therapeutic validity and effectiveness of physiotherapeutic exercise following total hip arthroplasty for osteoarthritis: A systematic review

Objective

To assess the therapeutic validity and effectiveness of physiotherapeutic exercise interventions following total hip arthroplasty (THA) for osteoarthritis.

Data sources

The databases Embase, MEDLINE, Cochrane Library, CINAHL and AMED were searched from inception up to February 2017.

Eligibility criteria

Articles reporting results of randomized controlled trials in which physiotherapeutic exercise was compared with usual care or with a different type of physiotherapeutic exercise were included, with the applied interventions starting within six months after THA. Only articles written in English, German or Dutch were included.

Study appraisal

Therapeutic validity (using the CONTENT scale) and risk of bias (using both the PEDro scale and the Cochrane Collaboration’s tool) were assessed by two researchers independently. Characteristics of the physiotherapeutic exercise interventions and results about joint and muscle function, functional performance and self-reported outcomes were extracted.

Results

Of the 1124 unique records retrieved, twenty articles were included. Only one article was considered to be of high therapeutic validity. Description and adequacy of patient selection were the least reported items. The majority of the articles was considered as having potentially high risk of bias, according to both assessment tools. The level of therapeutic validity did not correspond with the risk of bias scores. Because of the wide variety in characteristics of the physiotherapeutic exercise and control interventions, follow-up length and outcome measures, limited evidence was found on the effectiveness of physiotherapeutic exercise following THA.

Conclusion

The insufficient therapeutic validity and potentially high risk of bias in studies involving physiotherapeutic exercise interventions limit the ability to assess the effectiveness of these interventions following THA. Researchers are advised to take both quality scores into account when developing and reporting studies involving physiotherapeutic exercise. Uniformity in intervention characteristics and outcome measures is necessary to enhance the comparability of clinical outcomes between trials.

Comparison of postarthroplasty functional outcomes in skilled nursing facilities among Medicare and Managed Care beneficiaries

Background

After home health care, the skilled nursing facility (SNF) is the most commonly used postacute care modality, among Medicare beneficiaries, after total joint arthroplasty. Prior studies demonstrated that a loss in postsurgical ambulatory gains is incurred in the interval between hospital discharge and arrival at the SNF. The aim of this present study is to determine the consequences of that loss in function, as well as compare SNF-related outcomes in patients with Medicare vs Managed Care (MC) insurance.

Methods

We conducted a retrospective analysis of 80 patients (54 Medicare and 26 MC) who attended an SNF after hospitalization for total joint arthroplasty. Outcomes from physical therapy records were abstracted from each patient's SNF file.

Results

There was an approximately 40% drop-off in gait achievements between hospital discharge and SNF admission. This decline in ambulation was significantly greater in Medicare patients (Medicare: 94.6 ± 123.2 ft, MC: 40.0 ± 48.9 ft, P = .034). Larger reductions in gait achievements between hospital discharge and SNF admission were significantly correlated with longer SNF lengths of stay and poorer gait achievements by SNF discharge. Patients with MC insurance made significant improvements in gait training at the SNF beyond that which was acquired at the hospital, whereas Medicare patients did not (P_Medicare = .28, P_MC = .003).

Conclusions

Large losses in motor function between hospital discharge and SNF admission were associated with poor functional outcomes and longer stays at the SNF. These effects were more pronounced in Medicare patients than those with MC insurance.

Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty

BACKGROUND

In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty.

METHODS

Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01.

RESULTS

Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges.

CONCLUSIONS

Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty

BACKGROUND

The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.

METHODS

We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.

RESULTS

LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.

CONCLUSION

Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012

PURPOSE

To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012.

DESIGN

Longitudinal retrospective design

METHODS

Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data.

FINDINGS

A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased.

CONCLUSION

We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings.

CLINICAL RELEVANCE

Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

A Scoping Review of Clinical Practice Improvement Methodology Use in Rehabilitation

Context

The Clinical Practice Improvement (CPI) approach is a methodological and quality improvement approach that has emerged and is gaining in popularity. However, there is no systematic description of its use or the determinants of its practice in rehabilitation settings.

Method

We performed a scoping review of the use of CPI methodology in rehabilitation settings.

Results

A total of 103 articles were reviewed. We found evidence of 13 initiatives involving CPI with six different populations. A total of 335 citations of determinants were found, with 68.7% related to CPI itself. Little information was found about what type of external and internal environment, individual characteristics and implementation process might facilitate or hinder the use of CPI.

Conclusion

Given the growing popularity of this methodological approach, CPI initiatives would gain from increasing knowledge of the determinants of its success and incorporating them in future implementation.

A randomized trial to compare exercise treatment methods for patients after total knee replacement: protocol paper

Background

Although the outcome of total knee replacement (TKR) is favorable, surgery alone fails to resolve the functional limitations and physical inactivity that existed prior to surgery. Exercise is likely the only intervention capable of improving these persistent limitations, but exercises have to be performed with intensity sufficient to promote significant changes, at levels that cannot be tolerated until later stages post TKR. The current evidence is limited regarding the effectiveness of exercise at a later stage post TKR. To that end, this study aims to compare the outcomes of physical function and physical activity between 3 treatment groups: clinic-based individual outpatient rehabilitative exercise during 12 weeks, community-based group exercise classes during 12 weeks, and usual medical care (wait-listed control group). The secondary aim is to identify baseline predictors of functional recovery for the exercise groups.

Methods/Design

This protocol paper describes a comparative effectiveness study, designed as a 3-group single-blind randomized clinical trial. Two hundred and forty older adults who underwent TKR at least 2 months prior will be randomized into one of the three treatment approaches. Data will be collected at baseline, 3 months, and 6 months. The wait-listed control group will be randomized to one of the 2 exercise groups after 6 months of study participation, and will complete a 9-month follow-up. Primary outcome is physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale (WOMAC-PF). Physical function is also measured by performance-based tests. Secondary outcomes include performance-based tests and physical activity assessed by a patient-reported survey and accelerometry-based physical activity monitors. Exploratory outcomes include adherence, co-interventions, attrition, and adverse events including number of falls. Linear mixed models will be fitted to compare the changes in outcome across groups. Logistic regression will identify patient characteristics that predict functional recovery in the exercise groups. Instrumental variable methods will be used to estimate the efficacy of the interventions in the presence of non-compliance.

Discussion

Results will inform recommendations on exercise programs to improve physical function and activity for patients at the later stage post TKR and help tailor interventions according with patients’ characteristics.

Trial registration

ClinicalTrials.gov Identifier NCT02237911.

Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty

Research examining care process variables and their relationship to clinical outcomes after total knee arthroplasty has focused primarily on inpatient variables. Care process factors related to outpatient rehabilitation have not been adequately examined. We conducted a retrospective review of 321 patients evaluating outpatient care process variables including use of continuous passive motion, home health physical therapy, number of days from inpatient discharge to beginning outpatient physical therapy, and aspects of outpatient physical therapy (number of visits, length of stay) as possible predictors of pain and disability outcomes of outpatient physical therapy. Only the number of days between inpatient discharge and outpatient physical therapy predicted better outcomes, suggesting that this may be a target for improving outcomes after total knee arthroplasty for patients discharged directly home.

Variations in Delivery and Exercise Content of Physical Therapy Rehabilitation Following Total Knee Replacement Surgery: A Cross-Sectional Observation Study

Objective

Prevalence of total knee replacement (TKR) is large and growing but functional outcomes are variable. Physical therapy (PT) is integral to functional recovery following TKR but little is known about the quantity or content of PT delivered. Purposes of this study were to describe the amount and exercise content of PT provided in the terminal episode of PT care following TKR and to examine factors associated with utilization and content.

Methods

Subjects included participants in a clinical trial of behavioral interventions for patients undergoing primary unilateral TKR who had completed the 6-month study evaluation. PT records were requested from 142 consecutive participants who had completed their post-TKR rehabilitation, 102 in/out patient care, and 40 in homecare. Information on utilization and exercises was extracted from a retrospective review of the PT records.

Results

We received 90 (88%) outpatient and 27 (68%) homecare PT records. Records showed variability in timing, amount and content of PT. Patients receiving outpatient PT had more visits and remained in PT longer (p<0.001). Exercises known in the TKR literature were utilized more frequently in the outpatient setting (p=0.001) than in home care. Records from both settings had limited documentation of strengthening progression.

Conclusions

The study reveals considerable variability in timing, utilization and exercise content of PT following TKR and suggests sub-optimal exercise for strengthening. While methods we employed document variability, improved systematic PT documentation and in-depth research are needed to identify optimal timing, utilization and content of PT following TKR.

The Uniform Data System for Medical Rehabilitation: report of follow-up information on patients discharged from inpatient rehabilitation programs in 2002-2010

OBJECTIVE

The aim of this study was to present yearly aggregated summaries of rehabilitation outcomes at admission, discharge, and follow-up from a national sample of patients receiving inpatient medical rehabilitation for stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility.

DESIGN

This is an analysis of secondary data from more than 300 inpatient rehabilitation facilities in the United States that contributed inpatient and follow-up data to the Uniform Data System for Medical Rehabilitation during the period January 2002 through December 2010. Aggregate variables reported include demographic information, social situation, and functional status (Functional Independence Measure instrument ratings at admission, discharge, and follow-up). Follow-up data were obtained 80-180 days after discharge through telephone interviews by trained clinical staff.

RESULTS

The final sample included 287,104 patients with follow-up information. The median time to follow-up was 95 days. Overall, more than 90% of the patients within each impairment group were living in the community at follow-up. Follow-up Functional Independence Measure total ratings were stable to slightly increased over time. Change scores (discharge to follow-up) increased in all six groups. The mean Functional Independence Measure gains from discharge to follow-up, as a percentage of mean gains from admission to discharge, varied by impairment category: 46% for spinal cord injury to 71% for lower extremity fracture. Locomotion yielded the lowest ratings at all three assessments within each of the six impairment groups.

CONCLUSIONS

The follow-up data from the national sample of patients discharged from inpatient rehabilitation indicate that gains in mean functional independence scores from both admission to discharge and discharge to follow-up gradually increased from 2002 to 2010. At follow-up, more than nine of ten patients in all six groups are living in the community.

The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

Site-neutral payment for postacute care: framing the issue

This commentary evaluates the merits of proposals in the United States to create a site-neutral payment system for postacute care for patients with select rehabilitation-related conditions. Under a site-neutral payment system, Medicare would pay providers based on patients' clinical needs, not on the peculiarities of individual postacute settings such as skilled nursing facilities and inpatient rehabilitation facilities. This commentary frames the policy choices by taking into account the research evidence on setting costs and outcomes, the policy tools and preconditions needed for an effective site-neutral payment system, and the overall direction of American health and postacute policy.

Trajectories in functional recovery for patients receiving inpatient rehabilitation for unilateral hip or knee replacement

The purpose of this study was to explore trajectories of recovery in patients with lower extremity joint replacements receiving post-acute rehabilitation. A retrospective cohort design was used to examine data from the Uniform Data System for Medical Rehabilitation (UDSMR®) for 7434 patients with total knee replacement (TKR) and 4765 patients with total hip replacement (THR) who received rehabilitation from 2008 to 2010. Functional Independence Measure (FIM)™ instrument ratings were obtained at admission, discharge, and 80-180 days after discharge. Random coefficient regression analyses using linear mixed models were used to estimate mean ratings for items within the four motor subscales (self-care, sphincter control, transfers, and locomotion) and the cognitive domain of the FIM instrument. Mean improvements at discharge for motor items ranged from 1.16 (95% confidence interval [CI]: 1.14, 1.19) to 2.69 (95% CI: 2.66, 2.71) points for sphincter control and locomotion, respectively. At follow-up mean motor improvements ranged from 2.17 (95% CI: 2.15, 2.20) to 4.06 (95% CI: 4.03, 4.06) points for sphincter control and locomotion, respectively. FIM cognition yielded smaller improvements: discharge=0.47 (95% CI: 0.46, 0.48); follow-up=0.83 (95% CI: 0.81, 0.84). Persons who were younger, female, non-Hispanic white, unmarried, with fewer comorbid conditions, and who received a TKR demonstrated slightly higher functional motor ratings. Overall, patients with unilateral knee or hip replacement experienced substantial improvement in motor functioning both during and up to six months following inpatient rehabilitation.

Disparities in post-acute rehabilitation care for joint replacement

OBJECTIVE

To determine the extent to which demographic and geographic disparities exist in the use of post-acute rehabilitation care (PARC) for joint replacement.

METHODS

We conducted a cross-sectional analysis of 2 years (2005 and 2006) of population-based hospital discharge data from 392 hospitals in 4 states (Arizona, Florida, New Jersey, and Wisconsin). A total of 164,875 individuals who were age ≥ 45 years, admitted to the hospital for a hip or knee joint replacement, and who survived their inpatient stay were identified. Three dichotomous dependent variables were examined: 1) discharge to home versus institution (i.e., skilled nursing facility [SNF] or inpatient rehabilitation facility [IRF]), 2) discharge to home with versus without home health (HH), and 3) discharge to an SNF versus an IRF. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Interactions among race, socioeconomic, and geographic variables were explored.

RESULTS

Considering PARC as a continuum from more to less intensive care in regard to hours of rehabilitation per day (e.g., IRF→SNF→HH→no HH), the uninsured received less intensive care in all 3 models. Individuals receiving Medicaid and those of lower socioeconomic status received less intensive care in the HH versus no HH and SNF versus IRF models. Individuals living in rural areas received less intensive care in the institution versus home and HH versus no HH models. The effect of race was modified by insurance and by state. In most instances, minorities received less intensive care. PARC use varied by hospital.

CONCLUSION

Efforts to further understand the reasons behind these disparities and their effect on outcomes are needed.

A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery

OBJECTIVE

To examine differences in outcomes of patients after lower-extremity joint replacement across 3 post-acute care (PAC) rehabilitation settings.

DESIGN

Prospective observational cohort study.

SETTING

Skilled nursing facilities (SNFs; n=5), inpatient rehabilitation facilities (IRFs; n=4), and home health agencies (HHAs; n=6) from 11 states.

PARTICIPANTS

Patients with total knee (n=146) or total hip replacement (n=84) not related to traumatic injury.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Self-care and mobility status at PAC discharge measured by using the Inpatient Rehabilitation Facility Patient Assessment Instrument.

RESULTS

Based on our study sample, HHA patients were significantly less dependent than SNF and IRF patients at admission and discharge in self-care and mobility. IRF and SNF patients had similar mobility levels at admission and discharge and similar self-care at admission, but SNF patients were more independent in self-care at discharge. After controlling for differences in patient severity and length of stay in multivariate analyses, HHA setting was not a significant predictor of self-care discharge status, suggesting that HHA patients were less medically complex than SNF and IRF patients. IRF patients were more dependent in discharge self-care even after controlling for severity. For the full discharge mobility regression model, urinary incontinence was the only significant covariate.

CONCLUSIONS

For the patients in our U.S.-based study, direct discharge to home with home care was the optimal strategy for patients after total joint replacement surgery who were healthy and had social support. For sicker patients, availability of 24-hour medical and nursing care may be needed, but intensive therapy services did not seem to provide additional improvement in functional recovery in these patients.

Patterns of rehabilitation after hip arthroplasty and the association with outcomes: an episode of care view

OBJECTIVES

To examine the patterns of rehabilitation after elective and nonelective hip arthroplasty and its association with outcomes over an episode of postacute care.

DESIGN

Data were obtained from a multisite prospective observational cohort study and its companion follow-up study. Patterns of care were measured by the combination of settings of care where hip arthroplasty patients received rehabilitation therapy. Main outcome measure was motor portion of the functional independence measure.

RESULTS

Approximately 90% of hip arthroplasty patients received rehabilitation care from more than one setting. Eight patterns of care were identified in the follow-up period. Patterns of subsequent care were driven more by initial setting than by etiology. Nonelective hip arthroplasty patients had lower motor functional independence measure scores and used more rehabilitation services than did elective hip arthroplasty patients. Patterns of care were modest factors (accounted for only 7% of variance) in predicting patient motor functional independence measure over an episode of postacute care.

CONCLUSIONS

Etiology of hip arthroplasty is associated with amounts of rehabilitation care used and outcomes. After the initial postacute rehabilitation setting, patients continued to receive considerable amounts of therapy in various settings. It is important to look beyond a single setting of care to an entire episode of care when examining clinical outcomes.

Effects of competition on the cost and quality of inpatient rehabilitation care under prospective payment

OBJECTIVE

To determine the effect of competition in postacute care (PAC) markets on resource intensity and outcomes of care in inpatient rehabilitation facilities (IRFs) after prospective payment was implemented.

DATA SOURCES

Medicare claims, Provider of Services file, Enrollment file, Area Resource file, Minimum Data Set.

STUDY DESIGN

We created an exogenous measure of competition based on patient travel distances and used instrumental variables models to estimate the effect of competition on inpatient rehabilitation costs, length of stay, and death or institutionalization.

DATA EXTRACTION METHODS

A file was constructed linking data for Medicare patients discharged from acute care between 2002 and 2003 and admitted to an IRF with a diagnosis of hip fracture or stroke.

PRINCIPAL FINDINGS

Competition had different effects on treatment intensity and outcomes for hip fracture and stroke patients. In the treatment of hip fracture, competition increased costs and length of stay, while increasing rates of death or institutionalization. In the treatment of stroke, competition decreased costs and length of stay and produced inferior outcomes.

CONCLUSIONS

The effects of competition in PAC markets may vary by condition. It is important to study the effects of competition by diagnostic condition and to study the effects across populations that vary in severity. Our finding that higher competition under prospective payment led to worse IRF outcomes raises concerns and calls for additional research.

Factors influencing inpatient rehabilitation length of stay following revision hip replacements: a retrospective study

BACKGROUND

The annual incidence of revision hip replacements has increased in both Canada and United States, particularly in younger adults. Patients following revision hip replacements often require longer hospital length of stay (LOS) but little is known about predictors of inpatient rehabilitation LOS in this group of patients. The purpose of this study was to evaluate the socio-demographic, pre-surgery, surgery and post-surgery related factors that might influence rehabilitation LOS of inpatients following revision hip replacements.

METHODS

This study included inpatients discharged from a musculoskeletal ward between 2002 and 2006 following rehabilitation revision hip replacement. Data sources included the National Reporting System, a standardized, provincial administrative database and augmented by chart abstraction. The collected elements included the outcome LOS and the following independent variables: age, sex, support at home, environmental barriers, language barrier, number of revision surgeries on the affected hip, comorbidity, previous orthopaedic surgeries in the lower extremities (L/ES), the hip component(s) revised, weight-bearing status, hemoglobin level, complications, days lapsed from surgery to rehabilitation admission and admission scores on the Functional Independence Measure (FIM). Simple linear regression was used to take forward any predictors significant at p < .10 level. Variables that satisfied the significance level were grouped in blocks and entered for regression analyses.

RESULTS

The 275 patients in this sample had a mean age of 69 years; 62% were female and the mean LOS was 29.6 days. Statistically significant predictors of longer LOS were low admission FIM score, female sex, revision of only the femoral component, 2 or more prior surgeries in the L/Es and 2 or more hip revisions (redo revision). The final model explained 28% of variance in inpatient LOS.

CONCLUSIONS

A score of 9-14 points lower in admission FIM, female sex, revision of only the femoral component, prior surgeries in the L/Es and redo hip revision are all independent factors associated with 4-6 days longer LOS. These results may facilitate an understanding of bed flow. Additionally, patients with one or a combination of the above characteristics may benefit from enhanced care plans that facilitate achievement of rehabilitation goals for discharge home.