Physical therapy mandates by Medicare administrative contractors: effective or wasteful?

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Preoperative Interventions and Charges in the 2-Year Period Before Unicompartmental Knee Arthroplasty: What Happens Before Surgery

BACKGROUND

This study investigated preoperative interventions and their costs in the 2-year period before a patient undergoing a unicompartmental knee arthroplasty (UKA).

METHODS

A retrospective cohort analysis of patients undergoing UKA between 2009 and 2011 was conducted using the PearlDiver Patient Record Database to track inpatient and outpatient billing records.

RESULTS

One thousand eight hundred forty-one patients from Medicare and 4704 patients from United Healthcare underwent UKA between 2009 and 2011. In the 2 years before UKA, the per patient average charge was $3919.96 for Medicare patients and $5219.14 for United Healthcare patients, with 21.7% of Medicare-associated charges and 28.2% of United Healthcare-associated charges occurring within 3 months of surgery. In the 2-year period before surgery, 65.5% of Medicare patients and 53.6% of United Healthcare patients received an intra-articular injection, with 29.1% (Medicare) and 46.0% (United Healthcare) of these injections occurring within 3 months of surgery. In addition, 15.1% of Medicare patients and 20.7% of United Healthcare patients underwent an arthroscopy, with between 32.4% and 43.8% of these occurring in the final 6 months before UKA.

CONCLUSION

Preoperative interventions (ie, imaging, procedures, physical therapy, and injections) occur at a high frequency in close proximity to UKA resulting in substantial costs. The development of algorithms to guide management of these patients is critical in reducing costs before UKA.

The Cost-Utility of Total Hip Arthroplasty: Earlier Intervention, Improved Economics

We estimated the cost of Quality-Adjusted-Life-Years gained according to preoperative disease severity. We studied 159 primary unilateral THA, mean follow-up: 4 years. A median split of preoperative WOMAC scores was done to set apart a low (better) and a high (worse) score group. The groups with worse preoperative WOMAC were consistently associated with a less cost-effective intervention. The highest mean cost-effectiveness was achieved by patients with better WOMAC-total ($8256.32/QALY-gained). As patients aged, the cost-effectiveness of THA decreased. Patients 75 years of age or older and with worse scores had the least cost-effective interventions ($25,937.33/QALY-gained). THA remains a very cost-effective intervention even when performed in older "sicker" patients. Waiting for the patient to deteriorate will make the intervention more "expensive".

Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement

BACKGROUND

Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty.

METHODS

Historical claims data were analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency, or inpatient rehabilitation facility, during the ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs.

RESULTS

The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172).

CONCLUSIONS

The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. This association was sustained after adjusting for comorbidities, demographic characteristics, and procedural variables.

CLINICAL RELEVANCE

Health-care providers can use this methodology to achieve an integrative, cost-effective, patient care pathway using preoperative physical therapy.