Formal Physical Therapy May Not Be Necessary After Unicompartmental Knee Arthroplasty: A Randomized Clinical Trial

The Outpatient Experience in Unicompartmental Knee Arthroplasty - How to Perform Safely in the Ambulatory Surgery Center

The number of outpatient unicompartmental knee arthroplasty (UKA) procedures has increased substantially over the last decade. The ambulatory surgery center (ASC) and hospital outpatient department provide a safe, cost-effective alternative with a significant cost savings to the healthcare system. Advancements in technology and perioperative management strategies have expanded the number of eligible patients to optimize outcomes with a focus on safety. Therefore, this review will describe the safety, efficacy, economics, and perioperative protocols for performing UKA in an outpatient setting. Patient selection, risk factors, patient education and expectations, anesthesia, pain management strategies, and outcomes will be discussed.

Problems and Opportunities of a Smartphone-Based Care Management Platform: Application of the Wald Principles to a Survey-Based Analysis of Patients' Perception in a Pilot Center

(1) Background: Mobile health (mHealth) solutions can become a means of improving functional recovery and reducing the peri-operative burden and costs associated with arthroplasty procedures. The aim of this study is to explore the objectives, functionalities, and outcomes of a platform designed to provide personalized surgical experiences to qualified patients, along with the associated problems and opportunities. (2) Methods: A survey-based analysis was conducted on patients who were prescribed the use of a specific care management platform and underwent primary robotic total knee arthroplasty (rTKA) between January 2021 and February 2023. (3) Results: Patients registered on the platform who have undergone primary robotic TKA (rTKA) were considered. The mean age of registered patients is 68.6 years. The male (M)/female (F) ratio is 45.1%/54.9%. The patients interviewed were at an average distance of 485 days from the intervention, with a standard deviation of 187.5. The survey highlighted appreciation for the app and its features, but also limitations in its use and in its perception by the patients. All these data were evaluated according to the Wald principles and strategies to improve patient recruitment, enhance adherence, and create a comprehensive patient journey for optimized surgical experiences. (4) Conclusions: This patient care platform may have the potential to impact surgical experiences by increasing patient engagement, facilitating remote monitoring, and providing personalized care. There is a need to emphasize the importance of integrating the recruiting process, improving adherence strategies, and creating a comprehensive patient journey within the platform.

Effectiveness and safety of outpatient rehabilitation versus home-based rehabilitation after knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Rehabilitation post-knee arthroplasty is integral to regaining knee function and ensuring patients' overall well-being. The debate over the relative effectiveness and safety of outpatient versus home-based rehabilitation persists.

METHODS

A thorough literature review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across four databases. Two researchers independently identified eligible studies centering on knee arthroplasty patients undergoing either outpatient or home-based rehabilitation. Study quality was assessed using the Cochrane Collaboration's risk of bias tool, while continuous outcomes were subject to meta-analyses using Stata 17 software.

RESULTS

Our analysis identified no significant differences in primary outcomes, including Range of Motion, Western Ontario and McMaster Universities Arthritis Index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, and the Knee Society Score, between home-based and outpatient rehabilitation across different follow-up points. Adverse reactions, readmission rates, the need for manipulation under anesthesia, reoperation rate, and post-surgery complications were also similar between both groups. Home-based rehabilitation demonstrated cost-effectiveness, resulting in substantial annual savings. Furthermore, quality of life and patient satisfaction were found to be comparable in both rehabilitation methods.

CONCLUSIONS

Home-based rehabilitation post-knee arthroplasty appears as an effective, safe, and cost-efficient alternative to outpatient rehabilitation. Despite these findings, further multicenter, long-term randomized controlled trials are required to validate these findings and provide robust evidence to inform early rehabilitation choices post-knee arthroplasty.

Active physical therapy does not improve outcomes after reverse total shoulder arthroplasty: a multi-center, randomized clinical trial

OBJECTIVE

To compare range of motion (ROM) and patient-reported outcomes (PROs) between a structured home exercise program (HEP) and active, supervised physiotherapy (PT) after primary Reverse total shoulder arthroplasty (RTSA) by performing a multicenter randomized clinical trial.

METHODS

Patients undergoing primary RTSA at 2 centers were randomized to either a HEP group, in which they were given a handout and a rope pulley, or a PT group, in which they were given a standardized prescription. Surgical technique and implants were standardized. At baseline, 6 weeks, 3 months, and 1 year postoperatively, we obtained American Shoulder and Elbow Surgeons scores, Western Ontario Osteoarthritis Scores, visual analogue scale for pain scores, and measured ROM via videotape. On video, ROM was then measured by blinded observers. At all study visits, patients were asked how many days per week they were in PT and how many days a week they completed HEP to determine compliance and crossover. An a priori power analysis suggested 29 patients per group, 56 patients total to detect a difference of 30° in active forward elevation with a power of 0.8 at a 2-sided alpha of 0.05.

RESULTS

89 patients were randomized, 43 to PT, and 46 to HEP. We obtained 1-year PRO follow-up on 83 patients (93%) and ROM follow-up on 73 patients (82%). Nine patients (20%) crossed over from HEP to PT and 2 patients (4%) crossed over from PT to HEP. Complications occurred in 13% of HEP and 17% of PT patients (P = .629). Using mixed models that account for baseline values, there were no significant differences between groups in PROs or ROM at final follow-up.

CONCLUSION

In this 2-center, randomized clinical trial, there were no significant differences in patient outcomes or ROM between HEP and PT after RTSA. These findings suggest that it may not be necessary to recommend PT as a protocol for all patients after RTSA.

Early post-operative physiotherapy rehabilitation after primary unilateral unicompartmental knee replacement: a systematic review

BACKGROUND

Unicompartmental Knee Replacement (UKR) is an established treatment for end stage arthritis affecting one compartment of the knee. UKR lends itself to rapid recovery and early discharge. The content, type, timing and dose of early post-operative physiotherapy treatment has yet to be reviewed.

OBJECTIVE

To review the content of early physiotherapy in the first eight weeks following unilateral UKR.

DATA SOURCES

A literature search of Medline, CINAHL, AMED and PubMed and the Physiotherapy Evidence Database (PEDRo) plus citation searching.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and observational studies reporting a physiotherapy intervention for UKR involving a form of post-operative exercise/education/advice delivered within the first eight weeks of surgery and commencing as an in-patient. Two reviewers independently performed screening, data extraction and risk of bias assessment.

DATA SYNTHESIS

Narrative syntheses were undertaken due to the heterogeneity of the primary outcomes.

RESULTS

Eleven studies were included (n = 1293 participants), three RCTs and eight observational studies. The dose and content of post-operative physiotherapy was highly variable with a move in recent years to rapid recovery and same day discharge with more self-directed rehabilitation. No studies had a low risk of bias.

LIMITATIONS

Small sample sizes and high heterogeneity limit our findings CONCLUSIONS: This review highlights the range of post-operative physiotherapy provision following UKR with a recent move to minimal physiotherapy input. Further research is required to identify those patients who may need additional physiotherapy above that now routinely provided, along with the most effective timing, type, and dosage of the intervention.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021243238. CONTRIBUTION OF THE PAPER.

An orthopaedic intelligence application successfully integrates data from a smartphone-based care management platform and a robotic knee system using a commercial database

PURPOSE

To evaluate the feasibility of using a smartphone-based care management platform (sbCMP) and robotic-assisted total knee arthroplasty (raTKA) to collect data throughout the episode-of-care and assess if intra-operative measures of soft tissue laxity in raTKA were associated with post-operative outcomes.

METHODS

A secondary data analysis of 131 patients in a commercial database who underwent raTKA was performed. Pre-operative through six week post-operative step counts and KOOS JR scores were collected and cross-referenced with intra-operative laxity measures. A Kruskal-Wallis test or a Wilcoxon sign-rank was used to assess outcomes.

RESULTS

There were higher step counts at six weeks post-operatively in knees with increased laxity in both the lateral compartment in extension and medial compartment in flexion (p < 0.05). Knees balanced in flexion within < 0.5 mm had higher KOOS JR scores at six weeks post-operative (p = 0.034) compared to knees balanced within 0.5-1.5 mm.

CONCLUSION

A smartphone-based care management platform can be integrated with raTKA to passively collect data throughout the episode-of-care. Associations between intra-operative decisions regarding laxity and post-operative outcomes were identified. However, more robust analysis is needed to evaluate these associations and ensure clinical relevance to guide machine learning algorithms.

Follow-up after arthroplasty surgery : a changing landscape

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients' performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.Cite this article: Bone Joint J 2022;104-B(10):1104-1109.

Home-based rehabilitation programme compared with traditional physiotherapy for patients at risk of poor outcome after knee arthroplasty: the CORKA randomised controlled trial

OBJECTIVES

To evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy.

DESIGN

A prospective, single-blind, two-arm randomised controlled superiority trial.

SETTING

14 National Health Service physiotherapy departments in the UK.

PARTICIPANTS

621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

The primary outcome was the Late-Life Function and Disability Instrument (LLFDI) 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, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance.

RESULTS

621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4-7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2-6). The primary outcome, LLFDI 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% CI -0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions.

CONCLUSIONS

The CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group.

TRIAL REGISTRATION NUMBER

ISRCTN13517704.

Early outcomes of primary total hip arthroplasty with use of a smartphone-based care platform: a prospective randomized controlled trial

AIMS

The purpose of this study is to evaluate early outcomes with the use of a smartphone-based exercise and educational care management system after total hip arthroplasty (THA) and demonstrate decreased use of in-person physiotherapy (PT).

METHODS

A multicentre, prospective randomized controlled trial was conducted to evaluate a smartphone-based care platform for primary THA. Patients randomized to the control group (198) received the institution's standard of care. Those randomized to the treatment group (167) were provided with a smartwatch and smartphone application. PT use, THA complications, readmissions, emergency department/urgent care visits, and physician office visits were evaluated. Outcome scores include the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), health-related quality-of-life EuroQol five-dimension five-level score (EQ-5D-5L), single leg stance (SLS) test, and the Timed Up and Go (TUG) test.

RESULTS

The control group was significantly younger by a mean 3.0 years (SD 9.8 for control, 10.4 for treatment group; p = 0.007), but there were no significant differences between groups in BMI, sex, or preoperative diagnosis. Postoperative PT use was significantly lower in the treatment group (34%) than in the control group (55.4%; p = 0.001). There were no statistically significant differences in complications, readmissions, or outpatient visits. The 90-day outcomes showed no significant differences in mean hip flexion between controls (101° (SD 10.8)) and treatment (100° (SD 11.3); p = 0.507) groups. The HOOS, JR scores were not significantly different between control group (73 points (SD 13.8)) and treatment group (73.6 points (SD 13); p = 0.660). Mean 30-day SLS time was 22.9 seconds (SD 19.8) in the control group and 20.7 seconds (SD 19.5) in the treatment group (p = 0.342). Mean TUG time was 11.8 seconds (SD 5.1) for the control group and 11.9 (SD 5) seconds for the treatment group (p = 0.859).

CONCLUSION

The use of the smartphone care management system demonstrated similar early outcomes to those achieved using traditional care models, along with a significant decrease in PT use. Noninferiority was demonstrated with regard to complications, readmissions, and ED and urgent care visits. This technology allows patients to rehabilitate on a more flexible schedule and avoid unnecessary healthcare visits, as well as potentially reducing overall healthcare costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):91-97.

What is the effect of supervised rehabilitation regime vs. self-management instruction following unicompartmental knee arthroplasty? - a pilot study in two cohorts

PURPOSE

The optimal rehabilitation strategy after a unicompartmental knee arthroplasty (UKA) is unclear. This study aims to compare the effect of transitioning from a supervised to a self-management rehabilitation regime by pilot study of patient outcomes subsequent to UKA surgery.

METHODS

Fifty consecutive patients scheduled to undergo unilateral UKA surgery at our institution between 22nd February 2016 and 18thof January 2017 were prospectively identified via local medical database and included. Performed UKAs were grouped into two cohorts, Supervised Cohort and Self-management Cohort, temporally separated by introduction of new rehabilitation. Self-management Cohort(n = 25) received an extensive inpatient rehabilitation regime along with outpatient referral to rehabilitation center. The Self-management Cohort(n = 25) were only instructed in use of crutches and free ambulation at own accord. Follow-up (F/U) was 1 year from receiving UKA. A range of outcomes were recorded, and between-cohort differences compared: knee joint range of motion, pain and functional limitations, length of stay (LOS), readmission rate, pain during activity and rest, and knee circumference.

RESULTS

Complete data was obtained for n = 45 patients. The mean between-cohort difference in ROM (range of motion) from preoperatively to discharge was 15.4 degrees (CI:5.2,25.8, p = 0.004), favoring the supervised regime, with no difference detected in any outcome at 3- or 12 months F/U. Median LOS was 1 day in both cohorts.

CONCLUSION

Transition to a simple rehabilitation regime following UKA surgery was associated with decreased ROM at discharge, which was not present at 3-month F/U. We found no other between-cohort differences for any other outcomes at 3- and 12-month F/U including functional limitations, although the study was likely underpowered for these outcomes. We encourage large-scale replication of these findings using randomized designs.

LEVEL OF EVIDENCE

Therapeutic level II.

2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial

AIMS

The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model.

METHODS

A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution's standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA).

RESULTS

Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121^o; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014).

CONCLUSION

The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3-12.

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.

Prior Manipulation under Anesthesia is a Predictor of Contralateral Manipulation in Staged Bilateral Total Knee Arthroplasty

BACKGROUND

There are many risk factors for arthrofibrosis and manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). However, no study has elucidated whether a history of MUA increases the risk of contralateral MUA in patients undergoing staged bilateral TKA.

METHODS

A retrospective review of an institutional database of TKAs was performed. All patients aged ≥18 years who underwent primary staged bilateral TKAs were screened for inclusion. Staged bilateral TKAs were viewed as 2 distinct events based on the temporal order in which they occurred: TKA#1 (occurred first) and TKA#2 (occurred second). Following TKA#1, patients were split into 2 groups: those who underwent MUA (Group MANIP) and those who did not (Group NO MANIP). The subsequent risk of undergoing MUA following TKA#2 was then assessed and compared between the 2 groups. Chi-squared tests were used for comparison.

RESULTS

A total of 5,330 patients who underwent primary uncomplicated staged bilateral TKAs (10,660 knees) during the study period were identified. Overall, 2.1% of patients underwent MUA following TKA#1 and 1.9% of patients underwent MUA following TKA#2. In the MANIP group, 21.4% of patients underwent MUA following TKA#2, while only 1.5% underwent MUA in the NO MANIP group. This 14.3-fold increase in the risk of MUA in the MANIP group following TKA#2 was statistically significant (21.4% vs 1.5%, absolute risk reduction = 19.9%, relative risk reduction = 93.0%, P < .0001).

CONCLUSION

Patients who undergo MUA during the first TKA of a staged bilateral TKA are 14.3 times more likely to undergo a subsequent MUA than those who did not undergo MUA following their first TKA.

Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program

BACKGROUND

The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative.

METHODS

The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed.

RESULTS

The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%.

CONCLUSIONS

These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent.

LEVEL OF EVIDENCE

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