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Stern BZ, Banashefski B, Rozanski G, Hayden BL, Chen DD, Poeran J, Moucha CS. Impact of the Comprehensive Care for Joint Replacement Bundled Payment Model on Postoperative Utilization of Home Health and Outpatient Physical Therapy Services. Arch Phys Med Rehabil 2024:S0003-9993(24)00954-7. [PMID: 38719164 DOI: 10.1016/j.apmr.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/07/2024] [Accepted: 04/30/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To study the effect of the Comprehensive Care for Joint Replacement (CJR) bundled payment program on postoperative home health and outpatient physical therapy (PT) for total hip or knee arthroplasty (THA/TKA). DESIGN Retrospective cohort with national Medicare data (5% claims) using a difference-in-differences analysis comparing January 2013-September 2015 (before) versus October 2016-September 2019 (after). SETTING Administrative claims from hospitals in 34 metropolitan statistical areas with mandatory CJR participation as of 2018 and 42 control metropolitan statistical areas. PARTICIPANTS Episodes in fee-for-service Medicare beneficiaries (5% claims) undergoing elective THA (n=6327) or TKA (n=10,764) with community discharge. INTERVENTIONS Implementation of CJR bundled payment program. MAIN OUTCOME MEASURES Home health and outpatient PT, including any use and number of visits. RESULTS Program implementation was associated with an increased percentage of THA episodes using home health PT (+8.0 percentage-point change; 95% CI, +3.5 to +12.6; P=.001) but a decreased per-episode number of home health PT visits for THA (-1.1; 95% CI, -1.6 to -0.6; P<.001) and TKA (-1.1; 95% CI, -1.4 to -0.7; P<.001). The program was also associated with an increased per-episode number of outpatient PT visits for TKA in the primary but not sensitivity analyses (+0.8; 95% CI, +0.1 to +1.4; P=.02). CONCLUSIONS Findings of increased home health PT may reflect an intentional shift in care from the inpatient postacute setting to the community to decrease costs. Alternatively, the limited effect of CJR, particularly on outpatient PT, could reflect challenges with care coordination in a retrospective bundle spanning multiple care settings.
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Affiliation(s)
- Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Bryana Banashefski
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriela Rozanski
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Brett L Hayden
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Darwin D Chen
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin S Moucha
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Zhao R, Cheng L, Zheng Q, Lv Y, Wang YM, Ni M, Ren P, Feng Z, Ji Q, Zhang G. A Smartphone Application-Based Remote Rehabilitation System for Post-Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Trial. J Arthroplasty 2024; 39:575-581.e8. [PMID: 37572720 DOI: 10.1016/j.arth.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Remote rehabilitation after total knee arthroplasty has gradually gained popularity in recent years. This study aimed to determine whether smartphone application-based remote rehabilitation could outperform home-based rehabilitation and outpatient guidance in terms of 12-week outcomes following primary unilateral total knee arthroplasty. METHODS Patients who underwent primary unilateral total knee arthroplasty were recruited and randomly divided into a telerehabilitation group and a control group. A total of 100 patients were examined, with 50 each assigned to the telerehabilitation and control groups. In the telerehabilitation group, a telerehabilitation application was installed on the smartphones of the participants to allow postdischarge guidance. The primary outcomes were knee range of motion (ROM) at 12 weeks postoperatively. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score, The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Five Times Sit-to-Stand Test (5xSST), Single-Leg Stance Test (SLST), satisfaction, rehabilitation costs, complication rate, and 90-day readmission rate. All outcomes were collected at 2, 6, and 12 weeks after surgery. RESULTS At 12 weeks postoperatively, the telerehabilitation patients significantly outperformed the controls in terms of knee ROM (124 ± 8.7 versus 119 ± 5.5 P = .01), SF-36 (physiological function) (61.5 ± 20.3 versus 45.5 ± 18.1 P = .000), SF-36 (role-physical) (49.3 ± 41.5 versus 27.7 ± 28.9 P = .012), SLST (13.0 ± 9.1 versus 9.1 ± 5.9 P = .026), and 5xSST (17.7 ± 4.3 versus 19.4 ± 3.5 P = .043). No significant differences were found between groups in the Western Ontario and McMaster Universities Osteoarthritis Index score, Knee Society Score, rehabilitation costs, 90-day readmission rate, or incidence of adverse events. CONCLUSION Our study showed that smartphone app-based remote rehabilitation worked better than home-based rehabilitation with outpatient guidance in terms of short-term results in ROM, SLST, and 5xSST.
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Affiliation(s)
- Runkai Zhao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Long Cheng
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Qingyuan Zheng
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Yicun Lv
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Yi-Ming Wang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Ming Ni
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Peng Ren
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zeyu Feng
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; Medical School of Chinese PLA, Beijing, China
| | - Quanbo Ji
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guoqiang Zhang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China; Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
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Roy I, Karmarkar AM, Lininger MR, Jain T, Martin BI, Kumar A. Association Between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission After Joint Replacement. Phys Ther 2023; 103:pzad123. [PMID: 37694820 PMCID: PMC10715680 DOI: 10.1093/ptj/pzad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/08/2023] [Accepted: 07/05/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. METHOD This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. RESULTS Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20-1.26), mobility (OR = 1.15; 95% CI = 1.13-1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15-1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13-1.20) and mobility (OR = 1.26; 95% CI = 1.22-1.30) for hip replacement. CONCLUSION Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. IMPACT Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.
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Affiliation(s)
- Indrakshi Roy
- Department of Health Sciences, Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
| | - Monica R Lininger
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona, USA
| | - Tarang Jain
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona, USA
| | - Brook I Martin
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
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Lee MJ, Tucker CA, Fisher SR, Tahashilder MI, Prichard KT, Kuo YF. Increase in the Initial Outpatient Rehabilitation Utilization for Patients With Total Knee Arthroplasty. Arch Phys Med Rehabil 2023; 104:1812-1819.e6. [PMID: 37119952 DOI: 10.1016/j.apmr.2023.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES The objective of this study was to examine the patient characteristics and features associated with the initial rehabilitation utilization with a particular emphasis on outpatient rehabilitation after total knee arthroplasty (TKA) among 2016-2018 Texas Medicare enrollees. DESIGN This is a retrospective cohort study. We used chi-square tests to examine the variability in patient demographic and clinical characteristics across the different post-acute rehabilitation settings after TKA. A Cochran-Armitage trend test was used to investigate the yearly trend of outpatient rehabilitation utilization after TKA. SETTING Post-acute rehabilitation settings after TKA. PARTICIPANTS The target population was Medicare beneficiaries aged ≥65 with an initial TKA in 2016-2018 and complete demographic and residential information (N=44,313). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We identified whether patients first used (1) outpatient rehabilitation, (2) home health, (3) self-care, (4) inpatient rehabilitation, (5) skilled nursing, or (6) other setting within the 3 months after TKA. RESULTS Our results demonstrated an increasing use of the initial outpatient rehabilitation and home health, while the use of skilled nursing and inpatient rehabilitation facilities decreased from 2016 to 2018. The increase in outpatient utilization was significant in 2018 compared with 2016 controlling for distance to the TKA facilities, comorbid conditions, sex, race/ethnicity groups (White, Black, Hispanic, and Others), lower income (Medicaid eligible), Medicare entitlement types, age groups, and rurality (OR 1.23, 95% CI 1.12-1.34). However, the overall utilization rate of the initial outpatient rehabilitation after TKA remained low, increasing from 7.36% in 2016 to 8.60% in 2018. CONCLUSION Despite the growing use of the initial outpatient rehabilitation after TKA, the overall rate of outpatient rehabilitation utilization remained low. Our findings raise an important question as to whether certain patient demographics and clinical groups might have limited access to outpatient rehabilitation after TKA.
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Affiliation(s)
- Mi Jung Lee
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX.
| | - Carole A Tucker
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX; Center for Recovery, Physical Activity & Nutrition, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Steve R Fisher
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Kevin T Prichard
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Yong-Fang Kuo
- Office of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, TX; Department of Biostatistics and Data Science, University of Texas Medical Branch at Galveston, Galveston, TX
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Pellegrini CA, Brown D, DeVivo KE, Lee J, Wilcox S. Promoting physical activity via physical therapist following knee replacement: A pilot randomized controlled trial. PM R 2023; 15:965-975. [PMID: 36106651 PMCID: PMC11210327 DOI: 10.1002/pmrj.12895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/13/2022] [Accepted: 08/19/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Outpatient physical therapy may be an opportune time to promote aerobic physical activity after knee replacement; however, it is unknown if it is feasible to integrate a physical activity intervention within standard physical therapy. OBJECTIVE To examine the feasibility and acceptability of a physical activity intervention delivered within outpatient physical therapy for adults after knee replacement. METHODS As part of a cluster randomized trial, adults with knee replacement starting outpatient physical therapy were recruited across four physical therapy sites. Sites were randomized and physical therapists delivered either an enhanced physical activity intervention or a control condition. The enhanced physical activity intervention consisted of standard postoperative physical therapy plus goal setting, problem-solving, and use of motivational interviewing techniques to promote 150 minutes/week of aerobic moderate intensity physical activity. The control group received standard postoperative physical therapy only. Feasibility and acceptability were determined based on recruitment and retention rates at 12 weeks after surgery. Outcomes including objectively measured physical activity, pain, and self-reported function were examined at the baseline postoperative visit and 12 weeks later. RESULTS Thirty-three percent of candidates screened were randomized (n = 45) and retention at 12 weeks after surgery was 91% (no difference by condition). Moderate-intensity activity increased, pain decreased, and self-reported function improved, but there were no statistically significant group differences between baseline and 12 weeks. CONCLUSION Implementing a physical activity intervention within outpatient physical therapy for adults after knee replacement is feasible; however, in this pilot study, changes were not observed in moderate intensity physical activity as compared to standard postoperative physical therapy. Future studies are needed to explore additional low-cost strategies and the optimal time to promote physical activity after knee replacement.
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Affiliation(s)
- Christine A Pellegrini
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Debbie Brown
- Prisma Health Orthopedics, Columbia, South Carolina, USA
| | - Katherine E DeVivo
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Jungwha Lee
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sara Wilcox
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e238050. [PMID: 37052919 PMCID: PMC10102876 DOI: 10.1001/jamanetworkopen.2023.8050] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Importance Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results. Objective To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery. Data Sources Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022. Study Selection Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included. Data Extraction and Synthesis Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Main Outcomes and Measures Pain, function, muscle strength, and health-related quality of life (HRQOL). Results Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence. Conclusions and Relevance In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.
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Affiliation(s)
- Anuj Punnoose
- Young Adult Hip Service, Physiotherapy Department, Addenbrooke's-Cambridge University Hospitals NHS (National Health Service) Trust, Cambridge, United Kingdom
- School of Allied Health, Anglia Ruskin University, Chelmsford and Cambridge, United Kingdom
| | | | - Ori Weiss
- Department of Orthopedics, Meir Medical Centre, Kfar-Saba, Israel
| | - Jufen Zhang
- School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Alison Rushton
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Vikas Khanduja
- Young Adult Hip Service, Department of Trauma and Orthopedics, Addenbrooke's-Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Albrecht JS, Kumar A, Falvey JR. Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries. JAMA Surg 2023; 158:350-358. [PMID: 36696119 PMCID: PMC9878433 DOI: 10.1001/jamasurg.2022.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023]
Abstract
Importance Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures Black or White race. Main Outcomes and Measures Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City
| | - Jason R. Falvey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
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Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy. Pediatr Phys Ther 2023; 35:57-64. [PMID: 36638029 DOI: 10.1097/pep.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To characterize and examine the variability in receipt of inpatient (IP) physical therapy after lower extremity (LE) orthopedic surgery for individuals with cerebral palsy (CP) across hospital-level (region, bed size) and individual characteristics (gender, age, race/ethnicity, insurance type, technology dependency, and surgical burden). METHODS We retrospectively analyzed physical therapy billing data of children with CP who had LE orthopedic surgery from October 1, 2015, through September 30, 2017, from the Pediatric Health Information Services (PHIS) database. RESULTS Seventy-five percent of individuals received IP physical therapy during the hospital stay. Individuals from the South and West and those who were technology dependent were less likely to receive IP therapy. Those at large hospitals, aged 11 to 14 years, and with a high surgical burden were more likely to receive therapy. CONCLUSIONS Results provide a starting point for future research on the discrepancies of acute physical therapy services in children diagnosed with CP. (Supplemental digital content video abstract available at: http://links.lww.com/PPT/A420).
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Aoyagi K, Neogi T, Peloquin C, Dubreuil M, Marinko L, Camarinos J, Felson DT, Kumar D. Association of Physical Therapy Interventions With Long-term Opioid Use After Total Knee Replacement. JAMA Netw Open 2021; 4:e2131271. [PMID: 34705013 PMCID: PMC8552057 DOI: 10.1001/jamanetworkopen.2021.31271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Many individuals who undergo total knee replacement (TKR) become long-term opioid users after TKR. Associations of physical therapy (PT) interventions before or after TKR with long-term use of opioids are not known. OBJECTIVES To evaluate associations of PT interventions before and after TKR with long-term opioid use after TKR. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the OptumLabs Data Warehouse on 67 322 individuals aged 40 years or older who underwent TKR from January 1, 2001, to December 31, 2016, stratified by history of opioid use. The analyses for the study included data from January 1, 1999, to December 31, 2018. EXPOSURES Any PT interventions within 90 days before or after TKR, post-TKR PT dose as number of sessions (ie, 1-5, 6-12, and ≥13 sessions), post-TKR PT timing as number of days to initiation of care (ie, <30 days, 31-60 days, or 61-90 days after TKR), and post-TKR PT type (ie, active vs passive). MAIN OUTCOMES AND MEASURES The association of pre- and post-TKR PT with risk of long-term opioid use occurring more than 90 days after TKR was assessed using logistic regression while adjusting for confounders, including age, sex, race and ethnicity (Asian, Black, Hispanic, or White), obesity, type of insurance, geographical location, and physical and mental health comorbidities. RESULTS A total of 38 408 opioid-naive individuals (21 336 women [55.6%]; mean [SD] age, 66.2 [9.2] years) and 28 914 opioid-experienced individuals (18 426 women [63.7%]; mean [SD] age, 64.4 [9.3] years) were included. Receipt of any PT before TKR was associated with lower odds of long-term opioid use in the opioid-naive (adjusted odds ratio [aOR], 0.75 [95% CI, 0.60-0.95]) and opioid-experienced (aOR, 0.75 [95% CI, 0.70-0.80]) cohorts. Receipt of any post-TKR PT was associated with lower odds of long-term use of opioids in the opioid-experienced cohort (aOR, 0.75 [95% CI, 0.70-0.79]). Compared with 1 to 5 sessions of PT after TKR, 6 to 12 sessions (aOR, 0.82 [95% CI, 0.75-0.90]) and 13 or more sessions (aOR, 0.71 [95% CI, 0.65-0.77) were associated with lower odds in the opioid-experienced cohort. Compared with initiation of PT within 30 days after TKR, initiation 31 to 60 days or 61 to 90 days after TKR were associated with greater odds in the opioid-naive (31-60 days: aOR, 1.45 [95% CI, 1.19-1.77]; 61-90 days: aOR, 2.15 [95% CI, 1.43-3.22]) and opioid-experienced (31-60 days: aOR, 1.10 [95% CI, 1.02-1.18]; 61-90 days: aOR, 1.32 [95% CI, 1.12-1.55]) cohorts. Compared with passive PT, active PT was not associated with long-term opioid use in the opioid-naive (aOR, 1.00 [95% CI, 0.81-1.24]) or opioid-experienced (aOR, 0.99 [95% CI, 0.92-1.07]) cohorts. CONCLUSIONS AND RELEVANCE This cohort study suggests that receipt of PT intervention before and after TKR, receipt of 6 or more sessions of PT care after TKR, and initiation of PT care within 30 days after TKR were associated with lower odds of long-term opioid use. These findings suggest that PT may help reduce the risk of long-term opioid use after TKR.
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Affiliation(s)
- Kosaku Aoyagi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Tuhina Neogi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Christine Peloquin
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Maureen Dubreuil
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- OptumLabs, Eden Prairie, Minnesota
| | - Lee Marinko
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
| | - James Camarinos
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
| | - David T. Felson
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Deepak Kumar
- Department of Physical Therapy and Athletic Training, Boston University, Boston, Massachusetts
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10
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Jacobs H, Seeber GH, Allers K, Hoffmann F. Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review. BMC Musculoskelet Disord 2021; 22:711. [PMID: 34407785 PMCID: PMC8375073 DOI: 10.1186/s12891-021-04600-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/03/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use. METHODS A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded. RESULTS After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA. CONCLUSION Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.
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Affiliation(s)
- Hannes Jacobs
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany.
| | - Gesine H Seeber
- University Hospital for Orthopaedics and Trauma Surgery Pius-Hospital, Medical Campus University of Oldenburg, Oldenburg, Germany
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
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Li Y, Ying M, Cai X, Thirukumaran CP. Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients. Med Care 2021; 59:101-110. [PMID: 33273296 PMCID: PMC7855778 DOI: 10.1097/mlr.0000000000001473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Orthopaedics, University of Rochester Medical Center
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Risk-Adjusted Cost Performance for 90-Day Total Hip Arthroplasty Episodes: Comparing US Hospitals Nationwide Before CJR. J Arthroplasty 2020; 35:3452-3463. [PMID: 32713725 DOI: 10.1016/j.arth.2020.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance. METHODS We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals. RESULTS Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P < .001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P < .001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level. CONCLUSION Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.
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13
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DeJong G, Hsieh CJ, Vita MT, Zeymo A, Boucher HR, Thakkar SC. Innovative Devices Did Not Provide Superior Total Knee Arthroplasty Outcomes in Post-Operative Rehabilitation: Results From a Four-Arm Randomized Clinical Trial. J Arthroplasty 2020; 35:2054-2065. [PMID: 32360105 DOI: 10.1016/j.arth.2020.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/18/2020] [Accepted: 03/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Orthopedic surgeons face an increasing array of post-TKA (total knee arthroplasty) rehabilitation interventions that entail innovative equipment and devices, but their relative effectiveness remains unknown. The study compared patient outcomes among primary unilateral TKA patients participating in one of 4 post-TKA rehabilitation interventions-a standard-of-care intervention and 3 more recently developed physical therapy interventions. METHODS The Knee Arthroplasty Rehabilitation Outcomes Study is a 4-arm randomized clinical trial conducted across 15 outpatient rehabilitation clinics. The trial evaluated 4 alternative interventions: (1) a stationary recumbent bike (control intervention); (2) a body weight-adjustable treadmill; (3) a recumbent bike and use of a patterned electrical neuromuscular stimulation device; and (4) a body weight-adjustable treadmill and a patterned electrical neuromuscular stimulation device. The study's outcome measures were patient walking speed and the Knee injury and Osteoarthritis Outcome Score (KOOS) measured at therapy discharge and at follow-up. RESULTS The study enrolled 363 TKA patients with 90-92 patients in each of the 4 study arms. Participants were similar across the 4 groups: They were about 63 years old, 61% female, 67% white, living at home, overweight (mean body mass index = 31.6), with mostly private insurance (61%) or Medicare (32%). Walking speed was similar at admission and discharge; KOOS scores were similar at admission, discharge, and follow-up across the 4 intervention groups. CONCLUSION The study found no statistical or clinically meaningful differences across the 4 study arms in walking speed or KOOS outcomes. Clinicians, payers, and policy makers will want to encourage providers and patients to use the least expensive intervention since each provide similar outcomes. TRIAL REGISTRATION NCT02426190; https://clinicaltrials.gov/ct2/show/NCT02426190?term=NCT02426190&cntry=US&rank=1.
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Affiliation(s)
- Gerben DeJong
- Research Division, MedStar National Rehabilitation Hospital, Washington, DC; Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC
| | - Chinghui Jean Hsieh
- Research Division, MedStar National Rehabilitation Hospital, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | | | - Alexander Zeymo
- MedStar Health Research Institute, Hyattsville, MD; Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, MD
| | - Henry R Boucher
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - Savyasachi C Thakkar
- MedStar Orthopaedic Institute at MedStar Georgetown University Hospital and MedStar Washington Hospital Center, Washington, DC
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14
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Schilling PL, He J, Chen S, Placzek H, Bini S. Risk-Adjusted Cost Performance for 90-Day Total Knee Arthroplasty Episodes: Data and Methods for Comparing U.S. Hospitals Nationwide. J Bone Joint Surg Am 2020; 102:971-982. [PMID: 32251141 DOI: 10.2106/jbjs.19.01017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We propose a model to characterize the variation in total knee arthroplasty (TKA) episode payments in the U.S. Medicare population to establish a baseline prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model. METHODS We identified TKA episodes in Medicare Part A (100% sample) from 2014 to 2016 (n = 717,690) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed effects (age, sex, race, comorbidities) and region-level (U.S. Census Regions) and hospital-level random effects. Random-effect estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3,217) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high and low-performing hospitals. RESULTS During this period, the mean Part A episode payments declined throughout the United States ($18,665 to $16,978; p < 0.001), primarily because of decreased post-acute care payments ($6,401 to $4,873; p < 0.0001). The 90-day readmission rates fell by nearly 20% (7.2% to 5.8%; p < 0.001). We found significant variation (p < 0.05) in risk-adjusted episode payments, post-acute care utilization, and readmission rates across regions and even hospitals. The share of hospitals in each geographic region that were low-performance outliers for episode payments ranged from 13% to 31% and those that were high-performance outliers ranged from 16% to 30%. CONCLUSIONS Medicare Part A payments for TKA episodes were decreasing prior to the CJR model because of decreases in both post-acute care utilization and hospital readmissions. A significant variation in risk-adjusted hospital cost performance remained. Our results provide a baseline against which to measure the impact of alternative payment models and a methodology by which to measure hospital-level performance, which can be compared with peer hospitals and national benchmarks.
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Affiliation(s)
- Peter L Schilling
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Jason He
- Clarify Health Solutions, San Francisco, California
| | - Sarah Chen
- Clarify Health Solutions, San Francisco, California
| | | | - Stefano Bini
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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15
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A Risk Assessment Tool Based on Orthopedic Psychosocial and Health Status Factors is Associated With Post-Acute Resources. J Arthroplasty 2020; 35:S144-S150. [PMID: 32197959 DOI: 10.1016/j.arth.2020.02.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We implemented a risk assessment tool (RAT) used by clinical navigators to quantify pre-operative mobility, home safety, social/cognitive barriers, and patient health history. We sought to determine if this RAT is associated with the need for post-acute care (PAC) services defined as inpatient rehabilitation and skilled nursing facility, home health, and none (home) following total joint arthroplasty. METHODS The study sample comprised of a total of 1438 primary TJA patients included in a bundled payment model. The RAT score, which ranges from 0 to 100, with higher scores representing healthier, more independent patents, was the key independent variable and post-acute service was the primary outcome variable. RESULTS The median RAT score was 83 (interquartile range 78-87.5) for no PAC discharges compared to 74 (interquartile range 67-81) for inpatient PAC discharges (P < .0001). After adjusting for the effects of length of hospital stay, surgery type, and patient gender, there was 6× increased odds of inpatient PAC for higher risk patients compared to low risk patients. A RAT score of 74 predicts discharges without PAC 87% of the time. CONCLUSION The RAT that is based on psychosocial, cognitive, environmental factors, and health status was significantly associated with the need for PAC services. The next step is to build and validate a real time, risk adjustment model to assist physicians and patients with planning post-discharge resources.
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16
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Li Y, Ying M, Cai X, Kim Y, Thirukumaran CP. Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016. JAMA Netw Open 2020; 3:e200368. [PMID: 32129866 PMCID: PMC7057132 DOI: 10.1001/jamanetworkopen.2020.0368] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown. OBJECTIVES To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits. DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted of PAC use and outcomes among Medicare fee-for-service patients undergoing hip or knee replacement surgery from January 1, 2013, to December 31, 2016, in approximately 3000 hospitals, using Medicare claims, assessment, hospital, and skilled nursing facility (SNF) files. Statistical analysis was performed from October 1, 2018, to December 17, 2019. MAIN OUTCOMES AND MEASURES Risk-adjusted differences among dual-eligible groups in institutional PAC use (SNF, inpatient rehabilitation, or long-term hospital care), readmission rate, and payment for readmissions; for patients discharged to a SNF, risk-adjusted differences in SNF quality measured by star ratings, proportion successfully discharged to the community, proportion transitioned to long-stay residence, and SNF length of stay and payments. RESULTS The sample included 1 302 256 patients (837 256 women [64.3%]; mean [SD] age, 75.4 [7.2] years) who underwent joint replacement. The proportion of patients discharged to institutional PAC and the 30-day and 90-day readmission rates decreased for all 3 groups during the period from 2013 to 2016. In 2013, institutional PAC use was 43.7% (95% CI, 43.5%-43.9%) for Medicare-only patients (n = 1 182 555), 70.1% (95% CI, 69.4%-70.8%; n = 60 461) for dual-eligible patients with full benefits, and 70.3% (95% CI, 69.6%-71.0%; n = 59 240) for dual-eligible patients with partial benefits; in 2016, the rates decreased to 32.5% (95% CI, 32.4%-32.7%) for Medicare-only patients, 62.3% (95% CI, 61.5%-63.0%) for dual-eligible patients with full benefits, and 61.5% (95% CI, 60.7%-62.3%) for dual-eligible patients with partial benefits. Among patients discharged to SNFs, outcomes remained flat over time. For example, the proportion of patients successfully discharged to the community remained at 80.5% (95% CI, 80.4%-80.7%) for Medicare-only patients, 59.8% (95% CI, 59.3%-60.3%) for dual-eligible patients with full benefits, and 50.0% (95% CI, 49.4%-50.5%) for dual-eligible patients with partial benefits. Multivariable analyses with adjustment for patient, hospital (or SNF), and geographical covariates suggested maintained or enlarged gaps in all outcomes. CONCLUSIONS AND RELEVANCE This study suggests that, during the period from 2013 to 2016, Medicare patients undergoing hip or knee replacement showed reduced institutional PAC use, reduced readmissions, and, among those discharged to SNFs, roughly unchanged outcomes. However, dual-eligible patients, especially those with partial Medicaid benefits, had persistently worse outcomes than Medicare-only patients.
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Affiliation(s)
- Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Meiling Ying
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - Yeunkyung Kim
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Caroline Pinto Thirukumaran
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
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Hung A, Li Y, Keefe FJ, Ang DC, Slover J, Perera RA, Dumenci L, Reed SD, Riddle DL. Ninety-day and one-year healthcare utilization and costs after knee arthroplasty. Osteoarthritis Cartilage 2019; 27:1462-1469. [PMID: 31176805 PMCID: PMC6750955 DOI: 10.1016/j.joca.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/06/2019] [Accepted: 05/29/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study examined ninety-day and one-year postoperative healthcare utilization and costs following total knee arthroplasty (TKA) from the health sector and patient perspectives. DESIGN This study relied on: 1) patient-reported medical resource utilization data from diaries in the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial; and 2) Medicare fee schedules. Medicare payments, patient cost-sharing, and patient time costs were estimated. Generalized linear mixed models were used to identify baseline predictors of costs. RESULTS In the first ninety days following TKA, patients had an average of 29.7 outpatient visits and 6% were hospitalized. Mean total costs during this period summed to $3,720, the majority attributed to outpatient visit costs (84%). Over the year following TKA, patients had an average of 48.9 outpatient visits, including 33.2 for physical therapy. About a quarter (24%) of patients were hospitalized. Medical costs were incurred at a decreasing rate, from $2,428 in the first six weeks to $648 in the last six weeks. Mean total medical costs across all patients over the year were $8,930, including $5,328 in outpatient costs. Total costs were positively associated with baseline Charlson comorbidity score (P < 0.01). Outpatient costs were positively associated with baseline Charlson comorbidity score (P = 0.03) and a bodily pain burden summary score (P < 0.01). Mean patient cost-sharing summed to $1,342 and time costs summed to $1,346. CONCLUSIONS Costs in the ninety days and year after TKA can be substantial for both healthcare payers and patients. These costs should be considered as payers continue to explore alternative payment models.
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Affiliation(s)
- A Hung
- Duke Clinical Research Institute, Durham, NC, USA
| | - Y Li
- Duke Clinical Research Institute, Durham, NC, USA
| | - F J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - D C Ang
- Department of Medicine, Section of Rheumatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Slover
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY, USA
| | - R A Perera
- Department of Biostatistics, VA Commonwealth University, Richmond VA, USA
| | - L Dumenci
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, PA, USA
| | - S D Reed
- Duke Clinical Research Institute, Durham, NC, USA.
| | - D L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA
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Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines. BMC Musculoskelet Disord 2019; 20:214. [PMID: 31092230 PMCID: PMC6521339 DOI: 10.1186/s12891-019-2570-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status. Methods Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately. Results After excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P < 0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P < 0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)]. Conclusions Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors. Electronic supplementary material The online version of this article (10.1186/s12891-019-2570-8) contains supplementary material, which is available to authorized users.
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