Variation in the Use of Therapy following Distal Radius Fractures in the United States

Postoperative hand therapy and the 2018 Medicare therapy cap repeal: Appraising cost and use changes

BACKGROUND

Therapy use is common following carpal tunnel release (CTR), trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture, open reduction internal fixation or percutaneous pinning (DRF). Policy that improves coverage influences the cost and use of health care services.

PURPOSE

This study aims to evaluate changes to the cost and use of postoperative hand therapy by race and procedure following the repeal of a longstanding annual Medicare outpatient therapy cap.

STUDY DESIGN

Retrospective cohort study.

METHODS

This is a longitudinal retrospective cohort study using a quasi-experimental interrupted time series design, including patients who underwent common hand surgeries from January 1, 2016-December 31, 2019.

RESULTS

This study included 203,672 patients with a mean age of 71.4 years. Neither White (1.00, 95% confidence interval [CI]: 0.999-1.007, p = 0.45) nor non-White (1.00, 95% CI: 1.00-1.01, p = 0.06) patients experienced monthly changes in therapy use before policy implementation. Therapy frequency increased following CTR (odds ratio [OR] 1.12, 95% CI: 1.11-1.14, p < 0.001), trigger finger release (OR 1.09, 95% CI: 1.07-1.10, p < 0.001), and DRF (OR 1.05, 95% CI: 1.03-1.06, p < 0.001) following implementation.

CONCLUSIONS

This study found that improved coverage was associated with increased postoperative therapy use among some subsets, including CTR and DRF, suggesting the need to optimize coverage by means such as prior authorization or bundled payments, rather than only increasing coverage benefits.

Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study

OBJECTIVE

The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed.

RESULTS

Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%).

CONCLUSION

Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes.

IMPACT

Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

Distal radius fractures: What are the effects of ulnar styloid fracture and face-toface rehabilitation on the functional outcome?

OBJECTIVE

This study aimed to investigate the effects of the accompanying ulnar styloid fracture and 2 different postoperative rehabilitation protocols on the final outcomes following surgical treatment of distal radius fractures.

METHODS

In this retrospective study, 47 patients (11 male, 35 female; mean age=52.6 years, age range=24-85) who underwent plate fixation for distal radius fractures were divided into 4 groups based on the presence of an ulnar styloid fracture and type of rehabilitation. To evaluate clinical outcomes, wrist range of motion (ROM), grip strength, lateral pinch strength, disabilities of the arm, shoulder, and hand (DASH) questionnaire scores and visual analog scale (VAS) scores were obtained at the final follow-up. The rehabilitation exercises of the patients in groups 1 and 2 were carried out in the physical therapy room by the hand therapist during the postoperative 2 months. Patients in groups 3 and 4 were supplied with videos of the exercises of each phase and instructed to carry out those exercises at home routinely.

RESULTS

Patients who received home rehabilitation programs demonstrated greater grip strength loss. Patients without accompanying ulnar styloid fractures had better DASH and VAS scores. Final wrist ROM and the duration for return to preinjury activity level did not differ among groups.

CONCLUSION

This study has suggested that accompanying ulnar styloid fractures may worsen the functional outcomes after plate fixation of distal radius fractures. Home-based programs may provide patients with adequate overall wrist function with certain drawbacks compared to rehabilitation under direct supervision.

Use of Hand Therapy After Distal Radius Fracture: A National Perspective

PURPOSE

To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy.

METHODS

Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest.

RESULTS

In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use.

CONCLUSIONS

This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy.

CLINICAL RELEVANCE

Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

Physical and Occupational Therapy Use and Cost After Common Hand Procedures

PURPOSE

The use of routine physical therapy (PT) and occupational therapy (OT) after certain hand procedures, such as carpal tunnel release, remains controversial. The objective of this study was to evaluate baseline use, the change in use, variation in prescribing patterns by region, and costs for PT/OT after common hand procedures.

METHODS

Outpatient administrative claims data from patients who underwent procedures for carpal tunnel syndrome, trigger finger, carpometacarpal arthritis, de Quervain tenosynovitis, wrist ganglion cyst, and distal radius fracture were abstracted from the Truven Health MarketScan database from 2007 to 2015. The incidence of therapy and total reimbursement of therapy per patient were collected for each procedure over a 90-day postoperative observational period. Trends in use of therapy over time were described with average compound annual growth rates (CAGRs), a way of quantifying average growth over a specified observation period. Variations in the incidence of PT/OT use across 4 census regions were assessed.

RESULTS

The incidence of 90-day utilization of PT and OT after hand procedures was 14.0% and increased for all procedures during the observation period with an average CAGR of 8.3%. Cost per therapy visit was relatively stable when adjusted for inflation, with an average CAGR of 0.63%. Patients in the northeast had a significantly higher incidence of PT/OT use than those in the south and west for all procedures except carpometacarpal arthritis.

CONCLUSIONS

Use of PT and OT has increased over time after common hand procedures. Geographical variation in the utilization rate of these services is substantial. Limiting unwarranted variation of care is a health policy strategy for increasing value of care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Outcomes Research II.

Thirty-day Emergency Department Utilization after Distal Radius Fracture Treatment: Identifying Predictors and Variation

Supplemental Digital Content is available in the text.

Unplanned hospital visits are costly and may indicate reduced care quality. In this analysis, we aim to investigate the emergency department (ED) utilization for patients 30 days after treatment for a distal radius fracture (DRF) with an emphasis on DRF-related diagnoses of complications and examine nationwide variation in returns to the ED after treatment.

The Relationship between Hand Therapy and Long-Term Outcomes after Distal Radius Fracture in Older Adults: Evidence from the Randomized Wrist and Radius Injury Surgical Trial

BACKGROUND

Older patients are frequently referred to hand therapy after distal radius fracture. Supervised therapy sessions place a transportation burden on patients and are costly on both the individual and systematic levels. Furthermore, there is little evidence that supervised therapy or home exercises improve long-term outcomes.

METHODS

Data were collected for the Wrist and Radius Injury Surgical Trial, a multicenter, international, pragmatic, randomized trial of distal radius fracture treatment in patients aged 60 years and older. Referral to therapy and therapy protocol were at the discretion of the treating surgeon and therapist. The authors examined outcomes between participants who underwent therapy and those who did not and assessed the duration of therapy. The authors also analyzed the effect of therapy on subgroups at risk for poor outcomes: older participants and those who had more comorbidities or lower baseline activity.

RESULTS

Eighty percent of participants underwent therapy; 70 percent participated in both supervised therapy and home exercises. Participants had a mean 9.2 supervised sessions over 14.2 weeks. There were no differences in patient-reported outcomes between participants who underwent therapy and those who did not. Participants who did not have therapy recovered more grip strength. Participants who engaged in therapy for a shorter time reported greater function, ability to work, and satisfaction. There were no relationships revealed in subgroup analyses.

CONCLUSIONS

Hand therapy after distal radius fracture may not be necessary for older patients. Encouraging participants to resume activities of daily living as soon as possible may be as effective as formal therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The New Smartphone Application for Wrist Rehabilitation

BACKGROUND

The rehabilitation after wrist surgery is extremely important. An instructed therapy in hospital is widely practiced. However, a dependent aging society and rush life style in younger generation have precluded patients to access to the frequent formal therapy. With the advancement in telecommunication technology, we have invented an application for smartphone for home-based wrist motion rehabilitation.

METHODS

Twenty participants were included in four-week wrist motion rehabilitation programme after wrist surgery. Participants were instructed to use the application by physical therapist and informed details of home-based wrist rehabilitation. The feasibility of application was evaluated by satisfaction level in various aspects and the adherence to the therapy was monitored by function provided in the application. The degrees of motion were compared at the end of prescribed programme.

RESULTS

Patient satisfaction was consistently high in every aspects. Also, the adherence to the therapy was high (90.42%). Ranges of motion significantly gained in every plane of wrist motion ([Formula: see text]).

CONCLUSIONS

This novel smartphone application seems to be a promising and convenient alternative for patients who need to gain wrist motion without formal rehabilitation in the hospital. Adherence to the therapy is also easily traced with this application.

The Effect of Socioeconomic Factors on Outcomes of Distal Radius Fractures: A Systematic Review

BACKGROUND

Socioeconomic factors are known to affect outcomes for both medical and surgical conditions. The purpose of this systematic review was to assess the current evidence regarding the effect of socioeconomic factors such as income, geographic location, educational level, and occupation on clinical outcomes after distal radius fractures.

METHODS

A systematic search strategy was performed to identify studies commenting on the effect of socioeconomic factors on clinical outcomes following open or closed distal radius fracture repair. Abstract and full-text screening was performed by 2 independent reviewers, and articles were evaluated by Structured Effectiveness Quality Evaluation Scale (SEQES). Treatment outcomes of interest included, but were not limited to, pain, function, range of motion, and grip strength.

RESULTS

There were 1745 studies that met our inclusion and exclusion criteria for abstract screening. Of these, 48 studies met our inclusion criteria for full-text screening and 20 studies met our criteria for quality analysis with the SEQES score. There were 3 studies of high quality, 16 of moderate quality, and 1 of low quality. Meta-analyses were not possible due to the variability in outcomes of interest across papers.

CONCLUSIONS

Patient factors indicative of socioeconomic status are relevant predictors of functional outcome after distal radius fractures. There is currently limited evidence in this area of research, and further examination should be considered to improve outcomes from a patient and system standpoint.

Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

STUDY DESIGN

Randomized clinical study.

INTRODUCTION

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

PURPOSE OF THE STUDY

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

METHODS

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

RESULTS

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

CONCLUSIONS

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

LEVEL OF EVIDENCE

1b.

Utilization of Post-Acute Care Following Distal Radius Fracture Among Medicare Beneficiaries

PURPOSE

To examine the utilization and cost of post-acute care following isolated distal radius fractures (DRFs) among Medicare beneficiaries.

METHODS

We examined utilization of post-acute care among Medicare beneficiaries who experienced an isolated DRF (n = 38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post-acute care delivered by skilled nursing facilities, inpatient rehabilitation facilities, home health care agencies, and outpatient occupational therapy/physical therapy for the recovery of DRF.

RESULTS

In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post-acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post-acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post-acute care services from inpatient rehabilitation facilities and skilled nursing facilities ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation.

CONCLUSIONS

Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post-acute care following isolated DRFs, and post-acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post-acute care can inform strategies to improve the cost efficiency of rehabilitation and optimize scarce health care resources.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

A Review of the Use of Medicare Claims Data in Plastic Surgery Outcomes Research

With a growing national emphasis in data transparency and reporting of public health data, it is essential for researchers to know more about Medicare claims data, the largest and most reliable source of health-care utilization and expenditure for individuals older than 65 years in the United States. This article provides an overview of Medicare claims data for plastic surgery outcomes research. We highlight essential information on various files included in Medicare claims data, strengths and limitations of the data, and ways to expand the use of existing data for research purposes. As of now, Medicare data are limited in providing adequate information regarding severity of diagnosed conditions, health status of individuals, and health outcomes after certain procedures. However, the data contain all health-care utilization and expenditures for services that are covered by Medicare Parts A, B, and D (inpatient, outpatient, ambulatory-based and physician-based services, and prescription drugs). Additionally, Medicare claims data can be used for longitudinal analysis of variations in utilization and cost of health-care services at the patient level and provider level. Linking Medicare claims data with other national databases and utilizing the ICD-10 coding system would further expand the use of these datasets in health services research.