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Davila H, Mayfield B, Mengeling MA, Holcombe A, Miell KR, Jaske E, Iverson W, Walkner T, Stewart G, Solimeo S. Home health utilization in the Veterans Health Administration: Are there rural and urban differences? J Rural Health 2024. [PMID: 39075777 DOI: 10.1111/jrh.12865] [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: 10/26/2023] [Revised: 06/04/2024] [Accepted: 07/09/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one-third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality. METHODS We examined national VA administrative data for 2019-2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received. RESULTS Among home health users (n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans' characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72). CONCLUSIONS Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans' care needs are equitability addressed.
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Affiliation(s)
- Heather Davila
- Primary Care Analytics Team-Iowa City, Veterans Health Administration (VA) Office of Primary Care, Iowa City, Iowa, USA
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Bradely Mayfield
- Primary Care Analytics Team-Seattle, VA Office of Primary Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Michelle A Mengeling
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Andrea Holcombe
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Kelly R Miell
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Erin Jaske
- Primary Care Analytics Team-Seattle, VA Office of Primary Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - William Iverson
- Primary Care Analytics Team-Iowa City, Veterans Health Administration (VA) Office of Primary Care, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Primary Care, Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Tammy Walkner
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Greg Stewart
- Primary Care Analytics Team-Iowa City, Veterans Health Administration (VA) Office of Primary Care, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Tippie College of Business, University of Iowa, Iowa City, Iowa City, Iowa, USA
| | - Samantha Solimeo
- Primary Care Analytics Team-Iowa City, Veterans Health Administration (VA) Office of Primary Care, Iowa City, Iowa, USA
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Luo Y, Zhou L, Zhang W. Help or Hurt? The Impact of Digital Finance on the Physical Health of the Elderly in China. Healthcare (Basel) 2024; 12:1299. [PMID: 38998834 PMCID: PMC11241007 DOI: 10.3390/healthcare12131299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/17/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Under the backdrop of global aging, the escalating number of elderly individuals in poor health poses a growing social burden and impacts economic development and social stability. A fundamental question arises as to whether the advancements of digital finance (DF) can effectively enhance the physical health of the elderly. This study aims to investigate the impact of DF on the physical health of the elderly by utilizing data from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2013, 2015, and 2018. The results reveal a significant positive impact of DF on enhancing the physical health of the elderly. Furthermore, the study demonstrates that this impact is particularly pronounced among the elderly with higher educational attainment, stronger intergenerational links, and those residing in central cities. A mechanism analysis further reveals that DF contributes to improving the physical health of the elderly by augmenting household disposable income, alleviating liquidity constraints, and enhancing the utilization of medical services. These findings offer valuable insights for the future development of DF and the implementation of policies promoting healthy aging and active aging.
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Affiliation(s)
- Yaling Luo
- School of Public Administration, Sichuan University, Chengdu 610041, China
| | - Lei Zhou
- School of Public Administration, Sichuan University, Chengdu 610041, China
| | - Weike Zhang
- School of Public Administration, Sichuan University, Chengdu 610041, China
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Nuevo M, Rodríguez-Rodríguez D, Jauregui R, Fabrellas N, Zabalegui A, Conti M, Prat-Fabregat S. Telerehabilitation following fast-track total knee arthroplasty is effective and safe: a randomized controlled trial with the ReHub® platform. Disabil Rehabil 2024; 46:2629-2639. [PMID: 37403684 DOI: 10.1080/09638288.2023.2228689] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 06/18/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE After a total knee arthroplasty (TKA), ensuring rehabilitation is continued at home is essential for a successful recovery. The aim of this randomized clinical trial (NCT04155957) was to demonstrate the safety and efficacy of an interactive telerehabilitation system (ReHub®) to guide and provide feedback during exercise in the postoperative period of a fast-track TKA program. METHODS Fifty-two patients who underwent TKA were randomized to intervention (N = 26) or control (N = 26). Upon discharge, they followed a 4-week plan of 5 daily exercises and up to 10 physiotherapy home visits. The intervention group performed exercises with ReHub® autonomously, control did not use any auxiliary device. Data were collected 1) on the day of discharge, 2) after 2 weeks and 3) after 4 weeks. RESULTS Telerehabilitation patients showed higher adherence to exercise (p = 0.002) and greater quadriceps strength (p = 0.028). No significant differences between groups were found in other outcomes. Only 1 adverse event was linked to ReHub®. Patients gave the platform high System Usability Scale scores (83/100). CONCLUSION Interactive telerehabilitation with ReHub® during a post-TKA exercise program is effective, safe, and well-received by patients. It provides real-time performance feedback and ensures communication. Quadriceps strength and adherence to the exercise plan are improved with ReHub®.
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Affiliation(s)
- Montse Nuevo
- Clinic Institute of Medical and Surgical Specialties (ICEMEQ), Hospital Clinic of Barcelona, Barcelona, Spain
- Nursing Sciences, Faculty of Health Science, University Jaume I, Castellón de la Plana, Spain
| | | | | | - Núria Fabrellas
- Department of Public Health, Mental Health and Maternal and Child Health Nursing, Faculty of Medicine and Health Science, University of Barcelona, Barcelona, Spain
| | - Adela Zabalegui
- Department of Research and Teaching in Nursing, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Marco Conti
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Salvi Prat-Fabregat
- Clinic Institute of Medical and Surgical Specialties (ICEMEQ), Hospital Clinic of Barcelona, Barcelona, Spain
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Burgdorf JG, Ornstein KA, Liu B, Leff B, Brody AA, McDonough C, Ritchie CS. Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glad270. [PMID: 38071603 PMCID: PMC10878244 DOI: 10.1093/gerona/glad270] [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: 07/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD). METHODS We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors. RESULTS PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002). CONCLUSIONS Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.
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Affiliation(s)
- Julia G Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, New York, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, The Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Bruce Leff
- The Center for Transformative Geriatric Research, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, New York University Meyers College of Nursing, New York, New York, USA
| | - Catherine McDonough
- Department of Population Health Science and Policy, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Christine S Ritchie
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Fisher C, Wysin C, Moeller L, Nguyen J. Scaled TelePhysical Therapy Program a Promising Option for Post-acute Care of Lower-Extremity Arthroplasty Patients. HSS J 2024; 20:41-47. [PMID: 38356757 PMCID: PMC10863600 DOI: 10.1177/15563316231210865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 02/16/2024]
Abstract
Background Post-acute care for orthopedic surgery patients continues to evolve with the reduction in hospital length of stay (LOS), shift to ambulatory surgery, increased number of surgeries, and focus on value-based care. Purpose We sought to examine outcomes of a cohort of lower-extremity arthroplasty patients receiving telephysical therapy (TelePT) according to hospital LOS, as a means of exploring the viability of TelePT as a value-based discharge option. Methods A retrospective review was conducted of patients who participated in our institution's HSS@Home TelePT program after undergoing primary unilateral hip or knee arthroplasty, unicondylar knee replacement, or hip resurfacing. Demographic data and outcomes such as hospital LOS, number of days between discharge and TelePT evaluation, number of TelePT visits, number of re-admissions, Hip dysfunction and Osteoarthritis Outcome (HOOS Jr.) or Knee injury and Osteoarthritis Outcome (KOOS Jr.) scores, and patient satisfaction scores were collected. Patients were divided into categories based on hospital LOS to help determine the versatility of program. Results In the 2814 patients included, we observed an average of 4.1 TelePT visits; 1% of patients were readmitted within 90 days, and 97% of patients were satisfied or highly satisfied. There was no difference in HOOS or KOOS Jr. scores at each follow-up time point, except for the 6-month HOOS Jr. scores. Conclusion This retrospective study suggests that TelePT may be a viable option for care of lower-extremity arthroplasty patients in the post-acute setting, regardless of hospital LOS. As a discharge option, it may meet the needs of select patients to fill a gap in providing value-based care.
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Phelan I, Carrion-Plaza A, Furness PJ, Dimitri P. Home-based immersive virtual reality physical rehabilitation in paediatric patients for upper limb motor impairment: a feasibility study. VIRTUAL REALITY 2023; 27:1-16. [PMID: 36686613 PMCID: PMC9840166 DOI: 10.1007/s10055-023-00747-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Upper limb motor impairment (ULMI) rehabilitation is a long-term, demanding and challenging process to recover motor functionality. Children and adolescents may be limited in daily life activities due to reduced functions such as decreased joint movement or muscle weakness. Home-based therapy with Immersive Virtual Reality can offer greater accessibility, delivery and early rehabilitation to significantly optimise functional outcomes and quality of life. This feasibility study aimed to explore the perceptions and impacts of an immersive and interactive VR scenario suitable for ULMI rehabilitation for children at home. It was analysed using mixed methods (quantitative and qualitative) and from a multidirectional perspective (patients, clinicians and family members). Amongst the main results, it was found that IVR for ULMI home rehabilitation (1) is easy to learn and acceptable; (2) improves motor function; (3) reduces the difficulty in the reproduction of therapeutic movements; (4) is motivating and enjoyable and (5) improves quality of life. This study is the first study on the use of IVR applied to home rehabilitation of ULMI in children. These results suggested that similar outcomes may be possible with self-directed IVR home rehabilitation compared to face to face conventional rehabilitation, which can be costly to both the patient and the healthcare system, decreasing the length of stay at the hospital and treatment duration. It has also presented an innovative solution to the Covid-19 emergency where children could not receive their clinic therapy. Further research is recommended to understand better the mechanisms involved in physiotherapeutic recovery and how IVR rehabilitation helps to improve conventional treatments. Trial Registration Protocol ID NCT05272436. Release Date: 9th March 2022.
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Affiliation(s)
- Ivan Phelan
- Centre for Culture, Media and Society, College of Social Sciences and Arts, Sheffield Hallam University, Sheffield, S1 1WB UK
| | - Alicia Carrion-Plaza
- Centre for Culture, Media and Society, College of Social Sciences and Arts, Sheffield Hallam University, Sheffield, S1 1WB UK
| | - Penny J Furness
- Department of Psychology, Sociology and Politics, College of Social Sciences and Arts, Sheffield Hallam University, Sheffield, S1 1WB UK
| | - Paul Dimitri
- Sheffield Children’s NHS Foundation Trust, Sheffield Children’s, Sheffield, S10 2TH UK
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Quigley DD, Chastain AM, Kang JA, Bronstein D, Dick AW, Stone PW, Shang J. Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States. J Am Med Dir Assoc 2022; 23:1653.e1-1653.e13. [PMID: 36108785 PMCID: PMC9880873 DOI: 10.1016/j.jamda.2022.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs. DESIGN Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal. SETTING Care provided by urban and rural HHAs. METHODS We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality. RESULTS Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study). CONCLUSION AND IMPLICATIONS This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.
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Affiliation(s)
- Denise D. Quigley
- Health Unit, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407
| | - Ashley M. Chastain
- Center for Health Policy, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032
| | - Jung A. Kang
- Center for Health Policy, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032
| | - David Bronstein
- Center for Health Policy, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032
| | - Andrew W. Dick
- Health Unit, RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA, 02116
| | - Patricia W. Stone
- Center for Health Policy, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032
| | - Jingjing Shang
- Center for Health Policy, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032
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Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty. J Am Acad Orthop Surg 2022; 30:e799-e807. [PMID: 35594512 DOI: 10.5435/jaaos-d-21-00247] [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] [Received: 05/11/2021] [Accepted: 02/14/2022] [Indexed: 02/01/2023] Open
Abstract
Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.
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Capin JJ, Bade MJ, Jennings JM, Snyder-Mackler L, Stevens-Lapsley JE. Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures. Phys Ther 2022; 102:6556168. [PMID: 35358318 PMCID: PMC9393064 DOI: 10.1093/ptj/pzac033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/29/2021] [Accepted: 02/02/2022] [Indexed: 11/14/2022]
Abstract
Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy.
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Affiliation(s)
- Jacob J Capin
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA,Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, USA
| | - Michael J Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado, USA,Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado, USA
| | - Lynn Snyder-Mackler
- Department of Physical Therapy, Department of Biomedical Engineering, and Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA,Address all correspondence to Dr. Stevens-Lapsley at ; Follow the author(s): @JacobCapin, @PhysioBade, @DocLSmack, @JSLapsley
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Falvey J, Bade MJ, Forster JE, Stevens-Lapsley JE. Poor Recovery of Activities-of-Daily-Living Function Is Associated With Higher Rates of Postsurgical Hospitalization After Total Joint Arthroplasty. Phys Ther 2021; 101:pzab189. [PMID: 34339513 PMCID: PMC8565313 DOI: 10.1093/ptj/pzab189] [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: 08/12/2020] [Revised: 04/10/2021] [Accepted: 06/21/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Medicare beneficiaries are increasingly using home health (HH) as the first postacute care setting after hospital discharge following total joint arthroplasty (TJA). Yet, prior research has shown that changes in payment models for TJA may negatively influence functional outcomes for Medicare beneficiaries. The purpose of this study was to evaluate the impact of poor functional outcomes during an HH episode of care on hospitalization risk for older recipients of TJA. METHODS For this study, 5822 Medicare beneficiaries who underwent elective TJA and subsequently participated in HH care following hospital discharge were identified using Medicare hospitalizations records and HH claims. Recovery of activities-of-daily-living (ADL) function was evaluated using patient assessment data completed at HH admission and discharge from the Medicare Outcomes and Assessment Information Set (OASIS). Hospitalization outcomes were captured from Medicare hospital claims. Cox proportional hazards regression was used to evaluate the hazard ratio for hospitalization after HH discharge. RESULTS The 5822 Medicare beneficiaries who received a TJA and subsequently were discharged to HH were evaluated (n = 3989 [68.6%] following total knee replacement, n = 1883 [31.4%]) following total hip replacement). Nearly 9% (n = 534) of patients did not improve their ability to perform ADLs during the HH episode; this lack of improvement was associated with a more than 2-fold increase in hospital readmission rate following HH discharge (2.3% vs 4.9%). In adjusted models, there was a significant 77% increase (hazard ratio = 1.77; 95% CI = 1.14-2.74) in hospitalization risk during the 90-day postsurgical period. CONCLUSION Poor recovery of ADL function in HH settings following TJA is strongly associated with elevated risk of future hospitalizations. IMPACT Medicare beneficiaries who fail to make substantive improvements in basic ADL function during HH care episodes following TJA may need intensive monitoring from interdisciplinary team members across the continuum of care, especially during transitions from home care to outpatient care. LAY SUMMARY An increasing number of patients receive home health care after joint replacement surgery, but outcomes after home health are unclear. These findings suggest that improvements in basic tasks such as walking or bathing are associated with a lower likelihood of hospitalization.
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Affiliation(s)
- Jason Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Michael J Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeri E Forster
- Rocky Mountain Regional Veterans Affairs Medical Center, Mental Illness Research, Education, and Clinical Center, Aurora, Colorado, USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, Colorado, USA
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McGilton KS, Campitelli MA, Bethell J, Guan J, Vellani S, Krassikova A, Omar A, Maxwell CJ, Bronskill SE. Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures. Arch Phys Med Rehabil 2021; 102:1972-1981. [PMID: 34242626 DOI: 10.1016/j.apmr.2021.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 06/02/2021] [Accepted: 06/24/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia. DESIGN Retrospective cohort study of individually linked health administrative data. SETTING Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada. PARTICIPANTS A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex. RESULTS Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60). CONCLUSIONS Among older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.
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Affiliation(s)
- Katherine S McGilton
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario; Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, Ontario.
| | | | - Jennifer Bethell
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario; Institute for Clinical Evaluative Science, Toronto, Ontario; Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Jun Guan
- Institute for Clinical Evaluative Science, Toronto, Ontario
| | - Shirin Vellani
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario; Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, Ontario
| | - Alexandra Krassikova
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario; Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Abeer Omar
- Trent/Fleming School of Nursing, Trent University, Peterborough, Ontario
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Science, Toronto, Ontario; Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Science, Toronto, Ontario; Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
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12
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Riddle DL, Hung A. Letter to the Editor on: Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Additional Cost Without Improving Outcomes. J Arthroplasty 2020; 35:3779-3780. [PMID: 32868113 DOI: 10.1016/j.arth.2020.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/05/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Daniel L Riddle
- Department of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA
| | - Anna Hung
- Department of Population Health Sciences, Duke University, Durham, NC
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13
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Reynolds GL, Fisher DG. Postacute Care Disposition for Total Hip and Total Knee Replacement Surgery for Asian Americans. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2020. [DOI: 10.1177/1084822320913046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study explored differences in postacute disposition for total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a focus on whether Asian Americans (AS) experience joint replacement disparities observed in other racial/ethnic minorities compared with majority white patients. We used data from the Nationwide Inpatient Sample for 2009 through 2012. We looked at disposition to home health care (HHC) and transfer to another facility for postacute care (e.g., skilled nursing facility, rehabilitation facility) for each of the 4 years under study. Findings for AS were mixed. There were differences in discharge to postacute facilities other than HHC for AS compared with whites for THA for 2011 and 2012. For TKA, there were differences in disposition to HHC for Asians compared with whites for 2009 and 2012; for disposition to postacute facilities other than HHC for TKA, there were differences for 2011 and 2012 only. Differences for AS in postacute disposition to facilities other than HHC appear to increase over the 4 years of the study. Further research with additional data is warranted.
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14
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Bhatia M, Kaur S, Sood SK, Behal V. Internet of things-inspired healthcare system for urine-based diabetes prediction. Artif Intell Med 2020; 107:101913. [DOI: 10.1016/j.artmed.2020.101913] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 05/30/2020] [Accepted: 06/12/2020] [Indexed: 02/05/2023]
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15
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Wang J, Yu F, Cai X, Caprio TV, Li Y. Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse? PLoS One 2020; 15:e0233650. [PMID: 32453771 PMCID: PMC7250428 DOI: 10.1371/journal.pone.0233650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/09/2020] [Indexed: 11/23/2022] Open
Abstract
Objectives Evaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries. Methods Secondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults ≥ 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline. Results The sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R2 = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with dementia (β = 0.92, 95% CI: 0.38, 1.47, p = 0.001) and Asian Americans with dementia (β = 1.47, 95% CI: 0.81, 2.13, p<0.001) showed the least ADL improvement at HH discharge. Conclusion Racial/ethnic minority status and dementia were associated with less ADL improvement in HH with independent and interactive effects. Policies should ensure that these patients have equitable access to appropriate, adequate community-based services to meet their needs in ADLs and disease management for improved outcomes.
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Affiliation(s)
- Jinjiao Wang
- School of Nursing, University of Rochester, Rochester, NY, United States of America
- * E-mail:
| | - Fang Yu
- School of Nursing, University of Minnesota, Minneapolis, MN, United States of America
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States of America
| | - Thomas V. Caprio
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
- University of Rochester Medical Home Care, Rochester, NY, United States of America
- Finger Lakes Geriatric Education Center, Rochester, NY, United States of America
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, NY, United States of America
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16
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Falvey JR, Murphy TE, Gill TM, Stevens-Lapsley JE, Ferrante LE. Home Health Rehabilitation Utilization Among Medicare Beneficiaries Following Critical Illness. J Am Geriatr Soc 2020; 68:1512-1519. [PMID: 32187664 DOI: 10.1111/jgs.16412] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Medicare beneficiaries recovering from a critical illness are increasingly being discharged home instead of to post-acute care facilities. Rehabilitation services are commonly recommended for intensive care unit (ICU) survivors; however, little is known about the frequency and dose of home-based rehabilitation in this population. DESIGN Retrospective analysis of 2012 Medicare hospital and home health (HH) claims data, linked with assessment data from the Medicare Outcomes and Assessment Information Set. SETTING Participant homes. PARTICIPANTS Medicare beneficiaries recovering from an ICU stay longer than 24 hours, who were discharged directly home with HH services within 7 days of discharge and survived without readmission or hospice transfer for at least 30 days (n = 3,176). MEASUREMENTS Count of rehabilitation visits received during HH care episode. RESULTS A total of 19,564 rehabilitation visits were delivered to ICU survivors over 118,145 person-days in HH settings, a rate of 1.16 visits per week. One-third of ICU survivors received no rehabilitation visits during HH care. In adjusted models, those with the highest baseline disability received 30% more visits (rate ratio [RR] = 1.30; 95% confidence interval [CI] = 1.17-1.45) than those with the least disability. Conversely, an inverse relationship was found between multimorbidity (Elixhauser scores) and count of rehabilitation visits received; those with the highest tertile of Elixhauser scores received 11% fewer visits (RR = .89; 95% CI = .81-.99) than those in the lowest tertile. Participants living in a rural setting (vs urban) received 6% fewer visits (RR = .94; 95% CI = .91-.98); those who lived alone received 11% fewer visits (RR = .89; 95% CI = .82-.96) than those who lived with others. CONCLUSION On average, Medicare beneficiaries discharged home after a critical illness receive few rehabilitation visits in the early post-hospitalization period. Those who had more comorbidities, who lived alone, or who lived in rural settings received even fewer visits, suggesting a need for their consideration during discharge planning. J Am Geriatr Soc 68:1512-1519, 2020.
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Affiliation(s)
- Jason R Falvey
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, Colorado
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Abstract
In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports.
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Affiliation(s)
- Robert Samuel Mayer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA.
| | - Amira Noles
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA
| | - Dominique Vinh
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA
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18
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Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty. Clin Orthop Relat Res 2020; 478:231-237. [PMID: 31688209 PMCID: PMC7438147 DOI: 10.1097/corr.0000000000001040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown. QUESTIONS/PURPOSES (1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA? METHODS This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence. RESULTS Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008). CONCLUSIONS Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoing TJA, which may include participation in preoperative rehabilitation (pre-habilitation) or more aggressive follow-up in the 30 days after surgery. Further research is needed to determine whether severe ADL dependence can be modified before surgery, and whether these changes in dependency can reduce readmission risk after TJA. LEVEL OF EVIDENCE Level III, therapeutic study.
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19
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20
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LeDoux CV, Lindrooth RC, Seidler KJ, Falvey JR, Stevens‐Lapsley JE. The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia. J Am Geriatr Soc 2020; 68:867-871. [DOI: 10.1111/jgs.16307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 11/17/2019] [Accepted: 12/02/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Cherie V. LeDoux
- Department of Physical Medicine and Rehabilitation University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Richard C. Lindrooth
- Department of Health Systems, Management and Policy Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Katie J. Seidler
- Department of Physical Medicine and Rehabilitation University of Colorado Anschutz Medical Campus, Aurora Colorado
| | - Jason R. Falvey
- Division of Geriatrics Yale University School of Medicine New Haven Connecticut
| | - Jennifer E. Stevens‐Lapsley
- Department of Physical Medicine and Rehabilitation University of Colorado Anschutz Medical Campus, Aurora Colorado
- Veterans Affairs Geriatric Research Education and Clinical Center Aurora Colorado
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21
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Weyker PD, Webb CAJ. Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system. Pain Manag 2019; 10:23-41. [PMID: 31852383 DOI: 10.2217/pmt-2019-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.
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Affiliation(s)
- Paul David Weyker
- Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA
| | - Christopher Allen-John Webb
- Department of Clinical Sciences, Kaiser Permanente School of Medicine, Pasadena, CA 91101, USA.,Department of Anesthesia & Perioperative Medicine, The Permanente Medical Group of Northern California, South San Francisco, CA 94080, USA.,Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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22
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Vaudreuil N, Gulledge C, McGlaston T, Bove A, Klatt B. Ambulation milestones in post-operative physical therapy after total knee arthroplasty: how can we improve short-term outcomes? Physiother Theory Pract 2019; 37:1353-1359. [PMID: 31852404 DOI: 10.1080/09593985.2019.1706212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Post-operative day (POD) 0 physical therapy (PT) after total knee arthroplasty (TKA) has been associated with improved outcomes such as shorter hospital length of stay (LOS), though patient performance is variable. The purpose of this study was to evaluate PT performance and determine whether this affected LOS or discharge to home.Methods: Retrospective review including 412 patients who underwent TKA over 1 year. Specific data assessed included details about demographics, surgery/recovery, PT, LOS, and discharge destination.Results: Overall, 88.8% (366/412) of patients received POD 0 PT. About 73.9% of patients who did not receive POD 0 PT were prevented from doing so by reasons that kept them off of the orthopedic inpatient floor. Patients who walked greater than 10 feet on POD 0 or 100 feet on POD 1 were significantly more likely to have a shorter LOS and more likely to be discharged to home.Discussion: Objective milestones of walking 10 feet on POD 0 and 100 feet on POD 1 were associated with improved short-term outcomes. These performance markers may be useful for stratifying which patients are meeting milestones for early discharge. Late arrival to inpatient floor had the strongest associations with inability to perform PT.
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Affiliation(s)
- Nicholas Vaudreuil
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catarina Gulledge
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy McGlaston
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Allyn Bove
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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23
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HSS@Home, Physical Therapist-Led Telehealth Care Navigation for Arthroplasty Patients: A Retrospective Case Series. HSS J 2019; 15:226-233. [PMID: 31624477 PMCID: PMC6778161 DOI: 10.1007/s11420-019-09714-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND As the rate of total joint arthroplasties performed in the USA continues to increase, so does the push for more value-based care. Bundled payments have encouraged organizations to be creative in limiting care overuse. Telehealth is one option for caring for arthroplasty patients post-surgery while limiting costs and improving communication with the surgical team. QUESTIONS/PURPOSES We sought to determine the effects of the implementation of HSS@Home, a telehealth rehabilitation program that uses patients' existing technology, in patients after they had undergone total knee or total hip arthroplasty. METHODS In this retrospective case series, of 32 patients referred, 19 patients (nine men and ten women; average age, 69 years) were enrolled in HSS@Home after undergoing a pre- and post-operative screening process. Telehealth video visits were conducted, wherein a physical therapy navigator assisted patients in following exercise and mobility programs, addressing patients' concerns while transitioning to outpatient therapy. Patients were seen within 24 h of hospital discharge, 3 times a week for 3 weeks, for an average of 11 sessions. Episodes of care were recorded in the patient's electronic medical record. RESULTS There were no readmissions among the 19 patients. Nurse practitioners were consulted for all patients, predominantly for non-emergent reasons. Feedback from patients and physicians was positive, and no overutilization of care was found. CONCLUSION HSS@Home was a promising alternative to live, in-home physical therapy that was effective in monitoring this series of patients after hip or knee arthroplasty. This preliminary data sets the stage for further research into the use of telehealth technology to provide rehabilitative care to arthroplasty patients.
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24
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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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25
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Zogg CK, Falvey JR, Dimick JB, Haider AH, Davis KA, Grauer JN. Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale? J Arthroplasty 2019; 34:1058-1065.e4. [PMID: 30878508 PMCID: PMC6884960 DOI: 10.1016/j.arth.2019.01.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/08/2019] [Accepted: 01/25/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale. METHODS A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation. RESULTS Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains. CONCLUSION The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health: Brigham and Women’s Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA
| | - Jason R. Falvey
- Division of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Adil H. Haider
- Center for Surgery and Public Health: Brigham and Women’s Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA
| | | | - Johnathan N. Grauer
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT
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Correia FD, Nogueira A, Magalhães I, Guimarães J, Moreira M, Barradas I, Molinos M, Teixeira L, Tulha J, Seabra R, Lains J, Bento V. Medium-Term Outcomes of Digital Versus Conventional Home-Based Rehabilitation After Total Knee Arthroplasty: Prospective, Parallel-Group Feasibility Study. JMIR Rehabil Assist Technol 2019; 6:e13111. [PMID: 30816849 PMCID: PMC6416534 DOI: 10.2196/13111] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/30/2019] [Accepted: 02/17/2019] [Indexed: 12/23/2022] Open
Abstract
Background Physical rehabilitation is recommended after total knee arthroplasty (TKA). With the expected increase in TKA over the next few decades, it is important to find new ways of delivering cost-effective interventions. Technological interventions have been developed with this intent, but only preliminary evidence exists regarding their validity, with short follow-up times. Objective This study aimed to present the follow-up results of a feasibility study comparing two different home-based programs after TKA: conventional face-to-face sessions and a digital intervention performed through the use of an artificial intelligence-powered biofeedback system under remote clinical monitoring. Methods The digital intervention uses a motion tracker allowing 3D movement quantification, a mobile app and a Web portal. This study presents the results of the previous single-center, prospective, parallel-group, feasibility study including an 8-week active treatment stage and further assessments at 3 and 6 months post-TKA. Primary outcome was the Timed Up and Go score, and secondary outcomes were the Knee Osteoarthritis Outcome Scale (KOOS) score and knee range of motion. Results A total of 59 patients completed the study (30 in the digital intervention group and 29 in the conventional rehabilitation group) and follow-up assessments. During the active treatment stage, patients in the digital intervention group demonstrated high engagement and satisfaction levels, with an 82% retention rate. Both groups attained clinically relevant improvements from baseline to 6 months post-TKA. At the end of the 8-week program, clinical outcomes were superior in the digital intervention group. At the 3- and 6-month assessments, the outcomes remained superior for the Timed Up and Go score (P<.001) and all KOOS subscale scores (at 3 months, P<.001 overall; at 6 months, KOOS Symptoms: P=.006, Pain: P=.002, Activities of Daily Living: P=.001, Sports: P=.003, and Quality of Life: P=.001). There was progressive convergence between both groups in terms of the knee range of motion, which remained higher for standing flexion in the digital intervention group than the conventional group at 6 months (P=.01). For the primary outcome, at 6 months, the median difference between groups was 4.87 seconds (95% CI 1.85-7.47), in favor of the digital intervention group. Conclusions The present study demonstrates that this novel digital intervention for independent home-based rehabilitation after TKA is feasible, engaging, and capable of maximizing clinical outcomes in comparison to conventional rehabilitation in the short and medium term; in addition, this intervention is far less demanding in terms of human resources. Trial Registration ClinicalTrials.gov NCT03047252; https://clinicaltrials.gov/ct2/show/NCT03047252
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Affiliation(s)
- Fernando Dias Correia
- SWORD Health, Porto, Portugal.,Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | | | | | | | | | | | | | - Laetitia Teixeira
- Department of Population Studies, Abel Salazar Institute of Biomedical Sciences, Porto, Portugal.,Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal.,Epidemiology Research Unit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - José Tulha
- Orthopaedics Department, Hospital da Prelada - Dr. Domingos Braga da Cruz, Porto, Portugal
| | - Rosmaninho Seabra
- Orthopaedics Department, Hospital da Prelada - Dr. Domingos Braga da Cruz, Porto, Portugal
| | - Jorge Lains
- Physical Rehabilitation Medicine Department, Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal
| | - Virgílio Bento
- SWORD Health, Porto, Portugal.,Engineering Department, University Institute of Maia - ISMAI, Maia, Portugal
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