Looking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation

doi:10.1016/j.apmr.2008.10.035

Archives of Physical Medicine and Rehabilitation

Volume 90, Issue 8, August 2009, Pages 1260-1268

https://doi.org/10.1016/j.apmr.2008.10.035 Get rights and content

Abstract

Tian W, DeJong G, Brown M, Hsieh C-H, Zamfirov ZP, Horn SD. Looking upstream: factors shaping the demand for postacute joint replacement rehabilitation.

Since 1993, the numbers of hip and knee replacements in the United States have increased 2-fold to 3-fold while lengths of stay in acute care have decreased by about half, leading to a significant growth in the use of postacute rehabilitative care for patients with a joint replacement. To document these trends, this article uses secondary analysis of acute hospital discharge survey data and evaluates projections to 2030. This article uses a market approach to identify 3 sets of factors that influence the use of joint replacements: (1) increasing patient demand, (2) increasing supply of practitioners, and (3) the role of fiscal intermediaries. The article reviews underlying epidemiologic trends, growing numbers of orthopedic surgeons performing the procedure, technologic innovations, changing indications for the procedure, changing payer mix, and the effects of payer attempts to contain joint replacement costs. An unintended effect of Medicare payment policy has been to shift costs from acute care to downstream postacute care. Medicare and private health plan reimbursement policies need to take into account this broader perspective and not examine joint replacement care and payment in isolated care settings. Future research and health policy needs to consider the interdependent features of the health care system by linking changes in postacute care with upstream changes both in society at large and in the organization, delivery, and financing of acute care associated with joint replacement.

Section snippets

Rapid Increase in Joint Replacements

Using HCUPnet,¹ an online data tool, we reviewed 13 years of data (1993–2005) furnished by the AHRQ to evaluate major trends in the numbers of joint replacements performed in the United States. The AHRQ database, known as NIS, is based on a 20% sample of all hospital discharges in the nation. From 1993 to 2005, there has been nearly a 2.5-fold increase in the number of total knee replacements (identified as ICD-9-CM procedure code 81.54)—from 200,216 to 497,419—and a 1.75-fold increase in the

Variation in Use of Joint Replacement

To focus only on the rapid growth of arthroplastic surgeries overlooks important differences across populations and geographic areas. There remain significant differences in sex, race, and geographic location. Some of these disparities, especially those that relate to race and geography, suggest there may be additional increases in demand should these disparities diminish in the future.

Projections of Future Use

Although the procedure has become increasingly prevalent in the last few decades, researchers expect the trend to continue well into the future. Several studies have been conducted to project the number of primary hip and knee replacements as well as revisions. Based on a 2002 AAOS analysis, Frankowski and Watkins-Castillo²¹ projected that there will be over 274,000 total hip replacements and 474,000 total knee replacements in 2030. Apparently, this projection greatly underestimated the volume

Dynamics Behind Actual and Projected Growth Rates

Rapid growth in the actual and projected number of joint replacements poses important questions: what is fueling the growth? What are the implications of this growth for payers (eg, Medicare), downstream PAC providers, and health policy makers? To answer these questions, we use a market approach that examines (1) the demand side, (2) the supply side, and (3) the role of financial intermediaries whose policies modulate the interaction between demand and supply sides of the market.

Demand Side

Increasing demand for joint replacements from patients is the major engine driving the growth of joint replacements. Growing numbers of candidates for the procedure and the procedure's presumed underuse among selected groups will continue to contribute to increasing demand.

Aging remains the strongest risk factor associated with development of osteoarthritis, the most common condition leading an individual to seek a joint replacement.23, 24, 25 In 1999, about 12% of all American adults over 65

Supply Side

As demand for total joint replacements increases, changes in supply also are taking place. These changes include increases in the supply of practitioners, advances in surgical technology of joint replacement, and indications for joint replacement. Over the past few decades, these changes have strengthened the provider's capacity to offer more procedures, improved the surgical safety and efficacy, and expanded the target population that could benefit from the procedure.

Changing Payer Mix

Financial intermediaries have played an important and, perhaps, an inadvertent role in the growth of total joint replacement. Because of the age distribution of patients obtaining a joint replacement, Medicare remains the single most important payer and accounted for about 57% of all payment for total joint replacements in 2005. The payer mix for the procedure, however, has changed significantly over the last decade. Medicare's proportion of all charges continues to decline as younger

Implications for Postacute Rehabilitation Care

Upstream trends in society at large and acute care in particular have material downstream effects on demand for, and supply of, postacute rehabilitation services for individuals who acquire a joint replacement.

Oversimplified, increasing numbers of patients with joint replacement who participate in a postacute bed service rehabilitation program—that is, in SNFs or IRFs—are a function of 2 main variables: (1) volume of joint replacement patients and (2) rates at which they are discharged to a

Conclusions

Total joint replacement provides material benefits for patients who seek substantial pain relief, improved function, and quality of life.⁶⁸ This article reviews the use of total joint replacement in the United States. The number of joint replacements performed has increased rapidly in the last decade, and the trend is predicted to continue in the future. Three groups of factors—increasing demand, increasing supply, and financial incentives—are associated with the use of the procedure. Despite

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The role of pain and walking difficulties in shaping willingness to undergo joint surgery for osteoarthritis: Data from the Swedish BOA register
2021, Osteoarthritis and Cartilage Open
To investigate whether the association between pain intensity and willingness to undergo surgery is explained by walking difficulties, in patients with knee or hip osteoarthritis (OA).
This is an observational study using data from the Better management of patients with Osteoarthritis (BOA) register, which collects data from a publicly financed self-management programme for people with OA in Sweden. We included all patients with knee or hip OA who attended the baseline visit between 2008 and 2016. We conducted separate mediation analyses within a counterfactual framework to estimate the mediation effect of walking difficulties (yes/no) on willingness to undergo surgery (yes/no) for each one-point increase in pain (0–10 on a numeric rating scale), adjusted for relevant confounders.
We included 72,131 patients (69% women, mean age 66, mean pain 5.4, 81% had walking difficulties, 27% was willing to undergo surgery). A one-point increase in pain intensity was associated with 1.53 (95% CI: 1.51; 1.55) higher odds of being willing to undergo surgery. Walking difficulties mediated 10%–25% of the effect of one-point increase in pain when pain was <8/10, while at pain ≥8/10 this percentage decreased to 3%.
More than 80% of the BOA patients have mild to moderate pain (<8/10) and walking difficulties can mediate up to a quarter of the total effect of pain on the willingness to undergo surgery in these patients. Trials to evaluate the potential to lower surgery demand by reducing walking difficulties in people with these characteristics are needed.
Development of quality indicators for hip and knee arthroplasty rehabilitation
2018, Osteoarthritis and Cartilage
Citation Excerpt :
There is a growing body of evidence to suggest that implementing and measuring QIs result in improvements in processes of cares and patient-relevant outcomes1,2,6,10. Total joint arthroplasty (TJA) for advanced hip and knee osteoarthritis (OA) is a high priority, high demand elective surgical procedure in Canada and other countries11–13. QIs have been developed and implemented for OA14, and indicators and performance benchmarks have been established for medical and surgical TJA peri-operative care processes5, outcomes15, and TJA wait times16 in some countries.
To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA).
Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets.
Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three ‘across-continuum’ QIs were rated appropriate for both procedures.
This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.
Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty
2017, Journal of Arthroplasty
The most commonly used postacute care facility after total joint arthroplasty is a skilled nursing facility (SNF). However, little is known regarding the role of physical therapy achievements and insurance status on the decision to discharge from an SNF. In this study, we aim to compare functional outcomes and length of stay (LOS) at an SNF among patients with Medicare vs private health coverage.
We retrospectively collected physical therapy data for 114 patients who attended an SNF following acute hospitalization for total joint arthroplasty. Medicare beneficiaries were compared with patients covered by Managed Care (MC) policies (health maintenance organization [HMO] and preferred provider organization [PPO]) using several SNF discharge outcomes, including LOS, distance ambulated, and functional independence in gait, transfers, and bed mobility.
LOS at the SNF was significantly longer for Medicare patients (Medicare: 24 ± 22 days, MC: 12 ± 7 days, P = .007). After adjusting for LOS and covariates, MC patients had significantly greater achievements in all functional outcomes measured. In a study subanalysis, Medicare patients were found to achieve similar functional outcomes by SNF day 14 as MC patients achieved by their day of discharge on approximately day 12. Yet, the Medicare group was not discharged until several days later.
Medicare status is associated with poor functional outcomes, long LOS, and slow progress in the SNF. Our results suggest that insurance reimbursement may be a primary factor in the decision to discharge, rather than the achievement of functional milestones.
Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA
2015, Journal of Arthroplasty
This study evaluated the trends in discharge patterns and the prevalence and cost of post-discharge PT. The 5% Medicare database (1997–2010) was used to identify 50,886 primary THA and 107,675 TKA patients. More than 50% of patients were discharged from hospital to an inpatient facility. There were an increase in discharges to skilled nursing units and a reduced rate to rehabilitation facilities. In contrast to hospital, surgeon reimbursement, and implant costs, the average annual PT cost per patient rose through the study period. Approximately 25% of PT costs were used on less common modalities. PT costs more than $648 million a year. With the increased pressure to control costs for primary TJA, these patterns may change unless PT effectiveness can be demonstrated.
Postacute care
2014, Medicina Clinica
Los cuidados de las personas mayores después de una enfermedad aguda o accidente han adquirido una gran relevancia en el coste sanitario, debido tanto al envejecimiento de la población como al cambio en la estructura sociofamiliar.
El objetivo principal de los cuidados postagudos (CPA) es restituir la capacidad funcional del paciente después de un episodio agudo, puesto que este determinará su evolución y contactos posteriores con el sistema sanitario. Nos hemos propuesto revisar los siguientes aspectos de los CPA: a) objetivos; b) cuantificación de las necesidades e indicadores de acceso, y c) estrategias de transferencia desde los cuidados agudos. Para ello se ha realizado una revisión sistemática de la literatura médica desde el año 1990 hasta el 2011.
Se concluye que los CPA son un instrumento eficiente para mejorar la calidad de vida de los pacientes y para la sostenibilidad del sistema sanitario público. En la selección de los candidatos hay que manejar un conjunto de indicadores tanto sanitarios como sociales. La visión transversal de todo el proceso es fundamental para evitar un incremento en los costes totales.
The aging of the population and changes in family and social structures have led to increasing care needs for elderly persons following an acute disease or accident, with consequent concerns regarding costs and sustainability within the public health system.
The main objective of postacute care (PAC) is to restore the functional capabilities of the patient after an acute event and contribute to determine the patient's outcome and future healthcare requirements. With this background, we carried out a systematic review of the published literature from 1990 to 2011 focused on the following aspects of PAC: a) objectives; b) estimations of the need and the indicators for access to it, and c) transfer strategies from acute care to PAC.
The results of this review indicate that PAC is an efficient approach to improve patients’ quality of life and to sustain the public healthcare system. The choice of candidates for PAC should be based on both health and social indicators, and the overall process viewed in a cross-sectional manner in order to avoid increases in total cost.
In-home telerehabilitation compared with faceto-face rehabilitation after total knee arthroplasty: A noninferiority randomized controlled trial
2015, Journal of Bone and Joint Surgery - American Volume
The availability of less resource-intensive alternatives to home visits for rehabilitation following orthopaedic surgeries is important, given the increasing need for home care services and the shortage of health resources. The goal of this trial was to determine whether an in-home telerehabilitation program is not clinically inferior to a face-to-face home visit approach (standard care) after hospital discharge of patients following a total knee arthroplasty.
Two hundred and five patients who had a total knee arthroplasty were randomized before hospital discharge to the telerehabilitation group or the face-to-face home visit group. Both groups received the same rehabilitation intervention for two months after hospital discharge. Patients were evaluated at baseline (before total knee arthroplasty), immediately after the rehabilitation intervention (two months after discharge), and two months later (four months after discharge). The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the last follow-up evaluation. Secondary outcome measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, functional and strength tests, and knee range of motion. The noninferiority margin was set at 9% for the WOMAC.
The demographic and clinical characteristics of the two groups of patients were similar at baseline. At the last follow-up evaluation, the mean differences between the groups with regard to the WOMAC gains, adjusted for baseline values, were near zero (for 182 patients in the per-protocol analysis): −1.6% (95% confidence interval [CI]: –5.6%, 2.3%) for the total score, –1.6% (95% CI: –5.9%, 2.8%) for pain, –0.7% (95% CI: –6.8%, 5.4%) for stiffness, and –1.8% (95% CI: –5.9%, 2.3%) for function. The confidence intervals were all within the predetermined zone of noninferiority. The secondary outcomes had similar results, as did the intention-to-treat analysis, which was conducted afterward for 198 patients.
Our results demonstrated the noninferiority of in-home telerehabilitation and support its use as an effective alternative to face-to-face service delivery after hospital discharge of patients following a total knee arthroplasty.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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: Supported by the HealthSouth Corp, ARA Research Institute of the American Rehabilitation Providers Association, Brooks Health, National Rehabilitation Hospital, American Hospital Association, the Federation of American Hospitals, and others.

: A commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit on one or more of the authors.

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Special communicationLooking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation

Abstract

Section snippets

Rapid Increase in Joint Replacements

Variation in Use of Joint Replacement

Projections of Future Use

Dynamics Behind Actual and Projected Growth Rates

Demand Side

Supply Side

Changing Payer Mix

Implications for Postacute Rehabilitation Care

Conclusions

J Clin Epidemiol

Arch Phys Med Rehabil

J Arthroplasty

Arch Phys Med Rehabil

J Arthroplasty

HCUPnet, Healthcare Cost and Utilization Project

Variations in the use of medical and surgical services by the Medicare population

N Engl J Med

Geographic variations in the rates of elective total hip and knee arthroplasties among Medicare beneficiaries in the United States

J Bone Joint Surg Am

Demographic variation in the rate of knee replacement: a multi-year analysis

Health Serv Res

Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002

J Bone Joint Surg Am

Rates and outcomes of primary and revision total hip replacement in the United States Medicare population

J Bone Joint Surg Am

Epidemiology of total knee replacement in the United States Medicare population

J Bone Joint Surg Am

Differences between men and women in the rate of use of hip and knee arthroplasty

N Engl J Med

Gender differences in patient preferences may underlie differential utilization of elective surgery

Am J Med

Income, race, and surgery in Maryland

Am J Public Health

Trends in epidemiology of knee arthroplasty in the United States, 1990-2000

Arthritis Rheum

Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans

Ethn Dis

Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction

Med Care

Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients

N Engl J Med

Total hip arthroplasty: use and select complications in the US Medicare population

Am J Public Health

Total hip replacement rates are higher among Caucasians than Asians in Hawaii

Clin Orthop Relat Res

Disparity in total hip replacement affecting Hispanic Medicare beneficiaries

Med Care

The influence of income and race on total knee arthroplasty in the United States

J Bone Joint Surg Am

Effect of provider volume on resource utilization for surgical procedures of the knee

Knee Surg Sports Traumatol Arthrosc

Primary total knee and hip arthroplasty projections for the U.S. population to the year 2030

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study

Arthritis Rheum

Epidemiology of osteoarthritis: an update

Curr Opin Rheumatol

Changing demographics of patients with total joint replacement

Clin Orthop Relat Res

The impact of arthritis in rural populations

Arthritis Care Res

Osteoarthritis pain and its treatment

Curr Opin Rheumatol

Dramatic changes in U.S. aging highlighted in new census, NIH report: impact of baby boomers anticipated

65+ in the United States, 2005U.S. Census Bureau

Special communication
Looking Upstream: Factors Shaping the Demand for Postacute Joint Replacement Rehabilitation