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Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

  • Rehabilitation and Musculoskeletal Health / Original Article
  • Published:
HSS Journal ®

Abstract

Background

Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature.

Purposes

We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care.

Methods

This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models.

Results

The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care.

Conclusions

Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.

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References

  1. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46:399–424.

    Article  Google Scholar 

  2. Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472:188–193.

    Article  Google Scholar 

  3. Centers for Medicare & Medicaid Services. Comprehensive care for joint replacement model. Center for Medicare & Medicaid Innovation. 2016. Available at https://innovation.cms.gov/initiatives/cjr. [Accessed February 11, 2016].

  4. Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physiother. 2013;59:219–226.

    Article  Google Scholar 

  5. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012;308:1227–1236.

    Article  CAS  Google Scholar 

  6. Doran JP, Zabinski SJ. Bundled payment initiatives for medicare and non-medicare total joint arthroplasty patients at a community hospital: bundles in the real world. J Arthroplasty. 2015;30:353–355.

    Article  Google Scholar 

  7. Froemke CC, Wang L, DeHart ML, Williamson RK, Ko LM, Duwelius PJ. Standardizing care and improving quality under a bundled payment initiative for total joint arthroplasty. J Arthroplasty. 2015;30:1676–1682.

    Article  Google Scholar 

  8. Froimson MI, Rana A, White RE, et al. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013;28:157–165.

    Article  Google Scholar 

  9. Health Quality Ontario. Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Ont Health Technol Assess Ser. 2005;5:1–91.

    Google Scholar 

  10. John Hopkins Bloomberg School of Public Health. The Johns Hopkins ACG® System technical reference guide version 10.0. 2011. Available at: http://acg.jhsph.org/. [Accessed August 9, 2015].

  11. Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87:1487–97.

    PubMed  Google Scholar 

  12. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467:2606–2612.

    Article  Google Scholar 

  13. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014;96:624–630.

    Article  Google Scholar 

  14. Liebs TR, Herzberg W, Rüther W, Haasters J, Russlies M, Hassenpflug J, Multicenter arthroplasty aftercare project. Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Arch Phys Med Rehabil. 2012;93:192–199.

    Article  Google Scholar 

  15. Madsen M, Larsen K, Madsen IK, Søe H, Hansen TB. Late group-based rehabilitation has no advantages compared with supervised home-exercises after total knee arthroplasty. Dan Med J. 2013;60:A4607.

    PubMed  Google Scholar 

  16. Mallinson TR, Bateman J, Tseng H-Y, Manheim L, Almagor O, Deutsch A, Heinemann AW. A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Arch Phys Med Rehabil. 2011;92:712–720.

    Article  Google Scholar 

  17. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335:812.

    Article  Google Scholar 

  18. Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskelet Disord. 2009;10:98.

    Article  Google Scholar 

  19. Mont MA, Issa K. Updated projections of total joint arthroplasty demands in America. Commentary on an article by Steven M. Kurtz, PhD, et al.: “Impact of the Economic Downturn on Total Joint Replacement Demand in the United States. Updated Projections to 2021.” J Bone Joint Surg Am. 2014;96:e68.

    Article  Google Scholar 

  20. Nichols CI, Vose JG. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplasty. 2016;31:1400–1406.e3.

    Article  Google Scholar 

  21. Ong KL, Lotke PA, Lau E, Manley MT, Kurtz SM. Prevalence and costs of rehabilitation and physical therapy after primary TJA. J Arthroplasty. 2015;30:1121–1126.

    Article  Google Scholar 

  22. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56:e1–e25.

    Article  Google Scholar 

  23. Pathak S, Ganduglia CM, Awad SS, Chan W, Swint JM, Morgan RO. What factors are associated with 90-day episode-of-care payments for younger patients with total joint arthroplasty? Clin Orthop Relat Res. 2017;475(11):2808–2818.

    Article  Google Scholar 

  24. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877–892.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Arch Phys Med Rehabil. 2009;90:745–755.

    Article  Google Scholar 

  26. Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol. 2003;15:160–162.

    Article  Google Scholar 

  27. Schairer WW, Sing DC, Vail TP, Bozic KJ. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthop Relat Res. 2014;472:464–470.

    Article  Google Scholar 

  28. Sibia US, Mandelblatt AE, Callanan MA, MacDonald JH, King PJ. Incidence, risk factors, and costs for hospital returns after total joint arthroplasties. J Arthroplasty. 2017;32:381–385.

    Article  Google Scholar 

  29. Warren M, Kozik J, Cook J, Prefontaine P, Ganley K. A comparative study to determine functional and clinical outcome differences between patients receiving outpatient direct physical therapy versus home physical therapy followed by outpatient physical therapy after total knee arthroplasty. Orthop Nurs. 2016;35:382–390.

    Article  Google Scholar 

  30. Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States delphi study. Arthritis Care Res (Hoboken). 2014;66:411–423.

    Article  Google Scholar 

  31. Whitman E. Divided over bundled payments. Mod Healthc. 2016. Available at: http://www.modernhealthcare.com/article/20160928/NEWS/160929877/divided-over-bundled-payments. [Accessed October 7, 2016].

  32. Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. J Bone Joint Surg Am. 2013;95:1869–1876.

    Article  Google Scholar 

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Authors and Affiliations

  1. School of Public Health, University of Texas Health Sciences Center, 1200 Herman Pressler Blvd, Houston, TX, 77030, USA

    Shweta Pathak PhD, MPH, Cecilia M. Ganduglia MD, DrPH, Wenyaw Chan PhD, John M. Swint PhD & Robert O. Morgan PhD

  2. University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA

    Shweta Pathak PhD, MPH

  3. Operative Care Line, Surgery Service, Michael E. DeBakey VA Medical Center, Houston, TX, USA

    Samir S. Awad MD, MPH

  4. Department of Surgery, Baylor College of Medicine, Houston, TX, USA

    Samir S. Awad MD, MPH

  5. Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, TX, USA

    John M. Swint PhD

Authors
  1. Shweta Pathak PhD, MPH
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  2. Cecilia M. Ganduglia MD, DrPH
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  3. Samir S. Awad MD, MPH
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  4. Wenyaw Chan PhD
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  5. John M. Swint PhD
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  6. Robert O. Morgan PhD
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Corresponding author

Correspondence to Shweta Pathak PhD, MPH.

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Conflict of Interest

Shweta Pathak, PhD, MPH, Cecilia M. Ganduglia, MD, DrPH, Wenyaw Chan, PhD, John M. Swint, PhD, and Robert O. Morgan, PhD declare that they have no conflicts of interest. Samir S. Awad, MD, MPH, reports personal fees from TELA Bio, Applied Medical, Abbott Laboratories, and Pacira Pharmaceuticals, as well as grants and personal fees from Miromatrix Medical, outside the submitted work.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

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Disclosure forms provided by the authors are available with the online version of this article.

Additional information

Level of Evidence: Level II, retrospective study.

Work performed at School of Public Health, University of Texas Health Sciences Center, Houston, TX

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Pathak, S., Ganduglia, C.M., Awad, S.S. et al. Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?. HSS Jrnl 15, 234–240 (2019). https://doi.org/10.1007/s11420-019-09685-z

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  • DOI: https://doi.org/10.1007/s11420-019-09685-z

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