Impact of Self-Care and Mobility on One or More Post-Acute Care Transitions.

Objective: To investigate the association between functional status and post-acute care (PAC) transition(s). Methods: Secondary analysis of 2013-2014 Medicare data for individuals aged ≥66 years with stroke, lower extremity joint replacements, and hip/femur fracture discharged to one of three PAC settings (inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies). Functional scores were co-calibrated into a 0-100 scale across settings. Multilevel logistic regression was used to test the partition of variance (%) and the probability of PAC transition attributed to the functional score in the initial PAC setting. Results: Patients discharged to inpatient rehabilitation facilities with higher function were less likely to use additional PAC. Function level in an inpatient rehabilitation facility explained more of the variance in PAC transitions than function level while in a skilled nursing facility. Discussion: The function level affected PAC transitions more for those discharged to an inpatient rehabilitation facility than to a skilled nursing facility.

Joint replacement rehabilitation and the role of funding source.

OBJECTIVE: To examine associations between funding source, use of rehabilitation and outcomes after total joint replacement and to evaluate variations based on demographic characteristics. DESIGN: Cross-sectional, questionnaire-based national survey. SUBJECTS: Participants aged 45 years or older (n = 522) who received either private or public funding for their surgery, were recruited from the New Zealand Joint Registry 6 months after a total hip, total knee or unicompartmental knee replacement. RESULTS: The cohort was predominantly New Zealand European (90%), aged 68 years, with more men (55%) than women (45%). Privately funded participants were younger, had higher levels of education and employment, and lower rates of comorbidities at the time of surgery. Privately funded participants also reported spending less time on the surgical waiting list, were less likely to participate in pre-surgical rehabilitation, but reported more weeks of post-surgical rehabilitation and better patient-reported outcomes in terms of pain, function and quality of life, compared with their publicly funded counterparts. CONCLUSION: Factors already known to impact on joint replacement outcomes were associated with funding source in this cohort. Socio-economic differences and inequities between private and public systems exist consistent with limited available prior research. In this cross-sectional study, no clinically significant differences in outcomes between the groups were identified. Prospective research will help to clarify whether funding source directly affects joint replacement rehabilitation outcomes.

Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

BACKGROUND: Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. QUESTIONS/PURPOSES: We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. METHODS: An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. RESULTS: We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. CONCLUSIONS: When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

BACKGROUND: Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-component differences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. PURPOSE: (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. METHOD: Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. RESULTS: The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. CONCLUSION: Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. LEVEL OF EVIDENCE: Level II, economic analysis.

Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service.

Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.

Social Support and Actual Versus Expected Length of Stay in Inpatient Rehabilitation Facilities.

OBJECTIVES: To describe impairment-specific patterns in shorter- and longer-than-expected lengths of stay in inpatient rehabilitation, and examine the independent effects of social support on deviations from expected lengths of stay. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Medicare fee-for-service beneficiaries (N=119,437) who were discharged from inpatient rehabilitation facilities in 2012 after stroke, lower extremity fracture, or lower extremity joint replacement. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Relative length of stay (actual minus expected). The Centers for Medicare & Medicaid Services posts annual expected lengths of stay based on patients' clinical profiles at admission. We created a 3-category outcome variable: short, expected, long. Our primary independent variable (social support) also included 3 categories: family/friends, paid/other, none. RESULTS: Mean ± SD actual lengths of stay for joint replacement, fracture, and stroke were 9.8±3.6, 13.8±4.5, and 15.8±7.3 days, respectively; relative lengths of stay were -1.2±3.1, -1.6±3.7, and -1.7±5.2 days. Nearly half of patients (47%-48%) were discharged more than 1 day earlier than expected in all 3 groups, whereas 14% of joint replacement, 15% of fracture, and 20% of stroke patients were discharged more than 1 day later than expected. In multinomial regression analysis, using family/friends as the reference group, paid/other support was associated (P<.05) with higher odds of long stays in joint replacement. No social support was associated with lower odds of short stays in all 3 impairment groups and higher odds of long stays in fracture and joint replacement. CONCLUSIONS: Inpatient rehabilitation experiences and outcomes can be substantially affected by a patient's level of social support. More research is needed to better understand these relationships and possible unintended consequences in terms of patient access issues and provider-level quality measures.

What is the Best Strategy to Minimize After-Care Costs for Total Joint Arthroplasty in a Bundled Payment Environment?

BACKGROUND: The post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies. METHODS: We used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility. RESULTS: The results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. CONCLUSION: The data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.

Comparing Comorbidity Indices to Predict Post-Acute Rehabilitation Outcomes in Older Adults.

OBJECTIVE: Compare 5 comorbidity indices to predict community discharge and functional status following post-acute rehabilitation. DESIGN: This was a retrospective study of Medicare beneficiaries with stroke, lower-extremity fracture, and joint replacement discharged from inpatient rehabilitation in 2011 (N = 105,275). Community discharge and self-care, mobility, and cognitive function were compared using the Charlson, Elixhauser, Tier, Functional Comorbidity, and Hierarchical Condition Category comorbidity indices. RESULTS: Of the patients, 64.4% were female, and 84.6% were non-Hispanic white. Mean age was 79.3 (SD, 7.5) years. Base regression models including sociodemographic and clinical variables explained 56.6%, 42.2%, and 23.0% of the variance (R) for discharge self-care; 47.4%, 30.9%, and 18.6% for mobility; and 62.0%, 55.3%, and 37.3% for cognition across the 3 impairment groups. R values for self-care, mobility, and cognition increased by 0.2% to 3.3% when the comorbidity indices were added to the models. The base model C statistics for community discharge were 0.58 (stroke), 0.61 (fracture), and 0.62 (joint replacement). The C statistics increased more than 25% with the addition of discharge functional status to the base model. Adding the comorbidity indices individually to the base model resulted in C-statistic increases of 1% to 2%. CONCLUSION: Comorbidity indices were poor predictors of community discharge and functional status in Medicare beneficiaries receiving inpatient rehabilitation.

Examining the Association Between Comorbidity Indexes and Functional Status in Hospitalized Medicare Fee-for-Service Beneficiaries.

BACKGROUND: Medicare data from acute hospitals do not contain information on functional status. This lack of information limits the ability to conduct rehabilitation-related health services research. OBJECTIVE: The purpose of this study was to examine the associations between 5 comorbidity indexes derived from acute care claims data and functional status assessed at admission to an inpatient rehabilitation facility (IRF). Comorbidity indexes included tier comorbidity, Functional Comorbidity Index (FCI), Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Hierarchical Condition Category (HCC). DESIGN: This was a retrospective cohort study. METHODS: Medicare beneficiaries with stroke, lower extremity joint replacement, and lower extremity fracture discharged to an IRF in 2011 were studied (N=105,441). Data from the beneficiary summary file, Medicare Provider Analysis and Review (MedPAR) file, and Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) file were linked. Inpatient rehabilitation facility admission functional status was used as a proxy for acute hospital discharge functional status. Separate linear regression models for each impairment group were developed to assess the relationships between the comorbidity indexes and functional status. Base models included age, sex, race/ethnicity, disability, dual eligibility, and length of stay. Subsequent models included individual comorbidity indexes. Values of variance explained (R(2)) with each comorbidity index were compared. RESULTS: Base models explained 7.7% of the variance in motor function ratings for stroke, 3.8% for joint replacement, and 7.3% for fracture. The R(2) increased marginally when comorbidity indexes were added to base models for stroke, joint replacement, and fracture: Charlson Comorbidity Index (0.4%, 0.5%, 0.3%), tier comorbidity (0.2%, 0.6%, 0.5%), FCI (0.4%, 1.2%, 1.6%), Elixhauser Comorbidity Index (1.2%, 1.9%, 3.5%), and HCC (2.2%, 2.1%, 2.8%). LIMITATION: Patients from 3 impairment categories were included in the sample. CONCLUSIONS: The 5 comorbidity indexes contributed little to predicting functional status. The indexes examined were not useful as proxies for functional status in the acute settings studied.

Protocol-Based Arthroplasty: Less Is More.

EDUCATIONAL OBJECTIVES: As a result of reading this article, physicians should be able to: 1. State an argument for, and background information on, patient-centered arthroplasty protocols. 2. Describe specific recommendations for designing a simplified arthroplasty care pathway that is reproducible in other institutions. 3. Discuss cost-effectiveness research on the latest value-delivering protocols. 4. Recognize areas of continued research and opportunities for future improvement in protocol development. Total joint arthroplasty is a successful orthopedic procedure that is performed in high volume in the United States and internationally. As economic pressures continue to mount in the US health care system, it will become increasingly important to minimize cost and improve quality and value. At the authors' institution, a protocol-based arthroplasty model is used, in many ways based on simplification of the patient care pathway. The largely evidence-based protocol has its foundation in eliminating unnecessary dogmatic practices, enhancing the patient experience, and achieving cost-effectiveness. The authors believe that a model like this can be applied to joint arthroplasty practices across the country in the future to maximize the value delivered to patients.

Reproducibility of the six-minute walk test and Glittre ADL-test in patients hospitalized for acute and exacerbated chronic lung disease

Background: The 6-minute walk test (6MWT) and the Glittre ADL-test (GT) are used to assess functional capacity and exercise tolerance; however, the reproducibility of these tests needs further study in patients with acute lung diseases. Objectives: The aim of this study was to investigate the reproducibility of the 6MWT and GT performed in patients hospitalized for acute and exacerbated chronic lung diseases. Method: 48 h after hospitalization, 81 patients (50 males, age: 52±18 years, FEV1: 58±20% of the predicted value) performed two 6MWTs and two GTs in random order on different days. Results: There was no difference between the first and second 6MWT (median 349 m [284-419] and 363 m [288-432], respectively) (ICC: 0.97; P<0.0001). A difference between the first and second tests was found in GT (median 286 s [220-378] and 244 s [197-323] respectively; P<0.001) (ICC: 0.91; P<0.0001). Conclusion: Although both the 6MWT and GT were reproducible, the best results occurred in the second test, demonstrating a learning effect. These results indicate that at least two tests are necessary to obtain reliable assessments. .

Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.

IMPORTANCE: The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE: To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. MAIN OUTCOMES AND MEASURES: Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. RESULTS: Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. CONCLUSIONS AND RELEVANCE: Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Perceptions of inpatient rehabilitation changes after the Centers for Medicare and Medicaid Service 2010 regulatory updates contrasted with actual performance.

OBJECTIVES: To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual. DESIGN OR SETTING: Cross-sectional survey. PARTICIPANTS AND METHODS: An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011. MAIN OUTCOME MEASUREMENTS: Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing. RESULTS: Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality. CONCLUSION: Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation.

Development of a computer-adaptive version of the forgotten joint score.

Patient-reported outcomes (PROs) are an important endpoint in orthopedics providing comprehensive information about patients' perspectives on treatment outcome. Computer-adaptive test (CAT) measures are an advanced method for assessing PROs using item sets that are tailored to the individual patient. This provides increased measurement precision and reduces the number of items. We developed a CAT version of the Forgotten Joint Score (FJS), a measure of joint awareness in everyday life. CAT development was based on FJS data from 580 patients after THA or TKA (808 assessments). The CAT version reduced the number of items by half at comparable measurement precision. In a feasibility study we administered the newly developed CAT measure on tablet PCs and found that patients actually preferred electronic questionnaires over paper-pencil questionnaires.

Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review.

UNLABELLED: SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD: Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS: Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS: A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.