Changes in Total Knee Arthroplasty Utilization since the Implementation of ACA: An Analysis of Patient-Hospital Demographics, Costs, and Charges.

The Patient Protection and Affordable Care Act (PPACA) formed the Center for Medicare and Medicaid Innovation Center which has implemented experimental reimbursement models targeted at high-demand procedures to improve care quality. However, the effect of health care reform on total knee arthroplasty (TKA) procedures has not been explored. This study explores patient-hospital level demographics, inpatient costs, and charges related to TKA procedures between 2009 and 2015. The National Inpatient Sample database was utilized to identify patients who received primary TKA between January 2009 and October 2015 (4,283,387 cases). Categorical, continuous, and ordinal data were analyzed using chi-square/Fisher's exact test, t-test/analysis of variance, or Kruskal-Wallis' test, respectively. There was an increase in proportion of TKA recipients belonging to minority groups and the lowest quartile of median income (p < 0.05). There was a 1.9% increase in recipients using Medicaid as a primary payor and volume shifts from urban nonteaching toward urban teaching hospitals. There was a reduction in mean length of stay and mean inpatient costs. There were increases in hospital charges, but reductions in rates of inpatient mortality, and other postoperative complications. TKA procedures remain the most common surgical procedure; therefore, our study assessed national trends to capture the effect of PPACA. We found an increasing proportion of TKA recipients belonging to minority and low-income groups, volume shifts to urban teaching hospitals, and lower costs of care. These findings may be useful in objectively critiquing the effects of PPACA on TKA-related care.

Rehabilitation protocols following total knee arthroplasty: a review of study designs and outcome measures.

Total knee arthroplasty (TKA) is among the most common elective procedures performed worldwide. Recent efforts have been made to significantly improve patient outcomes, specifically with postoperative rehabilitation. Despite the many rehabilitation modalities available, the optimal rehabilitation strategy has yet to be determined. Therefore, this systematic review focuses on evaluating existing postoperative rehabilitation protocols. Specifically, this review analyses the study designs, rehabilitation methods, and outcome measures of postoperative rehabilitation protocols for TKA recipients in the past five years. The PubMed, EMBASE, and Cochrane Library databases were queried for studies evaluating rehabilitation protocols following primary TKA. Of the 11,013 studies identified within the last five years, 70 met the inclusion and exclusion criteria. After assessing for relevance and removing duplicates, a final count of 20 studies remained for analysis. Level-of-evidence was determined by the American Academy of Orthopaedic Surgeons (AAOS) classification system. Our findings demonstrated that continuous passive motion and inpatient rehabilitation may not provide additional benefit to the patient or healthcare system. However, early rehabilitation, telerehabilitation, outpatient therapy, high intensity, and high velocity exercise may be successful forms of rehabilitation. Additionally, weight-bearing biofeedback, neuromuscular electrical stimulation, and balance control appear to be beneficial adjuncts to conventional rehabilitation. Postoperative rehabilitation following TKA facilitates patient recovery and improves quality of life. This systematic review analyzed the existing rehabilitation protocols from the past five years. Some studies did not accurately describe the conventional rehabilitation protocols, the duration of therapy sessions, and the timing of these sessions. As such, future studies should explicitly describe their methodology. This will allow high-quality assessments and the conception of standardized protocols.