Associations Between Prehabilitation and Postoperative Healthcare Utilization for Total Hip or Total Knee Arthroplasty in Medicare Beneficiaries.

Prehabilitation has potential to improve outcomes in value-based care models. We examined the associations between the receipt of prehabilitation (physical therapy [PT] services within 30 days preoperatively) and postoperative healthcare utilization in a national cohort of fee-for-service Medicare beneficiaries. This retrospective cohort study used the 5% fee-for-service claims from the Medicare limited data set to identify unilateral elective inpatient total hip arthroplasty (THA) procedures (n = 25,509) and total knee arthroplasty (TKA) procedures (n = 40,091) from January 1, 2016 to September 30, 2021. Associations between prehabilitation and postoperative healthcare utilization were analyzed in mixed-effects generalized linear models adjusting for patient-level and hospital-level factors. We report adjusted odds ratios (OR) or % differences. Prehabilitation (13.1% THA, 13.1% TKA) was not significantly associated with institutional postacute care discharge, 30-day emergency department visits, or 90-day readmissions. For TKA, prehabilitation was significantly associated with decreased odds of an extended hospital length of stay (OR = 0.86, P = 0.02) and reduced length of stay in an institutional postacute care facility (-5.71%, P = 0.004). In both THA and TKA, prehabilitation was associated with decreased use of 90-day home health physical and/or occupational therapy (THA: OR = 0.82, P = 0.001; TKA: OR = 0.67, P < 0.001). In contrast, prehabilitation in both cohorts was associated with the increased odds of receiving any 90-day outpatient PT (THA: OR = 2.08, P < 0.001; TKA: OR = 2.48, P < 0.001) and an increased number of 90-day outpatient PT visits (THA: +4.04%, P = 0.01; TKA: +5.21%, P < 0.001). Prehabilitation was associated with some decreases in postoperative healthcare utilization, particularly for TKA. Associations of preoperative PT with increased postoperative outpatient PT may reflect variation in referral patterns or patient access. These results highlight the importance of continued research into the impact of prehabilitation on healthcare utilization, patient outcomes, and episode costs. Additionally, further research should identify which patients would benefit the most from prehabilitation to increase the value of care.

Sabo GC ，Stern BZ ，Balachandran U ，Agranoff R ，Hayden BL ，Poeran J ，Moucha CS ... -  《-》

Frailty Is Strongest Need Factor Among Predictors of Prehabilitation Utilization for Total Hip or Knee Arthroplasty in Fee-for-Service Medicare Beneficiaries.

Prehabilitation may have benefits for total hip arthroplasty (THA) and total knee arthroplasty (TKA), given an aging population with multimorbidity and the growth of value-based programs that focus on reducing postoperative costs. This study aimed to describe prehabilitation use and examine predictors of utilization in fee-for-service Medicare beneficiaries. This retrospective cohort study using the Medicare Limited Data Set included fee-for-service Medicare beneficiaries who were ≥66 years old and who underwent inpatient elective THA or TKA between January 1, 2016, and September 30, 2021. The study assessed predictors of receiving preoperative physical therapist services within 90 days of surgery (prehabilitation) using a mixed-effects generalized linear model with a binary distribution and logit link. Adjusted odds ratios (ORs) were reported. Of 24,602 THA episodes, 18.5% of patients received prehabilitation; of 38,751 TKA episodes, 17.8% of patients received prehabilitation. For both THA and TKA, patients with medium or high (vs low) frailty were more likely to receive prehabilitation (OR = 1.72-2.64). Male (vs female) patients, Black (vs White) patients, those with worse county-level social deprivation, those with dual eligibility, and those living in rural areas were less likely to receive prehabilitation before THA or TKA (OR = 0.65-0.88). Patients who were ≥85 years old (vs 66-69 years old) and who underwent THA were also less likely to receive services (OR = 0.84). Additionally, there were geographic differences in prehabilitation utilization and increased utilization in more recent years. The need factor of frailty was most strongly associated with increased prehabilitation utilization. The variation in utilization by predisposing factors (eg, race) and enabling factors (eg, county-level social deprivation) suggests potential disparities. The findings describe prehabilitation use in a large cohort of fee-for-service Medicare beneficiaries. Although services seem to be targeted to those at greater risk for adverse outcomes and high spending, potential disparities related to access warrant further examination.

Stern BZ ，Sabo GC ，Balachandran U ，Agranoff R ，Hayden BL ，Moucha CS ，Poeran J ... -  《-》

Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. Level III, therapeutic study.

Buchanan MW ，Gibbs B ，Ronald AA ，Novikov D ，Yang A ，Salavati S ，Abdeen A ... -  《-》

Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty.

While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.

Bonsel JM ，Kodali H ，Poeran J ，Bonsel GJ ... -  《-》

Do the Revision Rates of Arthroplasty Surgeons Correlate With Postoperative Patient-reported Outcome Measure Scores? A Study From the Australian Orthopaedic Association National Joint Replacement Registry.

Patient-reported outcome measures (PROMs) are a pragmatic and efficient means to evaluate the functional quality of arthroplasty beyond revision rates, which are used by most joint replacement registries to judge success. The relationship between these two measures of quality-revision rates and PROMs-is unknown, and not every procedure with a poor functional result is revised. It is logical-although still untested-that higher cumulative revision rates correlate inversely with PROMs for individual surgeons; more revisions are associated with lower PROM scores. We used data from a large national joint replacement registry to ask: (1) Does a surgeon's early THA cumulative percent revision (CPR) rate and (2) early TKA CPR rate correlate with the postoperative PROMs of patients undergoing primary THA and TKA, respectively, who have not undergone revision? Elective primary THA and TKA procedures in patients with a primary diagnosis of osteoarthritis that were performed between August 2018 and December 2020 and registered in the Australian Orthopaedic Association National Joint Replacement Registry PROMs program were eligible. THAs and TKAs were eligible for inclusion in the primary analysis if 6-month postoperative PROMs were available, the operating surgeon was clearly identified, and the surgeon had performed at least 50 primary THAs or TKAs. Based on the inclusion criteria, 17,668 THAs were performed at eligible sites. We excluded 8878 procedures that were not matched to the PROMs program, leaving 8790 procedures. A further 790 were excluded because they were performed by unknown or ineligible surgeons or were revised, leaving 8000 procedures performed by 235 eligible surgeons, including 4256 (53%; 3744 cases of missing data) patients who had postoperative Oxford Hip Scores and 4242 (53%; 3758 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 3939 procedures for the Oxford Hip Score and for 3941 procedures for the EQ-VAS. A total of 26,624 TKAs were performed at eligible sites. We excluded 12,685 procedures that were not matched to the PROMs program, leaving 13,939 procedures. A further 920 were excluded because they were performed by unknown or ineligible surgeons, or because they were revisions, leaving 13,019 procedures performed by 276 eligible surgeons, including 6730 (52%; 6289 cases of missing data) patients who had had postoperative Oxford Knee Scores and 6728 (52%; 6291 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 6228 procedures for the Oxford Knee Score and for 6241 procedures for the EQ-VAS. The Spearman correlation between the operating surgeon's 2-year CPR and 6-month postoperative EQ-VAS Health and Oxford Hip or Oxford Knee Score was evaluated for THA and TKA procedures where a revision had not been performed. Associations between postoperative Oxford and EQ-VAS scores and a surgeon's 2-year CPR were estimated based on multivariate Tobit regressions and a cumulative link model with a probit link, adjusting for patient age, gender, ASA score, BMI category, preoperative PROMs, as well as surgical approach for THA. Missing data were accounted for using multiple imputation, with models assuming they were missing at random and a worst-case scenario. Of the eligible THA procedures, postoperative Oxford Hip Score and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (Spearman correlation ρ = -0.09; p < 0.001), and the correlation with postoperative EQ-VAS was close to zero (ρ = -0.02; p = 0.25). Of the eligible TKA procedures, postoperative Oxford Knee Score and EQ-VAS and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (ρ = -0.04; p = 0.004 and ρ = 0.03; p = 0.006, respectively). All models accounting for missing data found the same result. A surgeon's 2-year CPR did not exhibit a clinically relevant correlation with PROMs after THA or TKA, and all surgeons had similar postoperative Oxford scores. PROMs, revision rates, or both may be inaccurate or imperfect indicators of successful arthroplasty. Missing data may limit the findings of this study, although the results were consistent under a variety of different missing data scenarios. Innumerable factors contribute to arthroplasty results, including patient-related variables, differences in implant design, and the technical quality of the procedure. PROMs and revision rates may be analyzing two different facets of function after arthroplasty. Although surgeon variables are associated with revision rates, patient factors may exert a stronger influence on functional outcomes. Future research should identify variables that correlate with functional outcome. Additionally, given the gross level of function that Oxford scores record, outcome measures that can identify clinically meaningful functional differences are required. The use of Oxford scores in national arthroplasty registries may rightfully be questioned. Level III, therapeutic study.

Hoskins W ，Bingham R ，Corfield S ，Harries D ，Harris IA ，Vince KG ... -  《-》