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Physical Therapy Before Hip, Knee Replacements May Save Medicare Mega-Millions

Also good news for senior citizens, who undergo most knee, hip replacements, to endure less stress following surgery

By Tucker Sutherland, editor,

hip replacement graphicOct. 7, 2014 – New research released today finds that postoperative care and costs could be reduced by about 30% for patients having total hip (THR) or total knee (TKR) replacement surgery, if physical therapy is administered before joint replacement surgery. It is good news for senior citizens, who have the majority of these procedures, and it makes sense considering the increasing abilities of seniors to tolerate physical exercise at increasing age levels.

This new study, appearing in the October 1 issue of the Journal of Bone & Joint Surgery (JBJS), says that physical therapy before joint replacement surgery, or “prehabilitation,” can save an average of $1,215 per patient in skilled nursing facility, home health agency or other postoperative care.

Physical therapy after total hip (THR) or total knee replacement (TKR) surgery has been standard care for all patients. But rarely in the recommendations on procedures for these massive operations had pre-surgery physical therapy been mentioned.

When we talk about these two procedures, the patients we are talking about are older people and primarily seniors citizens age 65 or older.


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In 2010 there were 332,000 hip replacements in short-stay hospitals in U.S. - 168,000 (51%) were patients age 65 or older, 148,000 (45%) were ages 45 through 64. Combining the two age groups shows about 96% of these operations involved people at least age 45, according to the National Hospital Discharge Survey: 2010.

Knee replacements totaled 719,000 in 2010: 385,000 (54%) were people 65 and older, 317,000 (44%) were ages 45 through 64. The combined groups here show about 98% of these procedures involved those age 45 or older.

This data shows there were a total of 553,000 THR and THK procedures in 2010 just for seniors age 65 and up. If we multiply that number by the projected $1,215 in savings per case, we can project a savings of $671,895,000 a year for the Centers for Medicare and Medicaid Services. This assumes, of course, that all these procedures on people 65 and older are paid for my Medicaid or Medicare. A part of this savings, however, would probably go to companies providing supplemental Medicare coverage.

Then, too, we would have to calculate the tremendous increase in older people in the U.S. population and probably estimate that a larger percentage of tomorrow’s seniors will qualify and choose this replacement surgery due to the improving physical health and abilities of elderly Americans.

Approximately 50 million U.S. adults have physician-diagnosed arthritis. As the condition progresses, arthritis patients often require THR and/or TKR to maintain mobility and life quality.

The number of THRs is expected to grow by 174 percent (572,000 patients) between 2005 and 2030, and TKRs by 673 percent (3.48 million).

In recent years, the length of hospital stay following surgeries has decreased from an average of 9.1 days in 1990 to 3.7 days in 2008, while the cost of post-acute care, primarily in skilled nursing facilities and home health agencies, has “skyrocketed.”

Utilizing Medicare claims data, researchers were able to identify both preoperative physical therapy and postoperative care usage patterns for 4,733 THR and TKR patients. Postoperative, or “post-acute” care, was defined as the use of a skilled nursing facility, home health agency or inpatient rehabilitation center within 90 days after hospital discharge.

Home health agency services included skilled nursing care, home health aides, physical therapy, speech therapy, occupational therapy and medical social services.

Approximately 77 percent of patients utilized care services following surgery. After adjusting for demographic characteristics and comorbidities (other conditions), patients receiving preoperative physical therapy showed a 29 percent reduction in postoperative care use. In addition:

    >>  54.2 percent of the preoperative physical therapy group required postoperative care services, compared to 79.7 percent of the patients who did not have preoperative therapy.

   >>  The decline in postoperative care services resulted in an adjusted cost reduction of $1,215 per patient, due largely to lower costs for skilled nursing facility and home health agency care.

   >>  Preoperative physical therapy cost an average of $100 per patient, and was generally limited to one or two sessions.

 “This study demonstrated an important opportunity to pre-empt postoperative outcome variances by implementing preoperative physical therapy along with management of comorbidities before and during surgery,” said orthopaedic surgeon Ray Wasielewski, MD, co-author of the study.

Study Details

Historical claims data was analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency or inpatient rehabilitation facility during the 90-day period after a surgical hospitalization. To evaluate the associations, the study authors utilized bivariate and multivariate techniques focused on post-acute care use and total episode of care costs.

Editor’s Note: This story is based on materials provided by JBJS and the American Academy of Orthopaedic Surgeons (AAOS) on Facebook, Twitter and Google+

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