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
Tucker Sutherland, editor, SeniorJournal.com
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.
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.
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
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.
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
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