Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

BACKGROUND: Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature. PURPOSES: We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care. METHODS: This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models. RESULTS: The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care. CONCLUSIONS: Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.

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.

Fine particulate matter components and emergency department visits among a privately insured population in Greater Houston.

Although adverse health effects of PM2.5 (particulate matter with aerodynamic diameter less than 2.5µm) mass have been extensively studied, it remains unclear regarding which PM2.5 components are most harmful. No studies have reported the associations between PM2.5 components and adverse health effects among a privately insured population. In our study, we estimated the short-term associations between exposure to PM2.5 components and emergency department (ED) visits for all-cause and cause-specific diseases in Greater Houston, Texas, during 2008-2013 using ED visit data extracted from a private insurance company (Blue Cross Blue Shield Texas [BCBSTX]). A total of 526,453 ED visits were included in our assessment, with an average of 236 (±63) visits per day. We selected 20 PM2.5 components from the U.S. Environmental Protection Agency's Chemical Speciation Network site located in Houston, and then applied Poisson regression models to assess the previously mentioned associations. Interquartile range increases in bromine (0.003µg/m(3)), potassium (0.048µg/m(3)), sodium ion (0.306µg/m(3)), and sulfate (1.648µg/m(3)) were statistically significantly associated with the increased risks in total ED of 0.71% (95% confidence interval (CI): 0.06, 1.37%), 0.71% (95% CI: 0.21, 1.22%), 1.28% (95% CI: 0.34, 2.24%), and 1.22% (95% CI: 0.23, 2.23%), respectively. Seasonal analysis suggested strongest associations occurred during the warm season. Our findings suggest that a privately insured population, presumably healthier than the general population, may be still at risk of adverse health effects due to exposure to ambient PM2.5 components.

Effect of Public Reporting on MR Imaging Use for Low Back Pain.

PURPOSE: To determine whether magnetic resonance (MR) imaging examination rates for low back pain before conservative therapy in the Medicare and privately insured populations changed after introduction of a Centers for Medicare & Medicaid Services public reporting initiative. MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. A retrospective study was performed by using fee-for-service claims data from Medicare and a commercial carrier (Blue Cross Blue Shield of Texas [BCBSTX]) for Texas enrollees. OP-8 was calculated, which is a publicly reported measure as of 2009 of the proportion of MR imaging examinations performed for low back pain without history of conservative therapy. For 330 463 MR imaging examinations, OP-8 rates, trends, and regional variation were analyzed for 2008-2011 within different outpatient settings-outpatient hospital department (OHD) and nonhospital outpatient department (NOD)-according to payer. Largest-volume hospitals were also evaluated within the Medicare population. RESULTS: No significant reduction was found in annual OP-8 values for Medicare or BCBSTX (Medicare OHD, 0.35 for 2008 vs 0.36 for 2009 [P = .01]; BCBSTX OHD, 0.42 for 2008 vs 0.44 for 2009 [P = .03]; Medicare NOD, 0.33 for 2008 vs 0.35 for 2009 [P < .0001]; and BCBSTX NOD, 0.43 for 2008 vs 0.42 for 2009[P = .23]). These changes were not sustained during subsequent years in the BCBSTX population, and there were no further changes in Medicare rates. Among hospitals with highest Medicare volumes, those with the highest OP-8 rates in 2008 were associated with the highest decrease in their measure. (The annual change rate was negative for all years, with 2008 as the reference [P < .0001 for 2009-2011].) Hospitals with the lowest OP-8 rates had increases in OP-8 rates, which persisted in following years (P = .006 for 2009, P = .037 for 2010, and P = .004 for 2011). Hospitals with baseline OP-8 rates in the 25th-75th percentile remained relatively steady over time. CONCLUSION: No evidence was found that public reporting (OP-8) reduced MR imaging rates for low back pain without conservative therapy in either Medicare or commercially insured populations in hospital or nonhospital settings.