April 2017

Protocol helps improve TKA outcomes, cut costs

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A multidisciplinary joint replacement program is improving patient outcomes, decreasing complications, and shortening hospital stays, which helps to lessen clinical anguish following total knee arthroplasty as well as the financial burden on patients and the healthcare system.

By Katie Mullen, SPT; Jon R. Cook, PT, DPT; Meghan Warren, PT, MPH, PhD; and Tarang Jain, PT, PhD, DPT

Yelling and groaning. Those of us who have ever been in a physical therapy (PT) clinic while a patient’s knee is being stretched following a total knee arthroplasty (TKA) have all heard the sounds that come with such an intensive process, and if you have ever been that patient, you know the pain that comes with it.

Although this may make TKA sound like a procedure to avoid, these surgeries have become increasingly popular over the last two decades. The life expectancy of our population continues to increase, as does the incidence of degenerative joint diseases and the demand for TKAs from patients, as these procedures have been shown to increase quality of life and decrease pain.1 It is projected that 3.5 million TKAs will be performed annually by 2030.2

As the demand for these surgeries has increased, improvements in surgical technique, decreased complications, and earlier rehabilitation have contributed to the increased success of TKAs. But with the increase in success, technology, and demand comes an increase in price, as costs associated with TKA have also risen over the last 20 years.1 Unfortunately for hospitals and healthcare providers, the rise in cost does not always match the rate of reimbursement. In 2006, the national average charge for total hip and knee arthroplasties was $38,447, but the national average reimbursement was $11,916.

As healthcare evolves and patients shop for the best outcomes at the lowest cost, multidisciplinary TKA programs will be positioned to provide results and savings

This disparity may lead to a decrease in the number of hospitals offering total joint replacements,3 which will pose a problem to our healthcare system if supply cannot match demand. Therefore, there is an increasing need to make TKAs more cost-effective. Physical therapists have a vital role to play in ensuring positive patient outcomes following TKA and in decreasing costs to the healthcare system.

Physical therapy and TKA

Physical therapists are involved throughout the recovery process following TKA, from acute postoperative care to outpatient discharge. The hospital discharge goal is a safe return to the home with referral to appropriate rehabilitation resources. This requires a patient to have functional mobility, which is typically gained through early mobilization. Aggressive PT following a total joint replacement has been proven effective;4 even elderly patients can tolerate and achieve increased functional ability through early, aggressive PT. Additionally, PT immediately following a total hip arthroplasty (THA) has been shown to decrease costs and increase the likelihood of a patient being discharged home.4

However, variability still exists in the initiation and intensity of PT following such procedures.4 A 2015 systematic review of randomized controlled trials by Artz et al found that following TKA, outpatient exercise therapy was initiated between two and 12 weeks postsurgery. The evidence supports the short-term effectiveness of PT after TKA with regard to decreased pain, improved function, and improved knee range of motion (ROM). There remains, however, a need to increase patient education prior to surgery so individuals have a greater awareness of what recovery will entail.5 Research suggests patient expectations are significantly associated with total joint replacement outcomes.6-9

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The Verde Valley JRP

Physical therapists and other healthcare providers at the Verde Valley Medical Center (VVMC) in Cottonwood, AZ, in response to the variability in TKA rehabilitation and the need for more preoperative education, have developed a joint replacement program (JRP) that aims to improve patient outcomes and decrease complications, with the goal of a safe discharge to the home.3 The JRP involves a multi­disciplinary team of healthcare professionals, the patient, and the patient’s family. The program includes a preoperative class, standard pathways for medical care, comprehensive perioperative pain management, aggressive PT, and proactive discharge planning.3

The preoperative class aims to reduce anxiety and increase awareness of postoperative recovery, and includes the patient in goal setting and hospital discharge planning. Through this class, the patient learns about details of the procedure, the benefits of the aggressive rehabilitation program, appropriate pain management strategies, exercises provided by the physical therapist, and goals to be achieved prior to hospital discharge.3

In agreement with evidence supporting the functional benefits of early PT following TKA, the JRP includes initiation of PT between two and four hours postsurgery. During this visit, the physical therapist evaluates the patient and then begins exercises. Rehabilitation first focuses on gait training, bed mobility, balance, closed kinetic chain (CKC) exercises, and ROM, while abiding by precautions. In subacute rehabilitation, exercises are progressed to include increasing ROM, isometric and CKC exercises to improve strength, advancing gait training, stationary biking, and walking on the treadmill. Postacute exercises focus on enabling the patient to return to previous activities; this is accomplished by continuing to increase ROM, performing open kinetic chain exercises for strengthening, improving single-leg balance, introducing pool therapy, and employing task-specific movements. Starting the day after surgery, the patient is seen by a physical therapist twice per day in a group setting, and continues to work toward the PT goals of being able to safely transfer independently, walk more than 150 feet, and complete a home-exercise program; achieving these goals contributes to the determination of discharge readiness.3

Discharge data

Safe discharge to the home is not only a goal of the JRP; in our clinical experience, it is also most often the primary goal of patients, and a significant contributor to decreased costs to the healthcare system. El Bitar et al noted that a 1974 study reported the average length of a hospital stay following total joint replacement was 23 days; that number has now decreased to an average in the US of 3.7 days.1

Data we collected from April 2006 to November 2007, which assessed the effectiveness of the JRP at six-month follow-up, showed an even shorter average length of stay for the 74 included patients. Discharge within two days was achieved by 53% of patients, 39% went home within three days, and 7% were discharged within four days. The average length of stay was 2.5 days.3

Discharge to the home compared with discharge to a skilled nursing facility (SNF) has been shown to decrease the odds of hospital readmission within 90 days, which also contributes to cost savings.10 In a 2008 study by Bini et al, data extracted from the Kaiser Permanente Total Joint Replacement Registry from April 2001 to December 2004 showed 15% of patients were discharged to an SNF following TKA.10 In our VVMC study, only three patients (4%) were discharged to an SNF following JRP participation.3

Physical therapists play a beneficial role in rehabilitation after TKA, both immediately after surgery and after hospital discharge, as well, by helping patients continue to improve their ROM, strength, and functional ability. We analyzed data from July 2005 to January 2010 from our JRP to assess the program’s impact on functional and clinical outcomes of direct referral to outpatient PT compared with referral to home health (HH) PT.11

Upon discharge home from the JRP, patients were referred to either outpatient PT (87 patients), or HH PT prior to outpatient PT (22 patients).11 Patients were discharged home and referred to outpatient PT if the orthopedist, along with the multidisciplinary team, determined the patient had achieved medical stability (ie, no other known conditions that could lead to readmission), wound stability (ie, no signs of infection), appropriate blood coagulation values, pain control with oral medications, and progress toward PT goals. If the patient needed additional medical treatment, was unsafe with mobility, or had transportation issues, he or she was referred to HH PT or another appropriate postacute care center.2

Although the number of outpatient visits did not differ between groups, patients who went directly to outpatient PT had shorter recovery times in terms of days from surgery to PT discharge than those in the HH group. However, there were no significant between-group differences in the number of patients who achieved their knee ROM goals or in patients’ walking endurance, self-reported pain, or quality of life at PT discharge. Given that these data show similar outcomes in both groups and a shorter recovery time for the outpatient PT group, outpatient PT following TKA may be more cost-effective than HH.

The JRP helps decrease expenditures through appropriate, direct referral of patients to outpatient PT. However, it is necessary to emphasize that patients can have similar outcomes postsurgery, even if HH PT is deemed necessary at discharge. These results are encouraging, as this may contribute to the JRP goals of patient safety and decreased complication rates, which still may result in cost savings.11

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Future directions

While results from the JRP have been encouraging so far, more research is needed for this program to continue to be meaningful for patient recovery and for the healthcare system. At VVMC we are currently assessing the association between preoperative functional characteristics, such as self-reported disability, walking distance, 30-day readmission, and length of hospital stay and recovery following TKA.2 This data will help the JRP team better understand which aspects of preoperative education and function should be prioritized before surgery to optimize recovery. Jon Cook, PT, DPT, coordinator of the Joint Replacement and Sports Medicine programs at VVMC and a coauthor of this paper, has noted the future of TKA rehabilitation will include “identification of prognostic indicators that may predispose patients to complications…” and the JRP team will utilize research to identify “…plans to resolve these.”

Yelling and groaning: Delayed PT, complications, and lack of mobility all contribute to these grievances and to prolonged recovery following TKA. The JRP at VVMC is achieving improved patient outcomes, decreased complications, and shortened hospital stays, all of which help to lessen the clinical anguish that occurs following TKA. In addition to decreasing recovery time, the JRP is also contributing to decreased financial burden on patients and the healthcare system.

For patients in need of TKA, awareness of hospitals that use programs like the JRP is important, as this could contribute to a safer, quicker return to home and physical function, with an improved quality of life, at a lower cost, compared with traditional protocols. As our healthcare system evolves, patients are encouraged to shop for the greatest outcomes at the lowest cost, and programs such as this are in a position to provide both results and savings.

For physical therapists and other healthcare providers, it is necessary to understand the trends of TKA rehabilitation and be a part of the solution to the problems associated with such high procedural demand. As the reimbursement system shifts its emphasis toward outcomes as opposed to services rendered, all healthcare providers must use programs supported by evidence, like the JRP, to provide appropriate care and increase the value they provide to the healthcare system.

Katie Mullen, SPT, is a physical therapy student at Northern Arizona University in Flagstaff. John R. Cook, PT, DPT, is the coordinator of the Joint Replacement and Sports Medicine programs at Verde Valley Medical Center in Cottonwood, AZ. Meghan Warren, PT, MPH, PhD, is an associate professor and Tarang Jain, PT, DPT, PhD is an assistant professor in the physical therapy department at Northern Arizona University.

  1. El Bitar Y, Illingworth K, Scaife S, et al. Hospital length of stay following primary total knee arthroplasty: data from the nationwide inpatient sample database. J Arthroplasty 2015;30(10):1710-1715.
  2. Cook J, Jain T, Warren M, et al. A comprehensive joint replacement rehabilitation program at the Verde Valley Medical Center. 2015.
  3. Cook J, Warren M, Ganley K, et al. A comprehensive joint replacement program for total knee arthroplasty: a descriptive study. BMC Musculoskelet Disord 2008;9:154.
  4. Roos E. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol 2003;15(2):160-162.
  5. Artz N, Elvers K, Lowe C, et al. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord 2015;16:1.
  6. Scott CEH, Bugler KE, Clement ND, et al. Patient expectations of arthroplasty of the hip and knee. J Bone Joint Surg Br 2012;94(7):974-981.
  7. Gonzalez Saenz de Tejada M, Escobar A, Herrera C, et al. Patient expectations and health-related quality of life outcomes following total joint replacement. Value Health 2010;13(4):447-454.
  8. Muniesa JM, Marco E, Tejero M, et al. Analysis of the expectations of elderly patients before undergoing total knee replacement. Arch Gerontol Geriatr 2010;51(3):e83-e87.
  9. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients’ expectations of knee surgery. J Bone Joint Surg Am 2001;83(7):1005-1012.
  10. Bini S, Fithian D, Paxton L, et al. Does discharge disposition after primary total joint arthroplasty affect readmission rates? J Arthroplasty 2010;25(1):114-117.
  11. Warren M, Kozik J, Cook J, et al. A comparative study to determine functional and clinical outcome differences between patients receiving outpatient direct PT versus home PT followed by outpatient PT after total knee arthroplasty. Orthop Nurs 2016;35(6):382-390.

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