title: Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement.
abstract: BACKGROUND
  Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty.
  
  
  METHODS
  Historical claims data were 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 ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs.
  
  
  RESULTS
  The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172).
  
  
  CONCLUSIONS
  The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. This association was sustained after adjusting for comorbidities, demographic characteristics, and procedural variables.
  
  
  CONCLUSIONS
  Health-care providers can use this methodology to achieve an integrative, cost-effective, patient care pathway using preoperative physical therapy.
authors.affiliation: OhioHealth, 155 East Broad Street, 18th Floor, Columbus, OH 43215. E-mail address for R. Snow: Richard.Snow@ohiohealth.com. E-mail address for K. Vogel: Karen.Vogel@ohiohealth.com.
authors.forename: Richard
authors.initials: R
authors.lastname: Snow
authors.affiliation: Orthopedic Foot and Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082. E-mail address: jaymes.granata@gmail.com.
authors.forename: Jaymes
authors.initials: J
authors.lastname: Granata
authors.affiliation: Ohio University, The Voinovich School of Leadership and Public Affairs, Building 21, Room 115, 1 Ohio University, Athens, OH 45701-2979. E-mail address: ruhil@ohio.edu.
authors.forename: Anirudh V S
authors.initials: AV
authors.lastname: Ruhil
authors.affiliation: OhioHealth, 155 East Broad Street, 18th Floor, Columbus, OH 43215. E-mail address for R. Snow: Richard.Snow@ohiohealth.com. E-mail address for K. Vogel: Karen.Vogel@ohiohealth.com.
authors.forename: Karen
authors.initials: K
authors.lastname: Vogel
authors.affiliation: Ohio Orthopedic Center of Excellence, 4605 Sawmill Road, Upper Arlington, OH 43220. E-mail address: MAMcShane@Ohio-Ortho.com.
authors.forename: Michael
authors.initials: M
authors.lastname: McShane
authors.affiliation: Minimally Invasive Orthopedics, 340 East Town Street, Suite 7-250, Columbus, OH 43215. E-mail address: Ray.Wasielewski@ohiohealth.com.
authors.forename: Ray
authors.initials: R
authors.lastname: Wasielewski
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000191:economics*; D019645:Arthroplasty, Replacement, Knee / Q000191:economics*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D019091:Critical Pathways; D005260:Female; D006801:Humans; D008297:Male; D026741:Physical Therapy Modalities / Q000706:statistics & numerical data*; D011300:Preoperative Care / Q000706:statistics & numerical data*; D019467:Subacute Care / Q000706:statistics & numerical data*; D014481:United States