Does “Prehab” Lower Episode-of-Care Costs in TJA?

Many orthopaedic surgeons still believe that physical therapy (PT) services simply add to the total cost of care without improving patient outcomes. During my orthopaedic education, several knowledgeable attending surgeons said patients can be shown exercises in the orthopaedic clinic and do them on their own to avoid the increased expense of PT services. This belief extended to preoperative PT (“prehab”) to prepare patients for joint-replacement procedures. Until now, the impact of prehab on the total cost of care had not been rigorously evaluated.

In a well-designed study in the October 1, 2014 edition of The Journal, Snow et al. investigated whether preoperative PT affected total episode-of-care cost for hip- and knee-replacement procedures. They used CMS (Centers for Medicare & Medicaid Services) data from 169 urban and rural hospitals in Ohio and gleaned 4733 complete records to answer the question. The outcome measures of interest were utilization of post-acute care in the first 90 days after the procedure and total episode-of-care costs. The study defined post-acute care as admission to a skilled nursing facility, use of inpatient rehabilitation services, or use of home health services.

Nearly 80% of patients who did not receive preoperative PT services utilized post-acute care services, compared with 54% of patients who did receive prehab services. This resulted in a mean cost reduction of $871 per episode (after adjusting for age and comorbidities), with much of the savings accruing from decreased use of skilled nursing facilities. In their discussion, the authors note that prehab in this study generally consisted of only one or two sessions, and they therefore suggest that “the value of preoperative physical therapy was primarily due to patient training on postoperative assistive walking devices, planning for recovery, and managing patient expectations, and not from multiple, intensive training sessions to develop strength and range of motion.”

So it seems that prehab can reduce the overall cost of care in the setting of joint replacement.  Further investigations using commercial insurance datasets to supplement this CMS data will be useful in developing treatment protocols and policies in this age of global payments for episodes of care.

Marc Swiontkowski. MD, Editor-in-Chief, JBJS

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3 responses to “Does “Prehab” Lower Episode-of-Care Costs in TJA?”

  1. Frank Kolisek MD says :

    This type of “prehab” may be better defined as “patient education” so as to not be confused with the multiple intensive pre-op training sessions previously attempted in the late 80’s and early 90’s which was also called prehabilitation and focused on patient outcomes.This one time pre-op education session (prehab) sets the post-op expectations and plan for the patient and the discharge disposition for the patient and family which is what lowers the overall cost of care as pointed out in this paper. This has worked in my practice for many years. Great information. Thanks, Frank Kolisek MD

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  2. Dara says :

    Do you think pre-hab would help educate the patients on the importance of DVT/VTE prevention? Educating the patient on the importance of early ambulation and the use of SCD’s when not ambulating? Also, the importance of patient compliance with Heparin or Lovenox injections can be taught during this pre-hab experience.

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  1. Why Prehabilitation for Total Knee Replacements Matters | Foothills Sports Medicine - October 20, 2015

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