It isn't news that the number of total knee and total hip replacements is rising across the country. But what may be news is that efforts to reduce hospital readmissions associated with the surgeries may be working, albeit in different ways for different age groups.
A study released by the American Association of Retired Persons (AARP) looked at over 142,000 insurance claims from individuals 50 and older enrolled with a "large insurance carrier" to calculate the prevalence of the replacement surgeries—and rates of 30-day readmissions—from 2009 to 2013. What they found was that while both total hip arthroplasty (THA) and total knee arthroplasty (TKA) numbers rose dramatically, readmission rates fell nearly as dramatically, particularly among the 65- to 84-year-old age group.
Overall, THA rates jumped by 73% between 2009 and 2013, with TKA rates rising by 46% during the same period. THA rates for the 65-84 age group increased by 113%, while the 50-64 group saw a 58% rise. For TKA procedures, the older group once again outpaced the younger group, with the 65-84 group registering an 80% increase in procedures, compared with the 50-64 group's 23% increase.
During that same period, unplanned 30-day hospital readmission rates fell significantly, according to the study. Overall rates for THA-related readmissions fell by 20% across age groups, while TKA readmission rates dropped by 23%.
Like the rates of increase for the procedures themselves, the drops in readmission rates were also different between the age groups—sometimes dramatically so.
THA-related readmission rates registered the most significant differences, with the 65-84 age group reporting a 38% drop in readmission rates (from 5.5% to 3.4%), while the younger group saw a drop of only 3% (from 3.5% to 3.4%). Similarly, TKA readmission rates dropped by 36% for the older group (from 5.2% to 3.2%), and 12% for the younger group (from 4% to 3.5%).
The bottom line: by the end of 2013, 30-day THA and TKA readmission rates were virtually identical among all adults age 50-84.
As for causes of readmission, device complications and complications from surgery led the list throughout the study period. "Rehabilitation/device adjustment" registered as a cause in 2009 for the older group only (11% of THA readmissions, and 9% of TKA readmissions), but fell off the list of top 3 causes by 2013.
The AARP study authors called the results "promising," but wrote that the relatively slower reduction in readmissions for the younger group "raises concerns that hospitals could be focusing their readmission reduction efforts on Medicare beneficiaries rather than the broader population."
In an online article on the AARP report in Forbes magazine, author Bob Rosenblatt offers up another theory on what's responsible for the drop: an increased use of "observation status" designations among hospitals. The Forbes article cites an AARP analysis of Medicare data that found the top 10% of hospitals with the largest drop in 30-day readmissions between 2011 and 2012 increased their use of observation status for returning patients by an average of 25%.
When it comes to rehabilitation, many physical therapists (PTs) and physical therapist assistants (PTAs) don't play around.
But maybe they should.
The "gamification" of physical therapy may not be anything new, but it's been receiving attention from the media lately. Here's a quick roundup of some of the highlights published recently.
The New Yorker looks at "a radical new approach to treating stroke patients"
This feature-length article in the November 23 issue of the magazine looks at "Bandit Shark Showdown," a rehabilitative video game designed by a team of neuroscientists and game developers in the Brain, Learning, Animation, Movement (BLAM!) lab at Johns Hopkins University. Writer Karen Russell explores the game's development and BLAM! leader John Krakauer's thoughts on the relationship between the brain and the motor system.
A new "virtual physical therapy" system gets FDA approval
Medical Device and Diagnostic Industry Online looks at Vera, not exactly a game itself but a system that incorporates the Microsoft Kinect platform often used for gaming. Reflxion Health's "Vera" system includes 2-way video connection between patient and PT, as well as an avatar that monitors and evaluates patients' home exercises to facilitate rehabilitation from joint replacement.
Inc. magazine declares virtual reality "will change physical therapy forever"
"Recently, with the expansion of medical-related technology, a new type of physical therapy has arisen," Inc. announces in this article. The piece includes links to clinics providing physical therapy via virtual reality as well as to a 2002 article on virtual reality and stroke rehabilitation from APTA's journal Physical Therapy (proving that what's news to Inc. may not necessarily be news to PTs).
Long-Term Living focuses on gamification
This brief article explores the trend toward "turning physical therapy into a game," and focuses on the Medical Interactive Recovery Assistant (MIRA) technology developed by TED fellow Cosmin Mihaiu.
New twists on virtual reality and gaming applications in physical therapy are developing constantly, but the basic concept is a familiar one to readers of PT in Motion, APTA's member magazine. The magazine covered virtual reality in 2012 and 2011, and published a feature article on gamification in physical therapy in 2014.
The Centers for Medicare and Medicaid Services' (CMS) plan to implement a mandatory bundled care system for total hip and knee replacements in 2016 is not quite as extensive as originally planned and won't start on January 1—but it's still a big change, and it hasn't been delayed for that long.
The basic idea is that in 67 metropolitan statistical areas, CMS will impose a bundled payment system—called the Comprehensive Care for Joint Replacement (CJR) model—for total knee and total hip replacements, comparing what hospitals spend in total on care, from admission to 90 days postdischarge, with what Medicare thinks they should be spending. If the total spending is less than the Medicare target, the hospitals may be eligible to receive additional payment from Medicare—but if they spend more than the Medicare target, they could be required to pay back Medicare for some portion of the difference.
In a final ruled issue this week, CMS reduced the number of areas that will be affected by the CJR from 75 to 67, and postponed startup of the project until April 1, 2016, instead of January 1. One element that remains unchanged: the hospitals included in the 67 metropolitan areas (a list of those areas can be found here) won't have a choice when it comes to participation.
APTA regulatory affairs staff members are reviewing the final rule and will provide a detailed summary in the coming weeks. In the meantime, here are a few highlights from the rule:
According to CMS, hip and knee surgeries were chosen because they are the most common inpatient surgery for Medicare patients, and they tend to be high-cost, high-utilization procedures with a wide variance in spending—from $16,500 to $33,000, according to a CMS press release. The initiative comes from CMS's Center for Medicare and Medicaid Innovation.
Stay tuned: APTA will be providing a full analysis and summary of the new rule in the coming weeks.
A lawsuit challenging the North Carolina Acupuncture Licensing Board's efforts to prevent physical therapists (PTs) from engaging in dry needling is being supported by the North Carolina Physical Therapy Association. Titled Henry v North Carolina Acupuncture Licensing Board, the challenge is an antitrust lawsuit filed in the US District Court for the Middle District of North Carolina, arguing that the North Carolina Acupuncture Licensing Board (NCALB) is violating antitrust law and due process rights in its actions to prevent PTs from practicing the skilled intervention.
NCALB's efforts to shut down dry needling began after the state's Board of Physical Therapy Examiners (NCBPTE) determined that dry needling is within the legal scope of practice of physical therapy in North Carolina, and issued a position statement providing guidance to its licensees. After that determination, NCALB engaged in various actions to prevent PTs from performing dry needling, including the issuing of "cease and desist" letters to PTs and clinics across the state claiming that the PTs practicing dry needling were illegally engaged in the practice of acupuncture, a Class 1 misdemeanor.
In September of this year, NCALB filed a lawsuit against NCBPTE, asking the Wake County Superior Court to declare that dry needling by PTs is the unlawful practice of acupuncture, and to require NCBPTE to advise its licensees that dry needling is outside the scope of physical therapy practice. The acupuncture board also requested that the court authorize the NCALB to send cease and desist letters to PTs who practice dry needling and to sue the PTs who refuse to comply. That lawsuit involves only the 2 state licensing boards.
In early October, the plaintiffs in the Henry case filed their lawsuit against NCALB. The Henry lawsuit has legal support in a 2015 decision by the US Supreme Court holding that state licensing boards controlled by market participants, such as NCALB, are not exempt from antitrust claims unless their conduct is actively supervised by the state. The NCPTA lawsuit is the first in the country to bring this type of antitrust violation claim on behalf of PTs since the Supreme Court decision.
The plaintiffs in the Henry case are 4 PTs and 2 patients. Among the PT plaintiffs, 2 received cease and desist letters from NCALB, and 2 are PTs who do not perform dry needling but want to be able to do so. The 2 patient plaintiffs, who are ballet dancers, are benefitting from dry needling performed by PTs in North Carolina. In addition to requesting an injunction that would prohibit NCALB from taking action against PTs, the lawsuit also seeks recovery of the PTs' lost profits and attorney fees.
NCPTA provides more information on the lawsuit in this letter (pdf), which also describes the chapter's fundraising efforts. APTA is working collaboratively with the chapter, and is providing support as NCPTA pursues the legal action.
Dry needling has been discussed in several states, most of which have included the intervention as part of the PT scope of practice. APTA has created a webpage with resources on the topic, and the association's learning center offers courses on dry needling and clinical decision-making and background evidence for dry needling.
Look out, fashion world: prosthetics are ready for their debut.
The Huffington Post recently reported on a new line of prosthetic limb covers that allows users to make a style statement through what it calls "truly pieces of wearable artwork."
Canada-based Alleles Design Studio now offers hip, edgy, and "downright cool" prosthetic covers that range from $250-$400, according to HuffPo. Custom covers are also possible, but more expensive.
Alleles cofounder McCauly Wanner tells HuffPo that "You can dress the rest of your body in different shirts, dresses, shorts, pants, etc, but until now you couldn't do that with your prosthesis. It has always just been this medical 'thing' that has nothing to do with one's mood, body, an activity, or an event."
"Amputations don't define people, and to be completely honest, it really has nothing to do with what we are doing," Wanner added. "We are simply giving people another product to coordinate with their wardrobe."
Here's another item to add to the repertoire of the physical therapist (PT) of the future: Spock-like mind-meld capabilities.
According to a recent article in Singularity, researchers from Duke University are beginning to make inroads on a project that they think will one day allow the brain waves of a PT to help a motor-impaired patient develop the brain signals necessary for recovery, all through a "Brainet" system that connects the 2 individuals.
So far, the research has been successful in allowing rats who have been "encoded" with an ability to turn left or right through a maze depending on the spacing of small bars on the walls of the maze (the rat could sense the spacing with its whiskers) to deliver that learning to other rats. Researchers recorded the brain activity of the rat as it correctly made its way through the maze, then they transferred the brain pulses to a dorsal column stimulation device implanted in a "receiver" rat's spine. That device transmitted the pulses to the second rat's brain, after which the rat was able to complete the maze—without the bars as cues—with 70% accuracy.
"This really suggests to us that complex plasticity is occurring at the level of the Brainet," a researcher is quoted as saying. "We're already one step closer to a therapistpatient interface, where neural signals from a healthy brain would control stimulation applied to the spinal cord of a patient."
Though still in the most rudimentary stages of development, if refined to the extent envisioned by researchers, the interface could be a valuable tool to help PTs ensure that their patients live long and prosper.
World Stroke Day may be over, but resources created for the event—and APTA's ongoing offerings—are as relevant as ever.
An initiative of the American Stroke Association (ASA) and the American Heart Association (AHA), this year's World Stroke Day, observed on October 29, included a special emphasis on educating the public about the warning signs of stroke. Those warning signs, and the need to take immediate action, are summed up by what the campaign calls "F.A.S.T."—face drooping, arm weakness, speech difficulty, time to call 9-1-1.
In addition to those public relations efforts, ASA and AHA have produced a useful infographic on stroke and collected information for health care providers on a Stroke Resource Center webpage.
For resources aimed at increasing the public's understanding of the role of physical therapists and physical therapist assistants in stroke rehabilitation, visit MoveForwardPT.com, APTA's website for consumers. MoveForward offers a physical therapist's guide to stroke, a MoveForward Radio podcast on stroke awareness, prevention, and recovery; and an article on the F.A.S.T. guidelines.
The White House has announced that APTA is among the organizations that have joined a public-private partnership to combat heroin use and prescription drug abuse, and that the association will reach out to the public and its members to deliver the message that pain can be effectively managed through conservative, nondrug approaches.
APTA is participating in the initiative along with 39 other health care provider groups that include the American Medical Association, the American Academy of Family Physicians, the American Nurses Association, the American Public Health Association, the American Academy of Hospice and Palliative Medicine, and the American College of Osteopathic Surgeons.
"Efforts like these are at the heart of what we mean when we talk about the transformative power of physical therapy," said APTA President Sharon L. Dunn, PT, PhD, OCS. "Physical therapists can help individuals manage pain, and greater use of physical therapy could make a real impact on the tragic levels of drug abuse in this country—abuse that often begins with a prescription for pain medication."
The partnership was announced by President Obama during an October 21 visit to Charleston, West Virginia, one of the states hardest-hit by growing rates of opioid abuse, heroin overdose, and related public health issues such as a rise in rates of Hepatitis B and C. During his visit, Obama spoke with individuals affected by the epidemic, including families, law enforcement personnel, and community leaders, before announcing the ramped-up efforts.
On hand for the White House announcement was Mick Bates, PT, a member of the West Virginia House of Representatives.
Earlier this year, the White House Office of National Drug Control Policy met with Dunn and Mandy Frohlich, APTA vice president of strategic communications and alliances—at that time the association's vice president of government affairs—to discuss the role of physical therapy in battling drug abuse.
The association's focus on the ways physical therapy can help patients manage pain is already being acknowledged by other media outlets, which have been writing about the importance of multidisciplinary approaches to pain that include exercise prescriptions.
President Barack Obama speaks about new White House efforts to combat opioid abuse. APTA is among the partners helping with the initiative. (Photo courtesy of Mick Bates, PT.)
APTA has long advocated for the role of the physical therapist (PT) in pain management, using its MoveForwardPT.com website to educate the public about it, and featuring new approaches to pain treatment being used by PTs in a 2014 feature story in PT in Motion magazine. More recently, the August issue of Physical Therapy (PTJ), APTA's peer-reviewed journal, includes a discussion of how to interpret the burgeoning effectiveness evidence from recent clinical trials and systematic reviews on pain treatment.
The Washington Post
reports that in what at least 1 administrator hopes will be the classroom of the near-future, kids can't sit still—as in, they're not supposed to sit still, because every desk and learning station incorporates equipment that keeps them moving.
And for 1 classroom in Charleston, South Carolina, that future is already here, according to the Post.
"Inside, 28 fifth-graders sit at the specially outfitted kinesthetic desks. Some pedal bikes, some march on climbers, some swivel, some stand at their desk and sway back and forth. But almost everyone in the class is moving all day long—even the teacher," the Post reports.
The description is included in a story on how 63-year-old David Spurlock, a school administrator in the Charleston district, is challenging educational assumptions about the need for children to remain seated and inactive while learning. Those assumptions couldn't be more incorrect, Spurlock argues, calling the current system "educational incarceration."
The article describes the ways in which Spurlock's campaign is catching on in the school district, with the creation of special learning labs that include exercise equipment, "advanced physical education" courses that aim to incorporate intense physical activity early in the day, and the fully-equipped classroom mentioned in the report—the first of its kind in the country.
An accompanying Post video offers a glimpse into a normal day in this special classroom.
"If you went to anybody who's in education, you say [physical education] versus instruction, they say instruction every time," Spurlock is quoted as saying. "But what we're trying to show is that more movement equals better grades, better behavior, better bodies."
APTA has long supported the promotion of physical activity and the value of physical fitness, and has representatives on the practice committee of Exercise is Medicine. The association offers several resources on obesity, including continuing education on childhood obesity, and a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.
Bipartisan legislation that will leave it to states to decide the cutoff number for what's defined as a "small employer" for purposes of health insurance coverage will likely be signed by President Obama, according to a recent story in the New York Times (NYT).
The NYT reports that although the administration "did not particularly like" the legislation that has moved out of the Senate, Obama is expected to approve a change aimed at saving businesses with between 51 and 100 employees from the "small employer" designation—and the designation's attendant "stringent insurance regulation" that would have started January 1 under the Affordable Care Act (ACA).
Instead, the Protecting Affordable Coverage for Employees Act will leave the issue to individual states to decide. The current cutoff for being designated a small employer is at 50 employees or fewer.
According to the NYT article, analysts predicted that employers with 51 to 100 employees would face premium increases averaging 18% next year if the numbers were changed as called for in the ACA.
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