Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ 86011 (USA).
Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
Phys Ther. 2018 Oct 1;98(10):855-864. doi: 10.1093/ptj/pzy077.
Despite the frequency of total knee arthroplasty (TKA) in the Medicare population, little is known about the use of postacute physical therapy among those discharged to home.
The objectives of this study were to explore factors associated with geographic variability in discharge disposition and outpatient physical therapy utilization for Medicare patients after TKA discharged to home/self-care.
The design of the study was a retrospective cohort study.
Medicare patients with TKA discharged alive from July 1, 2010, to June 30, 2011, with discharge disposition to home/self-care (HSC), home health agency (HHA), inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) were selected. Geography was measured with Census region. Outpatient physical therapy utilization was calculated from Medicare Part B claims. Odds ratios for discharge disposition and adjusted means for physical therapy utilization variables by Census region were calculated, accounting for county-clustered data and adjusting for demographics, clinical, and environmental characteristics.
There was significant variation with discharge destination by Census region among 18,278 patients. With discharge disposition analysis, the patients from the West region who were discharged home were the referent group. The patients from the South and Northeast regions had higher odds for discharge to HHAs (adjusted odds ratio [95% CI = 1.80 [1.48-2.19] and 2.20 [1.70-2.84]), SNFs (1.34 [1.08-1.66] and 4.42 [3.38-5.79]), and IRFs (2.36 [1.80-3.09] and 8.83 [6.41-12.18]). For those discharged to HSC, 40.4% received outpatient physical therapy within 4 weeks. Significant differences were found with time to first physical therapy visit (Midwest <South <[West = Northeast]) and length of therapy episode, but not with the number of therapy visits by geographic region.
Geographic region was associated with discharge setting, postacute physical therapy, and outpatient therapy utilization in Medicare beneficiaries after TKA. Differences in outcomes of outpatient therapy should be assessed to better describe the impact of geographic variation in care.
尽管全膝关节置换术（TKA）在医疗保险人群中很常见，但对于出院后在家接受康复治疗的患者的术后物理治疗的使用情况却知之甚少。
本研究的目的是探讨与医疗保险患者 TKA 出院后居家/自理的出院处置和门诊物理治疗利用的地理差异相关的因素。
本研究的设计为回顾性队列研究。
选择 2010 年 7 月 1 日至 2011 年 6 月 30 日期间存活出院并居家/自理（HSC）、家庭健康机构（HHA）、住院康复机构（IRF）或熟练护理机构（SNF）的 TKA 医疗保险患者。地理区域采用人口普查区域来衡量。门诊物理治疗的使用情况根据医疗保险 B 部分的报销来计算。根据人口普查区域计算出院处置和调整后的物理治疗利用变量的比值比，并考虑县级聚类数据，并调整人口统计学、临床和环境特征。
在 18278 名患者中，按人口普查区域划分，出院目的地存在显著差异。在出院处置分析中，来自西部地区出院回家的患者是参照组。来自南部和东北部地区的患者出院到 HHA 的可能性更高（调整后的比值比[95%CI]=1.80[1.48-2.19]和 2.20[1.70-2.84]）、SNF（1.34[1.08-1.66]和 4.42[3.38-5.79]）和 IRF（2.36[1.80-3.09]和 8.83[6.41-12.18]）。对于出院到 HSC 的患者，40.4%在 4 周内接受了门诊物理治疗。在第一次物理治疗就诊时间（中西部<南部<[西部=东北部]）和治疗时间方面存在显著差异，但不同地理区域的治疗次数无差异。
地理区域与医疗保险受益人 TKA 后的出院安置、术后急性物理治疗和门诊物理治疗的使用有关。应评估门诊治疗结果的差异，以更好地描述护理地理差异的影响。
