家庭医疗保健物理治疗可改善 Medicare 受益人的全膝关节置换术后早期功能恢复。
Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty.
机构信息
Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.
Denver Veterans Affairs Medical Center, Denver, Colorado.
出版信息
J Bone Joint Surg Am. 2018 Oct 17;100(20):1728-1734. doi: 10.2106/JBJS.17.01667.
BACKGROUND
Home-health-care utilization after total knee arthroplasty (TKA) is increasing. Recent publications have suggested that supervised rehabilitation is not needed to optimize functional recovery after TKA; however, few studies have evaluated patients in home-health-care settings. The objectives of this study were to (1) determine whether physical therapy (PT) utilization is associated with functional improvements for patients in home-health-care settings after TKA and (2) determine which factors are related to utilization of PT.
METHODS
This study was an analysis of Medicare home-health-care claims data for patients treated with a TKA in 2012 who received home-health-care services for postoperative rehabilitation. Multivariable linear regression models were used to evaluate relationships between PT utilization and recovery in activities of daily living (ADLs). Negative binomial regression models were used to determine factors associated with PT utilization.
RESULTS
Records from 5,967 Medicare beneficiaries were evaluated. Low home-health-care PT utilization (≤5 visits) was associated with less improvement in ADLs compared with 6 to 9 visits, 10 to 13 visits, or ≥14 visits. Compared with low home-health-care utilization, utilization of 6 to 9 visits was associated with a 25% greater improvement in ADLs over the home-health-care episode (p < 0.0001); 10 to 13 visits, with a 40% greater improvement (p < 0.0001); and ≥14 visits, with a 50% greater improvement (p < 0.0001). The findings remained robust following adjustments for medical complexity, baseline functional status, and home-health-care episode duration. After adjustment, lower PT utilization was observed for patients receiving home health care from rural agencies (10.7% fewer visits, 95% confidence interval [CI] = 7.9% to 13.7%), those with depressive symptoms (4.8% fewer visits, 95% CI = 1.3% to 8.3%), and those with any baseline dyspnea (5.3% fewer visits, 95% CI = 3.1% to 7.5%).
CONCLUSIONS
Low home-health-care PT utilization was significantly associated with worse recovery in ADLs after TKA for Medicare beneficiaries, after controlling for medical complexity, baseline function, and home-health-care episode duration. Patients who are served by rural agencies or who have higher medical complexity receive fewer PT visits after TKA and may need closer monitoring to ensure optimal functional recovery.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景
全膝关节置换术（TKA）后的家庭保健利用率正在增加。最近的出版物表明，在 TKA 后优化功能恢复并不需要监督康复；然而，很少有研究评估家庭保健环境中的患者。本研究的目的是：（1）确定在 TKA 后接受家庭保健康复治疗的患者在家庭保健环境中是否进行物理治疗（PT）与功能改善相关；（2）确定与 PT 使用相关的因素。
方法
这是一项对 2012 年接受 TKA 治疗并接受术后康复家庭保健服务的 Medicare 家庭保健索赔数据进行的分析。多变量线性回归模型用于评估 PT 使用与日常生活活动（ADL）恢复之间的关系。负二项回归模型用于确定与 PT 使用相关的因素。
结果
共评估了 5967 名 Medicare 受益人的记录。与接受 6 至 9 次、10 至 13 次或≥14 次家庭保健 PT 治疗的患者相比，家庭保健 PT 利用率低（≤5 次）与 ADL 改善程度较低相关。与低家庭保健利用率相比，接受 6 至 9 次家庭保健治疗的患者在家庭保健期间 ADL 改善程度提高了 25%（p<0.0001）；接受 10 至 13 次治疗的患者，改善程度提高了 40%（p<0.0001）；接受≥14 次治疗的患者，改善程度提高了 50%（p<0.0001）。在调整医疗复杂性、基线功能和家庭保健疗程后，这些发现仍然稳健。调整后，在农村机构接受家庭保健的患者（就诊次数少 10.7%，95%置信区间[CI]为 7.9%至 13.7%）、有抑郁症状的患者（就诊次数少 4.8%，95%CI 为 1.3%至 8.3%）和有任何基线呼吸困难的患者（就诊次数少 5.3%，95%CI 为 3.1%至 7.5%）的 PT 利用率较低。
结论
在 Medicare 受益人群中，TKA 后家庭保健 PT 利用率低与 ADL 恢复较差显著相关，在控制医疗复杂性、基线功能和家庭保健疗程后。在 TKA 后接受农村机构服务或医疗复杂性较高的患者接受的 PT 就诊次数较少，可能需要更密切的监测以确保最佳功能恢复。
证据水平
治疗水平 III。有关证据水平的完整说明，请参见作者说明。
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