Background Bundled payment models for lower extremity total joint arthroplasty (TJA) aim to improve value by decreasing costs via efficient care pathways. It is unclear how such models affect patient-centered outcomes such as functional recovery. We aimed to determine whether participation in bundled payment for TJA negatively affects patients’ functional recovery. Methods All patients, regardless of payer, undergoing elective TJA between July 2014 and December 2016 were identified retrospectively and categorized into prebundle (n = 680) and postbundle (n = 1216) cohorts. Mixed-effects linear regression and Wald postests were used to test for differences in patients’ functional recovery during the hospital period and over 12 months after TJA between cohorts. We also used multivariate regression to test for differences in hospital length of stay (LOS) and postacute care (PAC) facility use between cohorts. Results Compared with the prebundle cohort, patients in the postbundle cohort demonstrated a small and nonmeaningful difference in the trajectory of functional recovery in the hospital [χ 2 (3) = 31.3, P < .01] and no difference in the 12 months after TJA [χ 2 (3) = 3.9, P = .28]. They had a 0.4-day shorter hospital LOS (95% confidence interval: −0.5, −0.3) and decreased odds for PAC facility use (adjusted odds ratio = 0.3; 95% confidence interval: 0.2, 0.4). Conclusions Participation in bundled payment for TJA was not associated with significant changes in patients’ functional recovery, an important patient-centered outcome. For the postbundle cohort, hospital LOS and PAC facility use were decreased, consistent with previous studies describing cost-saving strategies in bundled payment. These findings support the need for an ongoing study of the long-term sustainability of these value-based payment models.

These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.

Study Design Retrospective cohort from the Intermountain Healthcare system, January 2007 to December 2014. Background Recent evolutions in health care delivery are putting physical therapists in the forefront to be more responsible for providing high-quality rehabilitation care in a more cost-effective manner. Studies investigating the association between physical therapy visit utilization and outcomes in vulnerable patient populations following anterior cruciate ligament (ACL) reconstruction may provide useful insights. Objectives To examine the relationship between patient age, sex, physical therapy visit utilization, and physical therapy intervention charges with revision rates and patient-reported outcomes in individuals following primary ACL reconstruction. Methods A sample of 660 patients who had an ACL reconstruction was identified through an electronic medical record database. Age and physical therapy visit utilization were categorized to examine effects between groups (20 years of age or younger, 21 to 34 years of age, 35 years of age or older; fewer than 9 visits, 9 to 14 visits, 15 or more visits). Multilevel mixed-effects linear models were conducted to compare differences between revision rates and patient-reported outcomes during the episode of care. Receiver operating characteristic curve analyses were also used to determine visit-number and charge-per-visit cut points to discriminate patients who achieved at least a minimal clinically important difference on the patient-reported outcomes. Results Of 660 patients, 22 (3.3%) had revision surgery. Compared with patients 20 years and younger, the incidence rate ratio of ACL reconstruction revision was lower in patients who were 35 years and older (85%) and 21 to 34 years (59%). Of 470 patients who attended physical therapy for longer than 3 months, change in Knee Outcome Survey activities of daily living subscale score was significantly lower among patients 20 years of age and younger and in the lowest visit category. Conclusion Achievement of favorable outcomes following ACL reconstruction may require categorization of patients beyond surgical diagnosis alone. Younger patients (aged 20 years or less) attending fewer physical therapy visits (fewer than 9) were more likely to have ACL revision surgery and had inferior patient-reported outcomes compared to older patients and those with higher physical therapy visit utilization. The study design of a retrospective cohort limits the ability to identify causal relationships. Additionally, this study was conducted in only 1 geographic region within a single health care delivery system, which may limit the generalizability of the results. Level of Evidence Prognosis, level 2c. J Orthop Sports Phys Ther 2017;47(11):834-844. Epub 9 Oct 2017. doi:10.2519/jospt.2017.7048.

To describe the recovery trajectory in a group of relatively older borderline dysplastic female femoroacetabular impingement syndrome (FAIS) patients following arthroscopic surgery, to determine if outcomes in this group differs from females with different age and bony morphology characteristics. Four subgroups were created to define (i) older females (>35 years), borderline dysplastic (lateral center edge angle [LCEA] ≤ 25 degrees) and anterior wall index (AWI) deficient (AWI ≤ 0.40) (older, borderline dysplastic, anterior wall deficient [ODD, reference]); (ii) younger (≤35 years), borderline dysplastic (LCEA ≤ 25 degrees) and deficient anterior wall (AWI ≤ 0.40) (younger, borderline dysplastic, anterior wall deficient [YDD]); (iii) older (>35 years), non-dysplastic (LCEA > 25 degrees) and non-deficient anterior wall (AWI > 0.40) (older, non-dysplastic, non-deficient anterior wall [ONN]); and (iv) younger (≤35 years), non-dysplastic (LCEA > 25 degrees) and non-deficient anterior wall (AWI > 0.40) (younger, non-dysplastic, non-deficient anterior wall [YNN]). One hundred and seventy-three female patients were included. Comparing mean scores, the ODD group reported significantly lower International Hip Outcome Tool (iHOT-12) change scores compared with the ONN group [23.58 ± 9.73; P = 0.03] at 12 months. ODD group also demonstrated significantly lower iHOT-12 change scores compared with the ONN (27.62 ± 8.22; P < 0.01) and YNN (25.39 ± 7.68; P < 0.01) groups at 24 months. Relatively older females with borderline dysplasia and anterior acetabular wall deficiencies had poorer iHOT-12 outcomes at both 12 and 24 months post-operatively compared with other female subgroups. In the absence of hip dysplasia and anterior wall deficiencies, superior iHOT-12 outcomes were observed in both older and younger females post-operatively.

Few studies have investigated transient global amnesia (TGA) in the context of a concussion and the concussion sequelae following TGA. Here we review the case of a 43-year-old male with onset of transient global anterograde and retrograde amnesia 22 days after a sustained concussion. The patient's head CT, MRI of brain, and EEG were reported normal, and the patient regained full cognitive function 8 h after the TGA episode, with no recollection of the conspiring events. Following the TGA episode, the patient experienced notable worsening of concussive symptoms, including headache, head pressure, anxiety, neck pain, feeling slowed down, fogginess, not feeling right, difficulty remembering, and fatigue. The patient remained symptomatic for 32 days after the TGA episode. We suggest that a lingering window of post-concussion cerebral vulnerability, which may extend beyond clinical recovery, could lead to increased susceptibility to acute cognitive deficits, such as TGA.

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