Patients who undergo more focused, enhanced milestone-based rehabilitation after anterior cruciate ligament (ACL) surgery experience better outcomes in the long run at a lower cost to the healthcare system, researchers at Hospital for Special Surgery (HSS) in New York City have found.
The findings address a common but counterproductive trade-off in orthopedic surgery: Health insurers typically stop paying for rehabilitation before patients are fully recovered and able to return to full physical activity. As a result, up to 30 percent of such patients may reinjure their surgically repaired knee or damage the other, healthy knee, leading to significantly increased healthcare costs in the long term.
The researchers say the findings, which are available online as part of the AAOS 2020 Virtual Education Experience, should prompt insurance companies to consider paying for more rehabilitation sessions for patients who have undergone reconstructive procedures such as ACL surgery.
“Historically, ACL reconstruction has been performed and patients have been cleared back to sports using simple time-based criteria, which is a one-size-fits-all solution for a problem that’s not one-size-fits-all,” said Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS. “The purpose of this study was to ask, ‘Is an enhanced postoperative rehabilitation approach cost-effective for insurers?’ We found that although it might cost them a little more money up front to pay for additional sessions and testing, they save money in the long run. These savings occur because they pay for fewer repeat surgeries due to re-tearing or tearing the ACL of the other knee. Both of these happen at a higher rate following reconstruction when using simple time-based criteria to release the patient back to sports participation. Also, patients are happier because they don’t reinjure their knees as frequently.”
For the study, Dr. Fabricant and his colleagues used nationally available data about the costs of rehabilitation and ACL surgery to develop a cost-benefit model for enhanced rehab. These comprehensive programs — which include improving biomechanics in the affected knee and retraining the muscles in the area — are thought to reduce the risk of re-tearing and needing a revision procedure by at least 25 percent, and also reduce the risk of tearing the ACL of the opposite knee by 50%.
According to the model, if the additional cost of a typical enhanced rehab program is less than about $2,500, insurers actually save money because that extra cost is offset by the savings associated with reducing subsequent injury of both knees. If the program is more successful — reducing the risk of revision surgery by say, 50% — the break-even point is even greater, the study showed. Additionally, these re-injuries tend to occur early on, so the cost of a second surgery comes quickly.
The specific nature of the particular rehabilitation program is less important than simply having access to the additional sessions. “This study doesn’t say you need to do exactly these exercises and exactly these things to get these better outcomes,” said Joseph T. Molony, Jr., PT, MS, SCS, CSCS, manager of the Young Athlete Program at HSS who helped conduct the research. “It simply says that if you spend more time at the end of rehabilitation working on neuromuscular retraining, return-to-play testing, looking at mechanics and having more follow-up visits with the physician, you’re going to lower the reinjury rate substantially.”
“The beauty of this study is that we’re not recommending a specific program or number of sessions,” Dr. Fabricant added. “Given any program, whether it involves testing, therapy sessions — whatever it is — if you stay within a certain range, any program that meets those criteria would be cost-effective.”
Dr. Fabricant said the findings empower physicians, surgeons, patients, and physical therapists with a critical piece of evidence in their efforts to convince insurers to cover more intensive rehabilitation for ACL injured patients. “This arms the provider with some ammunition so that they can show the insurance companies, not only is it medically necessary, it’s also cost saving.”
About HSS
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.
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