Frailty Is Strongest Need Factor among Predictors of Prehabilitation Utilization for Total Hip or Knee Arthroplasty in Fee-for-Service Medicare Beneficiaries

Objective: Prehabilitation may have benefits for total hip arthroplasty (THA) and total knee arthroplasty (TKA), given an aging population with multimorbidity and the growth of value-based programs that focus on reducing postoperative costs. We aimed to describe prehabilitation use and examine predictors of utilization in fee-for-service Medicare beneficiaries.

Methods: This retrospective cohort study using the Medicare Limited Data Set included fee-for-service Medicare beneficiaries who were ≥ 66 years old and who underwent inpatient elective THA or TKA between January 1, 2016, and September 30, 2021. We assessed predictors of receiving preoperative physical therapist services within 90 days of surgery (prehabilitation) using a mixed-effects generalized linear model with a binary distribution and logit link. We report adjusted odds ratios (ORs).

Results: Of 24,602 THA episodes, 18.5% of patients received prehabilitation; of 38,751 TKA episodes, 17.8% of patients received prehabilitation. For both THA and TKA, patients with medium or high (vs low) frailty were more likely to receive prehabilitation (OR = 1.72-2.64). Male (vs female) patients, Black (vs White) patients, those with worse county-level social deprivation, those with dual eligibility, and those living in rural areas were less likely to receive prehabilitation before THA or TKA (OR = 0.65-0.88). Patients who were ≥ 85 years old (vs 66-69 years old) and who underwent THA were also less likely to receive services (OR = 0.84). Additionally, there were geographic differences in prehabilitation utilization and increased utilization in more recent years.

Conclusion: The need factor of frailty was most strongly associated with increased prehabilitation utilization. The variation in utilization by predisposing factors (eg, race) and enabling factors (eg, county-level social deprivation) suggests potential disparities.

Impact: The findings describe prehabilitation use in a large cohort of fee-for-service Medicare beneficiaries. Although services seem to be targeted to those at greater risk for adverse outcomes and high spending, potential disparities related to access warrant further examination.