Impact On Outcomes: Nonoperative Management For Osteoarthritis Prior To Joint Replacement Surgery

As the population ages, rates of knee and hip osteoarthritis (OA) are on the rise with a subsequent spike in elective total knee and total hip replacement surgeries. Total joint replacement, also known as total joint arthroplasty (TJA), is the most effective treatment for management of pain caused by end-stage (or bone-on-bone) OA. As such, TJA is one of the most frequently performed procedures in the United States, with over 1 million performed annually. Furthermore, TJA represents the single largest procedural cost for Medicare, leading to several policy changes surrounding reimbursement, preoperative optimization, and postoperative care standards.

Changing Approval Process For Elective Hip And Knee Replacement Surgery

As reimbursement transitions from a fee-for-service to a value-driven model, payers are driving physicians to put in more effort on preoperative optimization and risk management strategies to decrease costs and patient length of stay.  One quality metric that has been imposed by payor and healthcare systems alike is the requirement of trialed nonoperative management for osteoarthritis prior to graduation to TJA. Oftentimes, this requirement can result in a delay of surgery for the nonoperative trial period. For example, CMS requires three of the following 5 criteria to be met prior to approval for a total joint arthroplasty:

• Advanced joint disease
• Pain and functional disability due to trauma or arthritis of the joint
• History of unsuccessful conservative treatment…usually implemented for three months or more to assess for effectiveness
• Distinct structural abnormalities
• Failed previous arthroplasty of the joint of interest that necessitates revision surgery

Similarly, Aetna requires a history of unsuccessful conservative therapy (non-surgical medical management; 12 or 24 weeks), among other criteria, for TKA to be deemed a “medical necessity” for a person without further complicating factors such as failed previous arthroplasty or malunion/nonunion affecting the joint. 

Does Nonsurgical Medical Management Of Osteoarthritis Benefit Patients?

There has some controversy surrounding the requirement of preoperative physical therapy and other conservative measures for patients desiring a TJA. A recent systematic review and meta-analysis looked at 22 studies to answer this question and found that, while postoperative pain and function may be better early on for those who did preoperative physical therapy, the effect remains “too small and short-term to be clinically important”. Additionally, there were no differences in total costs or hospital length of stay. 

Patient preference must also be considered in surgical decision-making. When patients were polled about their willingness to delay arthroplasty for payer-mandated physical therapy, nearly all (93%) said they would not want to delay surgery for physical therapy. Of the patients in this cohort that performed physical therapy prior to their joint replacement, nearly half of these patients had unchanged or worsening symptoms throughout their course of nonoperative management. 

The Role of PROs in Preoperative Management of TJA

Patient-reported outcomes provide a unique opportunity to monitor patient symptomatology and function without the need for a clinic visit or provider time. Bi-weekly or even monthly patient-reported outcome collection throughout the preoperative “conservative management” phase of patient care would allow for quick intervention and care plan redirection in the case of worsening symptoms and satisfaction. For example, a patient who has a clinically significant decrease in a patient-reported outcome measure during their first month of preoptimization would be re-routed to a more direct pathway to TJA. In conjunction with the physical results from physiotherapy (i.e. better range of motion or strength), collection of PROs provides a more robust analysis of overall patient wellbeing and can help drive a shared decision-making process.

In conclusion, as reimbursement policies for total joint arthroplasty continue to evolve, the emphasis on preoperative optimization and conservative management has sparked debate over its true benefits for patients. While these measures aim to improve outcomes and reduce costs, the evidence suggests that the impact on postoperative recovery may be minimal, and patient satisfaction can be compromised by delays in surgery. Integrating patient-reported outcomes into the preoperative phase offers a promising approach to personalize care, ensuring that decisions are driven by both clinical data and patient preferences. By focusing on the individual needs of patients, healthcare providers can better navigate the complexities of value-based care while enhancing the overall patient experience.