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INTENSIVE inpatient rehabilitation after uncomplicated total knee replacement is no more effective than simple outpatient rehabilitation, Australian researchers have reported in the MJA.
The researchers evaluated a propensity score-matched cohort of 258 (129 pairs) privately insured patients who underwent unilateral total knee arthroplasty (TKA) in one of 12 Australian hospitals. Patients who reported poor progress or complications within 90 days of their procedure were excluded from the study.
The study found that patients who underwent inpatient rehabilitation did not achieve superior patient-reported outcomes compared with patients in community-based programs.
Outcomes were evaluated using the Oxford Knee Score to assess knee pain and function at 90 and 365 days after surgery, and the EuroQol Visual Analogue Scale for “today” health at 35, 90 and 365 days after surgery. The only significant difference found was one month after the procedure, when patients in community-based programs reported a better “today” health rating than those in inpatient programs.
The researchers also found a significant cost difference between the two pathways, with the median rehabilitation cost of inpatient care ($9978) 26 times the cost of community-based care ($374).
In an MJA InSight podcast, lead author Associate Professor Justine Naylor said that the findings indicated that rehabilitation did not seem to be “penetrating the recovery envelope”.
“No matter what pathway you follow, your recovery is very similar,” she said.
Associate Professor Andrew Cole, president of the Australasian Faculty of Rehabilitation Medicine of the Royal Australasian College of Physicians, welcomed the research, but said that the findings were not surprising.
“Such is the state of the technology of knee replacement and the post-operative care, that an uncomplicated knee replacement does not usually require an inpatient rehabilitation program, and that has been the case for probably the past decade,” he said.
Patients required rehabilitation to ensure that they returned to a full range of movement and recovered their strength after surgery, Associate Professor Cole said, and this could be achieved in an outpatient setting in patients who had had an uncomplicated procedure.
He said that this approach was common in the public health setting, where he mostly practised.
“If a person can manage to be at home – and most patients prefer to be at home – they can come back for an outpatient program. They can do the hydrotherapy and the physiotherapy and the exercises in an outpatient setting at considerably less expense to the community,” he said.
However, Associate Professor Cole added that inpatient rehabilitation was necessary for some patients.
“If a person is old and frail; or there are complicating factors, such as nerve damage, more general medical problems like cardiac or respiratory disease; or maybe it’s the second time the knee has been replaced … those are not uncomplicated cases, and they may very well need an inpatient rehabilitation program,” he said. Patients who live in an difficult environment, such as a 2-storey house might also need inpatient rehabilitation before they go home, Associate Professor Cole added.
In an accompanying editorial in the MJA, Dr Andreas Loefler said that Medibank figures suggested that neither doctors nor patients were discerning in their use of rehabilitation services.
“It seems that 20% of surgeons send all their patients for inpatient rehabilitation, while another 20% send none. Similarly, many privately insured patients regard inpatient rehabilitation as their right, like visiting a spa for post-operative relaxation,” Dr Loefler wrote.
He said that many of these facilities were excellent, but they were also expensive, so it was “timely to audit the outcomes”.
Dr Keith Holt, president of the Australian Knee Society (a subspecialty society of the Australian Orthopaedic Association), agreed.
“I don’t think that in-hospital rehabilitation is all that helpful, and I do not think it should be used as a routine. In my hospital, Hollywood [Private Hospital], where over 90 joint replacements a week are performed, rehabilitation is a scarce resource,” Dr Holt said, adding that patients were only referred to inpatient rehabilitation if there was a medical reason for the additional care, or due to factors such as advanced age or a lack of home care. He said that this message was clear in his patient handouts.
Dr Holt noted that joint replacement surgery was increasingly conducted as day surgery in the US, but that this was “pushing the pendulum a bit far”.
“My view is that [patients] need a few days to sort out their analgesics and get them settled into a routine that works for them. I also think that they should be able to use crutches, where possible, before they go home. This is optimal for their home experience and ability to care for themselves,” he said.
Mr Phil Calvert, national president of the Australian Physiotherapy Association (APA), said that the findings were timely.
“It’s Australian research, it’s recent research, so it gives us a really good platform to work on those models of care and to refine the system so that it’s effective and sustainable.”
In a submission to the Senate inquiry into the value and affordability of private health insurance and out-of-pocket medical costs in August 2017, the APA called for a government-facilitated industry working group on private health insurance-funded rehabilitation to improve the value provided in rehabilitation as “a matter of priority”.
Mr Calvert said that under the present structure, there was a perverse incentive for some patients to choose inpatient rehabilitation.
“There are differences between health funds, but often when you stay in hospital for inpatient rehabilitation, all of those costs are paid for by your private health insurance cover,” Mr Calvert said. “If you elect to see a physiotherapist or other allied health professionals in an outpatient setting … extras cover will usually pay for a component of it, but it still leaves the patient with significant out-of-pocket costs.”
He said that modifying this part of the system could have significant benefits in making the system more sustainable.
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This is a great study and well designed. I’m an orthopaedic surgeon in QLD who performs > 250 TKR / year. I agree that only a minority of patient require in hospital rehabilitation after TKR. In hospital rehab rates are very variable depending on state.
Regarding who funded the study, this is clearly stated in the paper. The grant awarded was obtained via a very competitive, peer-reviewed grant process in 2012. The funder had no role in study design nor how the results were analysed or written up. In this case, source of funding does not change what was observed.
As an aside, I have received feedback that some believe the therapy costs of those who went directly home seem too low. We reported median charges as the charges were not normally distributed. What is not clear in the text, but can be appreciated from the tables and the appendices, is that some people who went directly home participated in NO FURTHER formalised rehab, thus spent $0 on formal rehab. These cases of $0 affects the median costs we report. I also note that private health insurers, when calculating the community-based rehab costs, would not know about the proportion who spend $0 on rehab as they only know about those that claim. Thus private insurers may think our community costs for the home group are lowish. It is appropriate to include the $0 costs in the calculation because the reality is some people have minimal/no rehab.
Aside from the difficult and non compliant patients. Is it a case (again) of what was old is new, again. Hospitals with “in patient” rehab, could look upon it as a nice little earner and certainly I do see many patients as out patients, who have been through the “in patient” rehab and are certainly no better in their progress, than those who have not followed that route, but have had a few appointments with an experienced therapist and a good home programme to follow.
I agree with Anonymous comment above. Extremely significant that this research was funded by HCF who serves benefit from these findings as a basis to deny access to inpatient rehab to its clients. Whether or not the research was good quality, the lack of loud disclosure about this conflict of interest, significantly detracts from its validity. Can we consider industry funded research as “the evidence”?
Interesting study, and I think in a time where we are facing the silver tsunami shrinking workforce, we need to examine our model of care to know how best to be efficient and effective at a reasonable cost to patients. I wonder if those discharged to outpatient rehab receive any discharge instructions on exercise before discharge or just receive gait training? And how long is the waiting time to appointment for their outpatient appointment?
I understand from listening to Radio National’s Health Report this morning that health fund HCF funded this study. I think this needs to be declared much more widely.
Thanks Lynette, by excluding the ones that really needed inpatient rehab, the study didn’t ‘make outpatient rehab look good’. It showed that outpatient rehab IS good for that group – the group that CAN be sent home. To discharge patients that couldn’t go home would have made outpatient care look bad.
Also, you don’t need to look at the biases of the researchers, but should look at how the study may have been biased. You can do that by picking through the methods. Our previous study was an RCT with similar findings. I am happy to be shown where either study may have been biased. This is more helpful than open ended statements like “look at who did the study”.
Dr Holt “view” about people needing a few days in Hospital to sort themselves out is not supported by the evidence. What matters most is providing excellent postoperative analgesia. The avoidance of the use of drains routinely and applying the ERAS principles and especially multimodal analgesia and avoiding the abuse of oxycodone are important. Application of the full blown adherence to the Kohan and Kerr LIA technique will provide excellent post op analgesia with early and sustained mobilisation and will see most patients home the next day or the one after. Clearly in Public practice the importance of someone at home needs the close attention of the Social Worker to achieve that discharge time frame. People want to be at home and the earliest full discussion about expectations is vitally important.
Avoid any RA technoque that stops early (4 hours post-op) mobilisation.
If your patient can access outpatient care that does work very well but by excluding the hard ones they make outpatient outcomes look good . You also need to look at who did the study and thier biases.