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Scientific Articles   |    
Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial
Nizar N. Mahomed, MD, ScD, FRCSC1; Aileen M. Davis, PhD2; Gillian Hawker, MD, FRCPC3; Elizabeth Badley, PhD2; J. Rod Davey, MD, FRCSC4; Khalid A. Syed, MD, FRCSC4; Peter C. Coyte, PhD5; Rajiv Gandhi, MD, FRCSC4; James G. Wright, MD, MPH, FRCSC6
1 Toronto Western Hospital, University Health Network, 399 Bathurst Street, East Wing 1-435, Toronto, ON M5T 2S8, Canada. E-mail address: nizar.mahomed@uhn.on.ca
2 Division of Health Care and Outcomes Research and Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, 399 Bathurst Street, MP 11-322, Toronto, ON M5T 2S8, Canada
3 Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, 76 Grenville Street, 10th Floor, East Room 1010, Toronto, ON M5S 1B6, Canada
4 Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, 1-011 East Wing, Toronto, ON M5T 2S8, Canada
5 Department of Health Policy, Management and Evaluation, McMurrich Building, University of Toronto, Toronto, ON M5S 1A8, Canada
6 Department of Surgery, The Hospital for Sick Children, 1218-555 University Avenue, Toronto, ON M5G 1X8, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Physicians' Services Incorporated. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at Toronto Western Hospital, University of Toronto, and North York General Hospital, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Aug 01;90(8):1673-1680. doi: 10.2106/JBJS.G.01108
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Abstract

Background: Home-based rehabilitation is increasingly utilized to reduce health-care costs; however, with a shorter hospital stay, the possibility arises for an increase in adverse clinical outcomes. We evaluated the effectiveness and cost of care of home-based compared with inpatient rehabilitation following primary total hip or knee joint replacement.

Methods: We randomized 234 patients, using block randomization techniques, to either home-based or inpatient rehabilitation following total joint replacement. All patients followed standardized care pathways and were evaluated, with use of validated outcome measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Short Form-36, and patient satisfaction), prior to surgery and at three and twelve months following surgery. The primary outcome was the WOMAC function score at three months after surgery.

Results: The mean length of stay (and standard deviation) in the acute care hospital was 6.3 ± 2.5 days for the group designated for inpatient rehabilitation prior to transfer to that facility compared with 7.0 ± 3.0 days for the home-based rehabilitation group prior to discharge home (p = 0.06). The mean length of stay in inpatient rehabilitation was 17.7 ± 8.6 days. The mean number of postoperative home-based rehabilitation visits was eight. The prevalence of postoperative complications up to twelve months postoperatively was similar in both groups, which each had a 2% rate of dislocation and a 3% rate of clinically important deep venous thrombosis. The prevalence of infection was 0% in the home-based group and 2% in the inpatient group. None of these differences was clinically important. Both groups showed substantial improvements at three and twelve months, with no significant differences between the groups with respect to WOMAC, Short Form-36, or patient satisfaction scores (p > 0.05). The total episode-of-care costs (in Canadian dollars) for the inpatient rehabilitation and home-based rehabilitation arms were $14,532 and $11,082, respectively (p < 0.01).

Conclusions: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the group that received home-based rehabilitation and the group that had inpatient rehabilitation. On the basis of our findings, we recommend the use of a home-based rehabilitation protocol following elective primary total hip or knee replacement as it is the more cost-effective strategy.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Victoria J Ashall
    Posted on October 31, 2008
    Financial Limitations of Hospital at Home within the NHS
    Kingston NHS Hospital

    To the Editor:

    We read with interest the recent article by Mahomed et al.(1) and the letter to the editor by Koushik Ghosh (26 August 2008) regarding home post operative rehabilitation programs following total joint replacement and the financial concerns about rolling out this service within the cash strapped National Health Service in England. We would like to take this opportunity to highlight certain limitations of implementing such a program in the current financial system in the NHS.

    We have recently completed an audit into the projected cost of a hospital at home management program for cellulitis within the Orthopaedic Department of a London District General Hospital based on admissions between 2006/7. In our audit, we evaluated all 319 admissions for cellulitis to the West Middlesex University NHS Hospital (WMUH) between 01/01/06 – 01/01/07. We found that over half of these patients were eligible for hospital at home management (56% 179/ 319); the average length of hospital stay for these patients was 3 days.

    Based on the Heath Resource Groups for these 179 patients, the potential cost savings for the hospital if these patients had been managed at home was calculated by NHS accountants according to the current contract with Medihome (the hospital at home agency used). If hospital at home had been fully implemented and used for these patients there would be a cost saving of £144,007 per year (Hospital cost £203,883 vs. Home cost £59,875).

    However, despite this obvious cost saving, the reimbursement for hospital expenditure on hospital at home services is less straightforward. Since the creation of the purchaser/provider split 1991, the government introduced “Payment by Results” which is the government's name for a reform that represents the largest change to the financing of NHS hospital care in England (2). What this means is that English NHS hospitals are paid a fixed price per inpatient spell, day case, outpatient attendance and Accident & Emergency attendance. Prices are fixed nationally but vary according to which of over 500 Healthcare Resource Groups (HRGs) the activity is coded under. Therefore, whilst the patient is in hospital, the NHS Trust receives reimbursement for the care the hospital provides, however, once the patient is discharged home the reimbursement stops.

    Given this current tariff system in England and also because the Primary Care Trust in Richmond and Hounslow currently do not recognize Hospital at Home as a service, WMUH does not receive any reimbursement. Consequently, the service does not appear cost effective, leading to a negative overall balance of approx -£3,490, which includes the cost saving of freeing up 537 hospital bed days a year. In comparison, under the current tariff system, managing these patients in hospital costs £203,883; the reimbursement for this is £222,000, resulting in a surplus net balance of +£18,117. This audit has been presented to Healthcare Directors at WMUH and subsequently negotiations are currently taking place with both primary care practitioners and commissioners regarding reimbursement for future hospital at home services employed by WMUH.

    We note a recent Cochrane review that supports our findings(3). The review included a full economic analysis of admission avoidance hospital at home services, concluding, that when the costs of informal care were excluded, “Admission Avoidance Hospital at Home” services were less expensive than admission to an acute hospital ward.

    We conclude that addressing concerns previously raised in the literature on the implementation of hospital at home within different healthcare systems around the world, is an important part of developing this worthwhile service for patients. Indeed, the UK National Office for Health Economics highlights the importance of continued monitoring and evaluation of the risks and potential benefits of this current tariff system.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial J Bone Joint Surg Am 2008; 90: 1673-1680.

    2.Assessing the Impact of Payment by Results. UK Office of Health Economics (http://www.ohe.org/) last accessed 02/11/08

    3. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD007491

    Koushik Ghosh
    Posted on August 19, 2008
    Home rehabilitation - variation of quality
    St George's Hospital, Tooting, London, U.K.

    To the Editor:

    Mahomed et al. add weight to a growing body of evidence that there is no significant difference in complication rates between inpatient versus home rehabilitation (1, 2).

    We believe the generallly, it is significantly more cost effective to rehabilitate in the community.However, we would like to stress the point that across the world and certainly in more cash-strapped health care systems (e.g. various Trusts within the NHS in the United Kingdom) there is much heterogeneity in the quality of home-rehabilitation and this may not be comparable to the CCAC protocols that the authors had in place for their home rehabilitation programs.

    Some studies have shown that home based- rehabilitation could be further augmented by pre and post operative education programs (3) indicating further potential quality improvements. It would be interesting to see whether a comparable study performed in a more ethnically diverse, poor, inner city area would yield similar results – just the type of health Trust that would benefit from these cost-effective transitions in post-operative rehabilitation.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References :-

    1. Iyengar KP, Nadkarni JB, Ivanovic N, Mahale A. Targeted early rehabilitation at home after total hip and knee joint replacement: Does it work? Disabil Rehabil. 2007 Mar 30;29(6):495-502.

    2. Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. A targeted home- and center-based exercise program for people after total hip replacement: a randomized clinical trial. Arch Phys Med Rehabil. 2008 Aug;89(8):1442-7. Epub 2008 Jun 30.

    3. Siggeirsdottir K, Olafsson O, Jonsson H, Iwarsson S, Gudnason V, Jonsson BY. Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement: randomized study of 50 patients with 6 months of follow-up. Acta Orthop. 2005 Aug;76(4):555-62.

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