Cost and Effectiveness of Home-Based Rehab After Joint Replacement
The hospital stay after a total hip or total knee replacement has been shortened by almost half. To make up the difference in care, outpatient (home-based) rehab has increased. Surgeons from Canada study the effect of this change on outcomes at three and 12 months after surgery. They compared the costs and complications between two groups.
The first group had inpatient rehabilitation after surgery. This involved a longer hospital stay. The second group was discharged sooner and received follow-up care at home. Everyone in both groups had the joint replacement for arthritis or osteonecrosis. Patients with fractures, tumors, or revision joint replacements were not included.
Outcomes were measured using three different surveys (questionnaires). These included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-36 (SF-36), and the Hip and Knee Satisfaction Scale. These tools helped measure pain, function, motion, and stiffness.
Everyone completed the surveys two weeks before surgery. They were randomly placed in one of the two groups before surgery. There were no differences in the patients placed in both groups in terms of age, diagnosis, body weight, gender, or education. Surgical care was equal between the two groups otherwise. They repeated the questionnaires three months after surgery and again at the end of one year.
Everyone stayed in the hospital for at least five days. All patients received the same basic physical therapy from day one. At the time of discharge, group one was transferred to inpatient rehab. Group two was discharged to home. Both groups continued to see a physical therapist for the same rehab program after transfer or discharge.
The cost of care was calculated for both groups. The focus was on direct healthcare costs. This did not include physician fees, medications, or indirect costs to the patient and/or family.
Analysis of the data showed that the average number of home-based rehab visits was eight. The average number of days in the inpatient rehab facility was 17 days. Infections were more common in the inpatient group but postoperative complications were similar otherwise.
Both groups had dramatic improvement in all areas measured after surgery. Patients in both groups continued to improve for up to the full 12 months of the study. This was equally true for both total hip and total knee patients.
The cost was six times greater for the inpatient group compared with the home-rehab group. In the United States, this difference is reportedly 10 times greater. Since the outcomes were the same, the authors suggest following a home-based rehab program for all ases of uncomplicated total hip or total knee patients. This policy may be especially helpful in facilities where transfer to an inpatient rehab facility is delayed due to a shortage of beds.
Inpatient rehab care is still recommended for anyone with serious health concerns or the likelihood of postoperative complications. These patients can be monitored more closely as needed. To contain costs, home-based rehab should be standardized so that number of treatments and protocols are the same from place to place.
Nizar N. Mahomed, MD, ScD, FRCSC, et al. Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial. In The Journal of Bone and Joint Surgery. August 2008. Vol. 90-A. No. 8. Pp. 1673-1680.