A benchmark for the referral rate to inpatient rehabilitation could reduce the evidence–practice gap
There are several reasons why inpatient rehabilitation after total knee replacement (TKR) should be reserved for those most in need. Randomised clinical trials1,2 and observational studies3,4 indicate that inpatient rehabilitation for patients after an uncomplicated TKR is not usually necessary. It is, however, considerably more expensive than the alternatives,1,3,4 whether the cost is borne by the patient, their insurer, or the government. These observations together suggest that the inpatient pathway is often low or no value health care. Further, there is low-level evidence from the United States that rates of re-admission and adverse events, after adjusting for relevant factors, are higher among patients discharged to inpatient rehabilitation or skilled nursing facilities.5,6
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- 1. Mahomed NN, Davis AM, Hawker G, et al. 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. Buhagiar M, Naylor JM, Harris IA, et al. Effect of inpatient rehabilitation vs a monitored home-based program on mobility in patients with total knee arthroplasty. The HIHO randomized clinical trial. JAMA 2017; 317: 1037-1046.
- 3. Tribe KL, Lapsley HM, Cross MJ, et al. Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis. Chronic Illness 2005; 1: 289-302.
- 4. Naylor JM, Hart A, Mittal R, et al. The effectiveness of inpatient rehabilitation after uncomplicated total knee arthroplasty: a propensity score matched cohort. Med J Aust 2017; 207: 250-255. <MJA full text>
- 5. Keswani A, Tasi MC, Fields A, et al. Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplasty 2016; 31: 1155-1162.
- 6. Pelt CE, Gililland JM, Erickson JA, et al. Improving value in total joint arthroplasty: a comprehensive patient education and management program decreases discharge to post-acute care facilities and post-operative complications. J Arthroplasty 2018; 33: 14-18.
- 7. Schilling C, Keating C, Barker A, et al. Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data. Med J Aust 2018; 209: 222-227.
- 8. National Joint Replacement Registry. Demographics of hip, knee and shoulder arthroplasty. Supplementary Report 2017. Adelaide: Australian Orthopaedic Association, 2017. https://aoanjrr.sahmri.com/documents/10180/397744/Demographics%20of%20Hip%2C%20Knee%20and%20Shoulder%20Arthroplasty (viewed June 2018).
- 9. Private Healthcare Australia. Urgent action on out-of-pocket expenses required for private health to remain viable [media release]. 28 May 2018. https://www.privatehealthcareaustralia.org.au/urgent-action-on-out-of-pocket-expenses-required-for-private-health-to-remain-viable/ (viewed June 2018).
- 10. Piccinin MA, Sayeed Z, Kozlowski R, et al. Bundle payment for musculoskeletal care. Current evidence (part 2). Orthop Clin N Am 2018; 49: 147-156.
- 11. Naylor J, Harris IA. Supplementary tables. Inpatient rehabilitation utilisation (public hospitals). Arthroplasty Clinical Outcomes Registry National (ACORN) annual report 2016. Sydney: Whitlam Orthopaedic Research Centre, 2017. http://acornregistry.org/images/2016%20ANNUAL%20REPORT%20SUPPLEMENT.pdf (viewed June 2018).
- 12. Siggeirsdottir K, Olafsson Ö, Jonsson H, et al. 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; 76: 555-562.
Justine Naylor has received competitive grant funding in the past from the HCF Research Foundation to conduct research related to rehabilitation after total knee replacement.