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Cost analysis of physiotherapy and rehabilitation treatments in the physiotherapy and home program groups (based on 2013 Health Practices Notification prices)
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[Purpose] The aim of this study was to determine the functional differences between total knee arthroplasty (TKA) patients who were treated with supervised physiotherapy or a standardized home program and perform a cost analysis. [Subjects and Methods] Patients who received total knee arthroplasty between January 2009 and June 2011 were enrolled in...
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... Our study showed that physical therapy after TKA can be related to improving the HRQoL of patients. In line with the results of our study, N Büker et al., showed that physical therapy after TKA was associated with improved functional outcomes and HRQoL of patients 46 . In another study, M Bahardoust et al., showed in a case-control study that post-operative care and adherence to physiotherapy were associated with improved HRQoL of patients after THA 29 . ...
Total knee arthroplasty (TKA) improves patients’ Health-related quality of life (HRQoL) compared to before surgery. However, based on our knowledge, the improvement in HRQoL after TKA, which depends on various factors, has yet to be investigated compared to healthy people. This study aimed to evaluate the HRQoL of patients compared to healthy people and the factors affecting the HRQoL after TKA. In this matched case–control study (1002 participants), HRQoL in 501 patients who underwent TKA between 2015 and 2022 at Shafa Yahyainan Hospital affiliated with Iran University of Medical Sciences were compared with 501 healthy controls. HRQoL was evaluated in two parts (before compared to 12 months after TKA and 12 months after TKA compared to the healthy population). The 36-item short-form health survey (SF-36) was used to evaluate HRQoL 12 months after surgery. The influencing factors on HRQoL were evaluated by multivariate logistic regression analysis. No significant difference was observed in the demographic characteristics of the participants in the two groups. The mean overall SF-36 score, 12 months after surgery, significantly improved compared to before surgery (64.21 ± 22.2 vs. 37.55 ± 15.13, p:0.001). The mean total score of SF-36 was statistically similar between the case and control groups (64.21 ± 22.2 VS 72.53 ± 25.3). The multivariate analysis showed that sex, BMI, number of comorbidities, postoperative compliance, and complications were significantly related to the decrease in patients’ HRQoL (P < 0.001).TKA can improve the HRQoL except for two subscales of happiness/vitality and physical performance, similar to the healthy population. Female gender, obesity and overweight, comorbidity, bilateral TKA, non-adherence to postoperative physiotherapy, and complications were associated with decreased HRQoL.
... After removing repetitive studies, reading titles and abstracts, and screening strictly according to the inclusion and exclusion criteria, 33 related studies were obtained, and 18 were excluded from further reading. Finally, 15 articles were included [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. The literature screening process and results are shown in Fig. 1. ...
... Variation in osteoarthritis index score. Six studies [11,15,[17][18][19]23] Index) post-knee replacement surgery. There was significant heterogeneity between studies (P < 0.05, I 2 = 61%), so a random effect model was used for meta-analysis. ...
... Three studies [10,11,23] reported comparisons of the medical costs between two groups. While the measures, parameters, and units varied among the studies, the home rehabilitation group consistently exhibited cost savings compared to the outpatient group. ...
Background
Rehabilitation post-knee arthroplasty is integral to regaining knee function and ensuring patients’ overall well-being. The debate over the relative effectiveness and safety of outpatient versus home-based rehabilitation persists.
Methods
A thorough literature review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across four databases. Two researchers independently identified eligible studies centering on knee arthroplasty patients undergoing either outpatient or home-based rehabilitation. Study quality was assessed using the Cochrane Collaboration’s risk of bias tool, while continuous outcomes were subject to meta-analyses using Stata 17 software.
Results
Our analysis identified no significant differences in primary outcomes, including Range of Motion, Western Ontario and McMaster Universities Arthritis Index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, and the Knee Society Score, between home-based and outpatient rehabilitation across different follow-up points. Adverse reactions, readmission rates, the need for manipulation under anesthesia, reoperation rate, and post-surgery complications were also similar between both groups. Home-based rehabilitation demonstrated cost-effectiveness, resulting in substantial annual savings. Furthermore, quality of life and patient satisfaction were found to be comparable in both rehabilitation methods.
Conclusions
Home-based rehabilitation post-knee arthroplasty appears as an effective, safe, and cost-efficient alternative to outpatient rehabilitation. Despite these findings, further multicenter, long-term randomized controlled trials are required to validate these findings and provide robust evidence to inform early rehabilitation choices post-knee arthroplasty.
... Nowadays, home-based rehabilitation exercise, whether supervised or unsupervised, is considered a preferable choice for patients post-discharge due to its convenience [11][12][13]. Recent studies have revealed comparable outcomes between supervised physical exercise conducted at outpatient facilities and unsupervised exercise performed at home following TKA [14][15][16][17][18]. Systematic reviews and meta-analyses have further confirmed that supervised rehabilitation exercise does not provide any additional benefits [19,20]. ...
Background
Total knee arthroplasty (TKA) is a surgical procedure primarily used to treat patients with end-stage knee osteoarthritis (KOA). Postoperative physical exercise is a critical part of the overall treatment of KOA and can bring significant benefits to the patients' recovery. Wearable devices can monitor patients' exercise data and upload it to the physician's workstation. This allows the rehabilitation physician to make timely adjustments based on the patients' movement feedback, and the surgeon can be informed of the patients' functional status. Overall, this study aims to evaluate the effectiveness of using wearable monitoring devices for rehabilitation exercise after TKA, with a focus on cost, time savings, and patient outcomes.
Method/design
This is a single-center, single-blinded, parallel randomized controlled trial conducted at Xi'an Honghui Hospital, a regional orthopedic medical center. Eligible patients will be recruited to participate in the study, and baseline data collection and clinical assessments will be conducted at the time of admission. Using the principle of random allocation, recruited patients will be divided into either the experimental or control group. Both groups will undergo a standard, widely promoted rehabilitation program. The patients in the experimental group will wear equipment to detect and track mobility in the lower limbs. All patients will return to the outpatient clinic for follow-up assessments at 2 weeks, 12 weeks, and 24 weeks after discharge, where outcome indicators will be measured. The primary outcome will be the cost and time after discharge, while secondary outcomes will include the 6-min walk test (6MWT), range of motion (ROM), visual analog scale (VAS), American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
Discussion
We should encourage the adoption of novel, easy-to-use, supervised devices if they prove to be beneficial for patients in terms of cost, time, and effectiveness after TKA. This type of device is particularly important for people in remote rural areas, those with limited financial resources, and those who are reluctant to return to hospitals for follow-up care.
Trial registration Chinese Clinical Trial Registry ChiCTR2300068418. Registered on 17 February 2023.
... Due to the increasing cost of health services, the interest in cost analysis is increasing, and costeffectiveness analyses are made for applications in the field of health (Büker et al., 2014). Therefore, the costeffectiveness of outpatient physical therapy needs to be investigated further (Wang et al., 2019). ...
... Therefore, the costeffectiveness of outpatient physical therapy needs to be investigated further (Wang et al., 2019). In a previous study, the 20-session cost of supervised physiotherapy after TKA per patient was roughly USD 236, while the cost of home-based physiotherapy was roughly USD 139 (Büker et al., 2014). Similarly, a previous report compared the cost of outpatient and home physical therapy after TKA, and the average total cost of outpatient physical therapy was USD 1,436 per patient. ...
Background:
Early rehabilitation after total knee arthroplasty (TKA) is crucial in functional outcomes. However, considering improvements in the first six months, there may be benefits to continuing rehabilitation beyond three months postoperatively to achieve maximum functionality and strength.
Objective:
The aim was to compare: (a) effectiveness of late-phase clinic-based and home-based progressive resistance training (PRT) in female patients with TKA; and (b) crude cost of both interventions and explore feasibility.
Methods:
Thirty-two patients were assigned to clinic-based PRT (n = 16) and home-based PRT (n = 16) groups. A training program was performed at the clinic or at home for eight weeks. Pain, quadriceps and hip abductor strength, patient-reported and performance-based outcomes, knee range of motion (ROM), joint awareness, quality of life (QoL) were assessed at baseline (three months postoperatively) and after 8-week intervention (five months postoperatively). Feasibility and crude cost were examined.
Results:
Exercise adherence was 100% in clinic-based PRT and 90.6% in the home-based PRT group. Both interventions improved quadriceps and hip abductor muscle strength, performance-based and patient-reported outcomes, knee ROM, and joint awareness without side effects (p < .05). Clinic-based PRT showed better results in: activity pain (p = .004, ES = -0.888); knee flexion (p = .002, ES = 0.875) and extension ROM (p = .004, ES = -1.081); chair sit-to-stand test (p = .013, ES = 0.935); joint awareness (p = .008, ES = 0.927); and QoL than home-based PRT (p < .05).
Conclusion:
Late-phase clinical-based and home-based PRT interventions may be beneficial in improving muscle strength and functionality in patients with TKA. Late-phase PRT is feasible, cost-effective, and recommended for rehabilitation after TKA.
... A total of 1,884 cases in 11 studies were included in this review and meta-analysis ( Table 1) [11][12][13][14][15][16][17][18][19][20][21]. All studies were published between 2003 and 2020. ...
... As access to technology improves over time, this may also fuel discussion for the need to develop webbased programs to help provide access for patients unable to commute to outpatient-based appointments. Additionally, there is a cost reduction benefit associated with unsupervised exercise regimens that were demonstrated by several studies included in this review [13,14,21]. In a retrospective study conducted on 2,971 total joint arthroplasty (TJA) patients in an insurance claims database, Yayac et al. demonstrated that up to 8% of the episode of care costs were directly attributable to formal PT after surgery [25]. ...
... Additionally, while a cost analysis between the two cohorts would have been useful, this was only reported in two of the included studies [13,21]. Although both demonstrated a substantially higher cost involved in supervised PT as expected, we were unable to perform any data synthesis due to the many factors that could have influenced cost, such as differences in healthcare costs based on country, equipment used in each study, and frequency of therapy visits. ...
Although postoperative physical therapy (PT) has long been considered essential to successful total knee arthroplasty (TKA) recovery, recent literature has suggested that unsupervised home exercise regimens may offer similar benefits to formal supervised sessions. We aimed to compare objectively measured physical function and subjective patient-reported outcomes (PROs) between primary TKA patients who received formal supervised physical therapy sessions and those who received unsupervised home exercise regimens after discharge. Six electronic databases were queried to identify randomized controlled trials comparing supervised physical therapy to unsupervised home exercise regimens in primary TKA patients after discharge. Outcomes of interest included change from baseline in objective measures (knee flexion range of motion (ROM), lower extremity strength, and aerobic capacity) and PROs (physical function and quality of life scores). These outcomes were subdivided into short-term (<6 months from surgery; closest data point to three months is used if multiple measurements were made in this time period) and long-term (≥6 months from surgery; closest data point to 12 months is used if multiple measurements were made in this time period) assessments.
A total of 1,884 cases performed in 11 studies were included in this review. There were no significant differences between cohorts with regard to short-term knee flexion ROM (p = 0.7), lower extremity strength (p = 0.6), or patient-reported quality of life (p = 0.5), as well as long-term knee flexion ROM (p = 0.7), patient-reported quality of life (p = 0.2), or patient-reported physical outcome scores (p = 0.3). A small difference in short-term patient-reported physical outcomes was observed in favor of the supervised cohort (standardized mean difference (SMD): 0.3 (95% confidence interval (CI): 0.01, 0.6); I2 = 82%; p = 0.04).
Formal supervised physical therapy regimens do not confer clinically significant benefits over unsupervised home exercise regimens following primary TKA. The routine use of supervised physical therapy after discharge may not be warranted. Further study is needed to determine the subset of patients that may benefit from supervised care.
... The full-text screening of the selected articles verified if they met the inclusion criteria and excluded the presence of any exclusion criteria. A total of 11 articles [15][16][17][18]22,[30][31][32][33][34][35] were included in systematic review, of which 10 [15][16][17]22,[30][31][32][33][34][35] included in the metaanalysis ( Figure 1). The study [18] was excluded due to the impossibility of finding the data in the form necessary for the Super group 1-to-1: 12 physiotherapy sessions with a physiotherapist over a 6 weeks period. ...
... The full-text screening of the selected articles verified if they met the inclusion criteria and excluded the presence of any exclusion criteria. A total of 11 articles [15][16][17][18]22,[30][31][32][33][34][35] were included in systematic review, of which 10 [15][16][17]22,[30][31][32][33][34][35] included in the metaanalysis ( Figure 1). The study [18] was excluded due to the impossibility of finding the data in the form necessary for the Super group 1-to-1: 12 physiotherapy sessions with a physiotherapist over a 6 weeks period. ...
... Eight of the 11 studies [15,17,22,30,31,[33][34][35] included in this systematic review were considered to carry out the metaanalysis on pain. These studies assessed pain using different evaluation scales: 2 studies used the KOOS Pain section [17,30], 3 studies used the VAS [15,31,35] and 3 studies used the WOMAC Pain section [22,33,34]. ...
Background
Outcomes after total knee arthroplasty (TKA) are strongly influenced by the adequacy of rehabilitation and the consequent functional recovery. The economic impact of rehabilitation it is not negligible. Inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation. This topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery. The aim of this review and meta-analysis is to investigate the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA.
Materials and Methods
Following PRISMA guideline, a comprehensive search of PubMed, Cochrane and Scopus databases using combinations of keywords and MeSH descriptors: “total “Knee replacement,” “Arthroplasty”, “Rehabilitation” was performed from inception to December 2021. All relevant articles were retrieved, and their bibliographies were searched for further relevant references. Only English written randomized controlled trials comparing supervised and unsupervised rehabilitation following TKA were included in this systematic review. The outcomes considered were long-term pain, physical function, knee flexion and extension ROM, 6 minute walking test (6MWT) and timed up and go test (TUG).
Results
11 studies (2.181 patients in total) were included in this systematic review.
The long-term pain outcome showed no significant differences (Std. Mean Difference [SMD] = 0.00, 95 % confidence interval [CI] −0.16, 0.017) between the supervised (n = 397) and unsupervised (n = 255). Physical function showed no significant differences among the two groups (mean difference [MD] = 0.84, 95 % CI = -1.82, 3.50). Non-significant differences were also found for knee ROM flexion (mean difference [MD] = -0.46, 95 % CI = -2.95, 2.04) and for knee extension (mean difference [MD] = 0.54, 95 % CI = -0.89, 1.97). At the 52-week follow-up, the unsupervised group showed significant better results in 6MWT (mean difference [MD] = -26.10, 95 % CI = -47.62, −4.59) and in Timed up and go test (mean difference [MD] = 1.33, 95 % CI = 0.50, 2.15).
Conclusion
This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therefore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.
... In the dependent group analyzes; when the parametric test assumptions were provided, Paired Sample T-Test was used; when the parametric test assumptions were not provided, Wilcoxon Test was used. A p level of ≤ 0.05 was accepted as statistically significant and interpreted 34 . ...
This study aimed to investigate the effect of a video-assisted discharge education program on activities of daily living, functionality, and patient satisfaction following total hip replacement (THR) surgery. This study included 31 patients who were randomly divided into the physiotherapy group (n = 18), and the video-assisted discharge education (VADE) group (n = 13). Both groups received a physiotherapy program. The VADE group was also received the VADE program. Face-to-face instruction was used in all of the educational programs. There was a significant difference in favor of the VADE group in Harris Hip Score, Nottingham Extended Activities of Daily Living Scale’s movement score, Tampa Scale of Kinesiophobia, Patient Satisfaction Questionnaire (p < 0.05). There was a significant difference between groups on resting pain levels in the first week and on resting and activity pain levels in the third month in favor of the VADE group (p < 0.05). The results of this study demonstrated that VADE can be effective in improving patient satisfaction and functionality, reducing pain and kinesiophobia following THR.
... Clearly, such a standard program requires professional and licensed therapists and the appropriate equipment and should be performed in the hospital or an accredited outpatient facility. As such, these posthospitalization programs require more outpatient facility visits (2-3 times/week) and related costs [4]. Time and economic burdens have, therefore, limited the use of these programs. ...
Background
This randomized controlled study compared standard supervised physiotherapy (SPT) with a self-developed, home-based, enhanced knee flexion exercise program involving a low stool (KFEH) in patients who underwent total knee arthroplasty (TKA).
Methods
Patients were recruited from July 2014 to December 2015 and randomly assigned to one of two groups: KFEH ( n = 60) and SPT ( n = 59). Outcomes (joint function) were evaluated according to the Knee Society Score (KSS), visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and range of motion (ROM) assessment at selected time points (preoperatively; 1 week; 1, 3, and 6 months; and 1 year after surgery).
Results
Pain and functional improvement were observed in both groups. Non-inferiority of KFEH was evident 12 months postoperatively; however, patients in the KFEH group exhibited better ROM at 1 month ( P < 0.01). Absolute WOMAC and KSS scores were slightly better in the KFEH group, although the difference was not statistically significant. There was no difference in VAS scores and complication rates between the two groups. Additionally, the home program would save patient time and decrease the economic burden associated with in-hospital SPT.
Conclusion
Considering rehabilitation and economic efficiency as well as the COVID pandemic, a home-based enhanced knee flexion exercise program for TKA rehabilitation is recommended.
... They also demonstrated that irrespective of the discharge status, the cost incurred on physiotherapy was substantial [17]. A cost-comparison study from Turkey demonstrated the total cost of home-based self-exercise without support was half (38 USD) compared to a clinic-based physiotherapist supported program (65 USD) with no difference in functional status at 2 years [18]. A meta-analysis of four trials [19] concluded the cost of hospital-based rehabilitation was higher (SMD 0.42 (95% CI 0.04, 0.80) compared to unsupported home-based program. ...
Background:
Expenditure for rehabilitation following knee arthroplasty for osteoarthritis- and rehabilitation-related challenges following discharge to home after surgery is not available in the Indian context.
Objectives:
To estimate cost of rehabilitation and document challenges in following rehabilitation advices, from a patient perspective.
Methods:
We conducted a hospital-based cross-sectional study of patients visiting the orthopedic department at a tertiary care public-funded hospital in New Delhi and included those who recently (less than 4 months) underwent primary knee arthroplasty for osteoarthritis. A trained physiotherapist not involved in clinical care collected information on expenditures incurred after discharge from hospital, patient's ability to recall the advices given by the physician and challenges they experienced using a semi-structured questionnaire. We report median costs by category of direct and indirect cost and used linear regression to explore determinants of cost.
Results:
We interviewed 82 consecutive patients (mean age 60.8 years and 68% females) with median time since surgery of 28 days. More than half (52%) sought some support for physiotherapy. The median cost of rehabilitation was INR 18,395 (Interquartile-range 11,325-27,775). Direct medical cost contributed to 74% of total cost (32% fee for services, 21% medications and lab investigations, 21% assistive devices). Twenty percent higher costs were incurred among those undergoing bilateral knee surgery after adjusting for age, sex, income, and type of physiotherapy support sought. Challenges were related to recall of advices, not understanding the recovery process and pain management.
Conclusion:
About half patients undergoing knee arthroplasty seek support for rehabilitation after discharge to home contributing to a major portion of expenses incurred during rehabilitation. Cost-effective support mechanism for home-based rehabilitation is required for improving patient rehabilitation experiences.
Supplementary information:
The online version contains supplementary material available at 10.1007/s43465-021-00405-6.
... The power calculation is based on the proof of superiority, and calculated for patients undergoing TKA and THA separately. The reported standard deviation (SD) of the KOOS-PS and HOOS-PS 3 months after physiotherapy in TKA and THA patients was 15.6 and 11.8, respectively [35][36][37][38][39][40][41]. For the intra cluster correlation coefficient we used an interclass correlation coefficient (ICC) of 0.06, which is generally reported in literature for hospital processes. ...
Background:
Physiotherapy is a proven effective treatment strategy after total knee and hip arthroplasty (TKA/THA), however there is considerable practice variation regarding its timing, content and duration. This study aims to compare the (cost-) effectiveness of a standardized, treat-to-target postoperative physiotherapy strategy with usual postoperative care.
Methods:
Using a cluster randomized study design, consecutive patients scheduled for a primary TKA/THA in 18 hospitals in the Netherlands will be assigned to the treat-to-target physio therapy strategy or usual postoperative care. With the treat-to-target strategy a standardized, individually tailored, exercise program is aimed at the attainment of specific functional milestones. Assessments are done at baseline, 6 weeks and 3, 6, 9 and 12 months follow up. The primary outcome will be the Knee injury / Hip disability and Osteoarthritis Outcome Score - Physical Function Short Form (KOOS-PS / HOOS-PS) at 3 months follow up. Secondary outcomes are the numeric rating scale for pain, the Oxford Knee and Hip Scores, performance-based test and the EuroQol 5D-5L for quality of life. Healthcare use, productivity and satisfaction with postoperative care are measured by means of questionnaires. In total, 624 patients will be needed of which 312 TKA and 312 THA patients.
Discussion:
The study will provide evidence concerning the (cost-) effectiveness of the treat-to-target postoperative physiotherapy treatment compared to usual postoperative care. The results of this study will address an important evidence gap and will have a significant impact in daily practice of the physio therapist.
Trial registration:
Registered in the Dutch Trial Registry on April 15, 2018. Registration number: NTR7129 .
