No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The effectiveness of inpatient physical therapy compared to outpatient physical therapy for older adults after total hip replacement in the post-discharge period: a systematic review protocol
Abstract
Background:
Total hip replacement is the most effective and safest method for treating severe degenerative, traumatic and other diseases of the hip joint. Total hip replacement can reliably relieve pain and improve function in the majority of patients for a period of 15 to 20 years or more postoperatively. Physical therapy follows each total hip replacement surgery. Physical therapy protocols after total hip replacement in the post-discharge period vary widely in terms of setting (inpatient, outpatient), content (the particular set of exercises used), and frequency (e.g. daily versus twice a week). In current literature, there is no systematic review which has compared the effectiveness of inpatient and outpatient physical therapy in patients after total hip replacement in the post-discharge period.
Objectives:
The objective of this systematic review was to compare the effectiveness of inpatient physical therapy with outpatient physical therapy on the quality of life and gait measures in older adults after total hip replacement in the post-discharge period.
Inclusion criteria:
Types of participants: This review considered studies that include older adults (over 65 years) who have had total hip replacement and are in the post-discharge period. Adults with bilateral or multiple simultaneous surgeries and also patients who have had hemiarthroplasty of the hip joint were excluded. Types of intervention: This review considered studies that included any type of physical therapy delivered in inpatient settings provided by professionals with education in physical therapy. Inpatient physical therapy delivered at any frequency and over any duration was included. Types of comparator: This review considered studies that included as a comparator any type of physical therapy delivered in outpatient settings provided by professionals with education in physical therapy or no physical therapy. Types of outcomes: This review considered studies that included the following primary and secondary outcomes. The primary outcome was quality of life, assessed by any validated assessment tool. The secondary outcome was measures of gait assessed by any valid methods. Types of studies: This review considered both experimental and observational study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.
Search strategy:
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in 12 databases. Studies published in all languages and any date were considered for inclusion in this review.
Methodological quality:
Assessment of methodological quality was not conducted as no studies were identified that met the inclusion criteria.
Data extraction and synthesis:
Data extraction and synthesis was not performed because no studies were included in this systematic review.
Results:
During to the three-step search strategy 4330 papers were identified. The primary and secondary reviewer independently retrieved 42 potentially relevant papers according to the inclusion criteria by title and abstract screening. Following assessment of full text all of the retrieved papers were excluded based on the inclusion criteria.
Conclusions:
There is no scientific evidence comparing the effectiveness of inpatient physical therapy with outpatient physical therapy in older patients after total hip replacement in the post-discharge period.
... Thus, a comparative study contrasting inpatient to outpatient physical therapy might facilitate the identification of some non-adherence parameters. However, a systematic review attempting to compare the effectiveness of inpatient with outpatient physiotherapeutic care found that no scientific evidence is in existence concerning the research question at hand [11]. ...
... Thus, a comparative study contrasting inpatient to outpatient physical therapy might facilitate the identification of some non-adherence parameters. However, a systematic review attempting to compare the effectiveness of inpatient with outpatient physiotherapeutic care found that no scientific evidence is in existence concerning the research question at hand [11]. The effectiveness of delivering musculoskeletal physical therapy by the means of telerehabilitation has been proven for a variety of conditions ranging from lower back pain to rehabilitation after knee or hip replacement [12,13]. ...
Background:
The elements of previously designed questionnaires do not take into consideration the burdens encountered in an inpatient hospital setting. The purpose of this study is to validate elements of a non-compliance survey in an in-hospital setting and discuss aspects of compliance with telerehabilitative physiotherapy in the early postoperative period.
Methods:
A literature search was conducted to identify elements that prevent patients from performing their prescribed physical therapy exercises. These items were then evaluated by the expert review technique as described by Ikart. Afterwards, the synthesized survey was handed out to patients for the assessment of the quality of its items.
Results:
The results of the expert review technique identified some conceptual and grammatical problems. This led to the adjustment of some of the elements. The quality of the resulting questionnaire was deemed to be good, as patients were able to fully understand the concepts and answer accordingly. A statistical analysis was conducted to evaluate the responses.
Conclusions:
The items of this second questionnaire have proven to be reliable to assess the compliance of patients in an in-hospital setting. These items will be added to the cross-culturally adapted items of a previous questionnaire.
... So-called empty reviews are the results of a comprehensive search in which no studies are located that meet the a priori inclusion criteria for a systematic review. [1][2][3][4] These empty reviews are more likely to be subject to publication bias and not published in scholarly journals. However, organizations such as the Joanna Briggs Institute and the Cochrane Collaboration understand the benefits of publishing empty reviews. ...
... 5 An empty review may arise when review questions are asked about an area of practice with a limited research base. 1 Empty reviews may also be the result of review questions that are highly specific in terms of the population, intervention or outcome criteria compared with questions asked in primary research studies. [2][3][4] In addition, the use of highly specific methodological inclusion criteria, as can be seen when systematic reviews focus solely on randomized controlled trials as the highest level of evidence but the review question being asked cannot easily be answered by a randomized design, may produce no eligible studies for inclusion. 5 Some of these issues may be foreseen at the time of protocol development when reviewers conduct initial pilot searches to identify existing literature to support and inform the inclusion criteria and establish the need for conducting the review. ...
Titanium-based implants utilized in total joint arthroplasties could restore primary musculoskeletal function to patients suffering from osteoarthritis and other conditions. Implants are susceptible to failure stemming from aseptic loosening and infection at the joint site, eventually requiring revision surgery. We hypothesized that there might be a feedback loop by which metal degradation particles and ions released from the implant decrease cell viability and increase immune response, thereby creating biochemical conditions that increase the corrosion rate and release more metal ions. This study focused on the synergistic process through cell viability assays and electrochemical tests. From the results, inflammatory conditions from ion release resulting in cell death would further increase the corrosion rate at the metal implant site. The synergistic interaction in the implant surroundings in which infectious conditions produce Ti ions that contribute to more infection, creating a potential cycle of accelerating corrosion.
Background:
Aseptic loosening of artificial hip joint is a major complication affecting the long-term use of the artificial hip joint, and is the main cause of joint replacement failure. However, the mechanism of aseptic loosening of THR has not yet cleared. The aim of this study was to investigate the underlying mechanism of DANCR in osteoblast differentiation (OD).
Methods:
We detected the expressions of DANCR and FOXO1 in clinical samples and mesenchymal stem cells (MSCs) by qRT-PCR and western blotting. The effects of polymethylmethacrylate (PMMA) on OD of MSCs were examined by alkaline phosphatase (ALP) activity and Alizarin Red S (ARS) staining. The expressions of OD markers were measured by qRT-PCR and western blotting. The mechanism of DANCR in OD was detected by RNA pull-down, RNA immunoprecipitation (RIP) assay and ubiquitination assays.
Results:
Compared with the surrounding normal tissues, DANCR expression was up-regulated and FOXO1 expression was down-regulated in periprosthetic tissues. PMMA suppressed ALP activity, increased DANCR expression, and decreased the expressions of FOXO1, Runx2, Osterix (Ostx) and osteocalcin (OCN). ARS staining showed that PMMA inhibited the OD of MSCs. Knockdown of DANCR attenuated the inhibitory effect of PMMA on OD. Knockdown of FOXO1 could reverse the effect of si-DANC. RNA pull-down and RIP assay implicated that DANCR bound to FOXO1. Ubiquitination assay indicated that si-DANCR could repress Skp2-mediated ubiquitination of FOXO1.
Conclusion:
LncRNA DANCR could inhibit OD by regulating FOXO1 expression.
In people who have been discharged from hospital after a total hip replacement, do rehabilitation exercises directed by a physiotherapist improve strength, gait, function and quality of life? Are these exercises as effective in an unsupervised home-based setting as they are in a supervised outpatient setting?
Systematic review with meta-analysis of randomised trials.
Adult patients after elective total hip replacement.
Physiotherapist-directed rehabilitation exercises after discharge from hospital following total hip replacement.
Hip and knee strength, gait parameters, functional measures, and quality of life.
Five studies comprising 234 participants were included in the review. Sufficient data for meta-analysis were only obtained for hip and knee strength, gait speed and cadence. Physiotherapy rehabilitation improved hip abductor strength by a mean of 16Nm (95% CI 10 to 22), gait speed by 6 m/min (95% CI 1 to 11) and cadence by 20 steps/min (95% CI 8 to 32). Favourable but non-significant improvements in strength were noted for other muscle groups at the hip and knee. Function and quality of life could not be meta-analysed due to insufficient data and heterogeneity of measures, but functional measures tended to favour the physiotherapy rehabilitation group. Most outcomes were similar between outpatient and home-based exercise programs.
Physiotherapy rehabilitation improves hip abductor strength, gait speed and cadence in people who have been discharged from hospital after total hip replacement. Physiotherapist-directed rehabilitation exercises appear to be similarly effective whether they are performed unsupervised at home or supervised by a physiotherapist in an outpatient setting.
Objective
To synthesize professional and patient expertise with available evidence to recommend best practices for post-acute rehabilitation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). Methods
Two expert panels of clinicians, researchers, and patients from Canada and the US participated in a 3-round, online Delphi survey. ResultsConsensus was reached on 22 THA and 24 TKA best practice key statements. Recommendations common to both procedures included the need for supervised rehabilitation interventions provided by trained health professionals early after discharge from the acute care setting to optimize patient outcomes. Personal and environmental contextual factors were identified as influencing the process and outcomes of THA and TKA rehabilitation. Routine outcome assessment was recommended and several standardized outcome tools identified. Short-term followup care in the first 2 years postsurgery was recommended for both procedures. Specifics on timing, rehabilitation providers, need for long-term followup, and interventions differed for THA and TKA. Some recommendations received different levels of support based on the type of panelist (patient, physical therapist, surgeon), professional role (clinician, researcher), and/or country. ConclusionA rigorous consensus method led to key recommendations for post-acute rehabilitation after primary THA and TKA for OA, which together with available evidence and acknowledgment of contextual factors will inform the development of clinical practice guidelines. This is an important step toward reducing practice variation, closing the evidence-practice gap, and improving the quality of rehabilitation services after THA and TKA.
Osteoarthritis is a common indication for hip and knee arthroplasty. An accurate assessment of current trends in healthcare utilization as they relate to arthroplasty may predict the needs of a growing elderly population in the United States. First, incidence data was queried from the United States Nationwide Inpatient Sample from 1993 to 2009. Patients undergoing total knee and hip arthroplasty were identified. Then, the United States Census Bureau was queried for population data from the same study period as well as to provide future projections. Arthroplasty followed linear regression models with the population group >64 years in both hip and knee groups. Projections for procedure incidence in the year 2050 based on these models were calculated to be 1,859,553 cases (hip) and 4,174,554 cases (knee). The need for hip and knee arthroplasty is expected to grow significantly in the upcoming years, given population growth predictions.
The aim of this study was to systematically review and compare the measurement attributes of multidimensional, patient-reported outcome measures used in hip and knee arthroplasty rehabilitation.
A search of PubMed, CINAHL, Cochrane Central Registry, SCOPUS and PEDro databases up to December 2009 identified the validation studies. The quality of the measurement properties were assessed based on the Terwee and Bot criteria, and Scientific Advisory Committee of the Medical Outcomes Trust guidelines.
A total of 68 studies examining 28 instruments were identified. Three instruments had positive ratings for content validity. None of the instruments satisfied both factor analysis and Cronbach's α criteria for internal consistency. Four measures were positively-rated for agreement. Nine tools had positive ratings for construct validity. Twenty-four of the instruments had indeterminate ratings for responsiveness to clinical change. Only certain subscales of 2 instruments were positively-rated for responsiveness to clinical change.
A wide variety of multidimensional patient-reported instruments has been used to assess rehabilitation outcomes after hip and knee arthroplasty, but information about their measurement attributes in these populations is inadequate. More data are needed to clarify their reproducibility and responsiveness to clinical change. :
Most research on failure leading to revision total hip arthroplasty (THA) is reported from single centers. We searched PubMed between January 2000 and August 2010 to identify population- or community-based studies evaluating ten-year revision risks. We report ten-year revision risk using the Kaplan-Meier method, stratifying by age and fixation technique.
Thirteen papers met the inclusion criteria. Cemented prostheses had Kaplan-Meier estimates of revision-free implant survival of ten years ranging from 88% to 95%; uncemented prostheses had Kaplan-Meier estimates from 80% to 85%. Estimates ranged from 72% to 86% in patients less than 60 years old and from 90 to 96% in older patients.
Data reported from national registries suggest revision risks of 5 to 20% ten years following primary THA. Revision risks are lower in older THA recipients. Uncemented implants may have higher ten-year rates of revision, regardless of age.
Physiotherapy has long been a routine component of patient rehabilitation following hip joint replacement. The purpose of this systematic review was to evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for osteoarthritic patients following elective primary total hip arthroplasty.
Design: Systematic review, using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Quorom Statement. Database searches: AMED, CINAHL, EMBASE, KingsFund, MEDLINE, Cochrane library (Cochrane reviews, Cochrane Central Register of Controlled Trials, DARE), PEDro, The Department of Health National Research Register. Handsearches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. No language restrictions were applied. Selection: Trials comparing physiotherapy exercise versus usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. Outcomes: Functional activities of daily living, walking, quality of life, muscle strength and range of hip joint motion. Trial quality was extensively evaluated. Narrative synthesis plus meta-analytic summaries were performed to summarise the data.
8 trials were identified. Trial quality was mixed. Generally poor trial quality, quantity and diversity prevented explanatory meta-analyses. The results were synthesised and meta-analytic summaries were used where possible to provide a formal summary of results. Results indicate that physiotherapy exercise after discharge following total hip replacement has the potential to benefit patients.
Insufficient evidence exists to establish the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. Further well designed trials are required to determine the value of post discharge exercise following this increasingly common surgical procedure.
The annual number of total hip arthroplasties (THA) has increased in Denmark over the past 15 years. There is, however, limited detailed data available on the incidence of THAs.
We calculated the incidence rates (IR) of primary THA and revision in Denmark between 1996 and 2002 and estimated the demands for primary THA in Denmark until 2020. We used data from the Danish Hip Arthroplasty Registry, a nationwide and population-based clinical database, to identify patients who had undergone primary THA (n = 37,144) or revision arthroplasties (n = 6446). Age and sex-specific data on the Danish population were obtained from the StatBank Denmark. All IRs were standardized according to two standards, i.e. the Danish population in 1996 and the European standard population (18 age groups). The future demands for primary THA were estimated using the age and sex-specific incidence of primary THA for 2002 as a reference, and taking into account the expected changes in the age distribution of the population and the trend in IRs seen in Denmark between 1996 and 2002.
The annual overall standardized IRs of primary THAs and revisions increased from 101 (95% confidence interval (CI): 97.6-104) to 134 (CI: 131-138) and from 19.2 (CI: 17.9-20.5) to 21.1 (CI: 19.8-22.4) per 100,000 inhabitants from 1996 to 2002, respectively (IRs adjusted to the Danish population in 1996). The IRs of primary THAs and revisions increased by 30% and 10% during this period. The relative increase in IRs of primary THAs was found to be similar in both women and men. The increase was higher among patients aged 50-59 years, however. Furthermore, a decrease in IRs was seen in patients who underwent primary THA due to rheumatoid arthritis. IRs of primary THAs have been estimated to increase by 22% in 2020 compared with 2002, based only on the expected changes in the age distribution of the population. However, assuming that the annual age and sex-independent increase in the IRs seen in the period 1996-2002 will continue, the IR of primary THA is estimated to increase by as much as 210% in 2020.
The overall annual standardized IRs of primary THAs and revisions in Denmark increased during the period from 1996 to 2002. Moreover, the demands for THA procedures in the coming decades may exceed the current capacity due to the ageing population and a continued age and sex-independent increase in surgical activity.
In 2010, 310,800 total hip replacements were performed among inpatients aged 45 and over. The number and rate of total hip replacements among inpatients aged 45 and over increased from 2000 to 2010: from 138,700 to 310,800 in number and from a rate of 142.2 to 257.0 per 100,000 population. The age distribution of inpatients aged 45 and over who received total hip replacements changed significantly between 2000 and 2010, with the percentage of total hip replacements increasing for younger age groups and decreasing for older age groups. The average length of stay after total hip replacement among inpatients aged 45 and over decreased from 2000 to 2010, from nearly 5 days to just under 4 days.
All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
Existing review required updating.
To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis.
Systematic review from January 2007 to November 2013.
AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied.
Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed.
Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion.
Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered.
11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.
The overall quality and quantity of trials, and their diversity, prevented meta-analyses.
Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.
Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Background:
Early multidisciplinary rehabilitation can improve the recovery after total hip arthroplasty (THA). However, optimal exercise therapy has not been defined. We aimed to answer the question: "Which type and/or timing of exercise therapy is effective following THA?"
Design:
Systematic review.
Methods:
We searched four databases: MEDLINE, PEDro, Cochrane Library, and Cinahl since January 2008 till December 2012. Literature before 2008 was not searched for, because it was previously analyzed by two systematic reviews. Eligible criteria for studies were: Randomized Controlled Trials (RCTs); English language; interventions on type and/or timing of physical exercise initiating after THA; outcome measures including at least one among impairment, activity, participation, quality of life, or length of stay in hospital.
Results:
Eleven papers on nine RCTs were identified. Trial quality was mixed. PEDro scores ranged from four to eight. Exercise therapy varied greatly in type and timing. Each of the nine RCTs addressed a specific issue and overall the results were sparse. In the early postoperative phase favorable outcomes were due to ergometer cycling and maximal strength training. Inconclusive results were reported for aquatic exercises, bed exercises without external resistance or without its progressive increase according to the overload principle, and timing. In the late postoperative phase (> 8 weeks postoperatively) advantages were due to weight-bearing exercises.
Conclusion:
Insufficient evidence exists to build up a detailed evidence-based exercise protocol after THA. Sparse results from few RCTs support specific exercise types which should be added to the usual mobility training in THA patients.
People with osteoarthritis (OA) often are physically inactive. Surgical treatment including total hip arthroplasty or total knee arthroplasty can substantially improve pain, physical function, and quality of life. However, their impact on physical activity levels is less clear.
We used accelerometers to measure levels of physical activity pre- and (6 months) postarthroplasty and to examine the proportion of people meeting the American Physical Activity Guidelines.
Sixty-three people with hip or knee OA awaiting arthroplasty were recruited from a major metropolitan hospital. Physical activity was measured using accelerometry before, and 6 months after, surgery. The ActiGraph GT1M (ActiGraph LLC, Fort Walton Beach, FL, USA) was used in this study and is a uniaxial accelerometer contained within a small activity monitor designed to measure human movement through changes in acceleration, which can then be used to estimate physical activity over time. Questionnaires were used to assess patient-reported changes in pain, function, quality of life, and physical activity. Complete data sets (including valid physical activity data) for both time points were obtained for 44 participants (70%). At baseline before arthroplasty, the activity level of patients was, on average, sedentary for 82% of the time over a 24-hour period (based on accelerometry) and self-rated as "sometimes participates in mild activities such as walking, limited shopping, and housework" according to the UCLA activity scale.
There was no change in objectively measured physical activity after arthroplasty. The majority of participants were sedentary, both before and after arthroplasty, and did not meet the American Physical Activity Guidelines recommended to promote health. This was despite significant improvements in self-reported measures of pain, function, quality of life, and physical activity after arthroplasty.
Despite patient-reported improvements in pain, function, and physical activity after arthroplasty, objectively measured improvements in physical activity may not occur. Clinicians should incorporate strategies for improving physical activity into their management of patients after hip and knee arthroplasty to maximize health status. Future research is needed to explore the factors that impact physical activity levels in people after arthroplasty.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
We report the clinical and radiological outcomes of a series of contemporary cementless ceramic-on-ceramic total hip replacements (THRs) at ten years in patients aged ≤ 55 years of age. Pre- and post-operative activity levels are described. A total of 120 consecutive ceramic cementless THRs were performed at a single centre in 110 patients from 1997 to 1999. The mean age of the patients at operation was 45 years (20 to 55). At ten years, four patients had died and six were lost to follow-up, comprising ten hips. The mean post-operative Harris hip score was 94.7 (55 to 100). Radiological analysis was undertaken in 90 available THRs of the surviving 106 hips at final review: all had evidence of stable bony ingrowth, with no cases of osteolysis. Wear was undetectable. There were four revisions. The survival for both components with revision for any cause as an endpoint was 96.5% (95% confidence interval 94.5 to 98.7). The mean modified University of California, Los Angeles activity level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6 to 10) at the ten-year post-operative period.
Alumina ceramic-on-ceramic bearings in cementless primary THR in this series have resulted in good clinical and radiological outcomes with undetectable rates of wear and excellent function in the demanding younger patient group at ten years.
Cite this article: Bone Joint J 2013;95-B:1603–9.
Purpose:
The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of the Balgrist total hip replacement cup.
Methods:
We report the results of a retrospective review of 195 total hip prostheses with Balgrist cup implanted in 178 patients. There were 59 men and 119 women with a mean age at surgery of 52.3 years (range, 19-72). Cox regression was used to determine the influence of independent variables on the survivorship of the prosthesis.
Results:
There were 117 (66 %) of 178 patients, and 131 (67 %) of 195 hips available for assessment at a mean follow-up of 17.4 years. A total of 21 patients (22 hips) were lost from follow-up (12 %). A total of 25 patients (27 hips) required some type of re-operation during the follow-up period. Eight of 27 re-operations (30 %) were directly caused by the Balgrist cup failure due to fatigue fracture of the metallic shell (n = 5; 19 %), polyethylene wear (n = 2; 7 %) and aseptic loosening (n = 1; 4 %). The mean polyethylene wear rate was 0.068 mm/year (range, 0.008-0.230; SD = 0.043). The risk of re-operation for any reason was decreased with dysplastic hip as a primary diagnosis (hazard ratio; HR = 0.250; 95 % CI 0.086-0.725) and with greater age at the time of surgery (HR = 0.923; 95 % CI 0.880-0.969). The 19-year survivorship with re-operation for any reason was 75.6 % (95 % CI 67.0-84.2). The 19-year survivorship with re-operation for the Balgrist cup failure was 90.5 % (95 % CI 83.4-97.6).
Conclusions:
The Balgrist cup continues to provide excellent clinical and radiological outcomes. This is associated at least in part with a low polyethylene wear rate. The main reason for the Balgrist cup failure is fatigue fracture of the metallic shell.
There has been lengthy debate as to which setting, skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF), is more efficient in treating joint replacement patients. This study aims to determine the efficiency of rehabilitation care provided by SNF and IRF to joint replacement patients with respect to both payment and length of stay (LOS).
This study used a prospective multisite observational cohort design. Tobit models were used to examine the association between setting of care and efficiency. The study enrolled 948 knee replacement patients and 618 hip replacement patients from 11 IRFs and 7 SNFs between February 2006 and February 2007. Output was measured by motor functional independence measure (FIM) score at discharge. Efficiency was measured in 3 ways: payment efficiency, LOS efficiency, and stochastic frontier analysis efficiency.
IRF patients incurred higher expenditures per case but also achieved larger motor FIM gains in shorter LOS than did SNF patients. Setting of care was not a strong predictor of overall efficiency of rehabilitation care. Great variation in characteristics existed within IRFs or SNFs and severity groups. Medium-volume facilities among both SNFs and IRFs were most efficient. Early rehabilitation was consistently predictive of efficient treatment.
The advantage of either setting is not clear-cut. Definition of efficiency depends in part on preference between cost and time. SNFs are more payment efficient; IRFs are more LOS efficient. Variation within SNFs and IRFs blurred setting differences; a simple comparison between SNF and IRF may not be appropriate.
In the 1960s, total hip replacement revolutionised management of elderly patients crippled with arthritis, with very good long-term results. Today, young patients present for hip-replacement surgery hoping to restore their quality of life, which typically includes physically demanding activities. Advances in bioengineering technology have driven development of hip prostheses. Both cemented and uncemented hips can provide durable fixation. Better materials and design have allowed use of large-bore bearings, which provide an increased range of motion with enhanced stability and very low wear. Minimally invasive surgery limits soft-tissue damage and facilitates accelerated discharge and rehabilitation. Short-term objectives must not compromise long-term performance. Computer-assisted surgery will contribute to reproducible and accurate placement of implants. Universal economic constraints in healthcare services dictate that further developments in total hip replacement will be governed by their cost-effectiveness.
Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis
- O Health Quality
Health Quality O. Physiotherapy rehabilitation after total knee or hip replacement: an
evidence-based analysis. Ont Health Technol Assess Ser 2005;5:1-91.
Guideline of Physiotherapy recommended by Union of Physiotherapists of the Czech Republic. Total hip replacement. Czech Republic: Union of Physiotherapists of the Czech Republic
- Unify
Unify. Guideline of Physiotherapy recommended by Union of Physiotherapists of the Czech
Republic. Total hip replacement. Czech Republic: Union of Physiotherapists of the Czech Republic;
2004:16.