Inpatient rehab after arthroplasty: extra costs, no benefit

Private patients are being funnelled into an expensive inpatient rehabilitation pathway after total hip arthroplasty with no evidence that they will have better outcomes than patients who access their rehab in the community, researchers say.

An observational study of 246 privately insured patients, from one of 12 private hospitals across five states, has shown the only significant difference with inpatient rehab was the higher cost.

Patient outcomes such as the Oxford Hip Score at 90 and 365 days, Euroqol Visual Analogue Scale for health ‘today’ (EQVAS) at 35, 90 and 365 days, and time off paid employment were similar with or without inpatient rehabilitation.

Associate Professor Justine Naylor from the South Western Sydney Clinical School at the University of NSW, said the inpatient rehab pathway continued to cost extra with most of those patients moving onto a day hospital program.

“So the patients go and have their 10-12 days in inpatient rehab and then they come back twice a week for the next six weeks in a day hospital program. Whereas the day hospital typically isn’t available if you go straight home.”

The study found 62% of patients who had inpatient rehab went on to day hospital with only 1% accessing domiciliary care such as physio visits at home. In comparison, only 6% of patients who did not have inpatient rehab accessed day hospital but 40% used domiciliary care.

“Those subtle differences add to the really large cost differential because that day hospital is still about $300 per visit.”

In another complicating twist, patients who accessed services in the community had out-of-pocket expenses that did not apply to people going to inpatient rehab and day hospital programs.

“So there is a really perverse incentive to choose the more expensive pathway because you are not out of pocket.”

Effecting change

She said encouraging people to go straight home after their surgery required some effort from multiple players.

“Part of the solution has to be around the insurers looking at how they reimburse and there is the responsibility of the hospitals to present the rehab options truthfully and according to the evidence.”

“And that means it’s not essential to go to inpatient rehab. If you are otherwise well enough to go straight home, you are no worse off because you didn’t have inpatient rehab.”

“And it’s up to physios, surgeons and rehab physicians to also promote the appropriate pathways which is that uncomplicated patients can go straight home and they’ll do fine.”

The hip findings are consistent with those from an earlier study of patients undergoing total knee arthroplasty, previously reported in the limbic.

Dr Naylor said inpatient rehab should be reserved for the most impaired patients including those with complications such as dislocation, clot or nerve damage who may be slower to progress.

“In this space, the arguments are clouded by a whole lot of conflicts of interest because private hospitals own private inpatient rehab facilities. So they make money by people going to inpatient rehab.”

“Rehab physicians are potentially biased towards the inpatient model because they get to see these patients regularly and that is a lot of what they do – consult with patients in inpatient rehab.”

“They can’t really argue around the efficacy and that is if you take people who pretty much look the same pre-surgery, are balanced on their age, gender and health profile, and even their level of impairment, you will see largely no difference based on the rehab pathway they follow.”

However patients did require some sort of prescribed program with monitoring.

“They need to be able to recognise when there is a problem like a deep infection or a clot and certainly physios and rehab people are in a good position to see that. And you do need some specific advice around what to strengthen and when to get off your walking sticks but for the average person without major complications, it doesn’t need to be particularly intensive.”

Dr Naylor said the study was part of larger study funded by the HCF Research Foundation, although HCF had no role in study design or data analysis.

“They’re concerned about the cost of inpatient rehab on their budget as they are the cost of other low value products but they have nothing to do with the design of the study. It isn’t HCF saying we want to stop funding this, this is us scrutinising an expensive and low-value pathway.”

Professor Kim Bennell, Director of the NHMRC Centre of Research Excellence in Translational Research in Musculoskeletal Pain, told the limbic she agreed with the study’s findings.

She said inpatient rehab was costly and its use was often related to expectations and insurance status rather than need.

“It should for people who actually really, really need it and not for those who could just as well get the same benefits from less costly care.”

“And so it should be reserved for those people whose social circumstance is perhaps that they don’t have support to get to outpatient rehab or they have other health issues and are quite impaired.”

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