Private hospitals ‘biggest factor’ in rise in-patient rehab after TKR: study

Private hospitals are encouraging patients to have in-house rehabilitation after total knee replacements because health insurers pay them per-day to deliver it, new research suggests.

But in-hospital rehab offers no benefits over community and home-based options, and the fact almost half of TKR private patients now use it represents ‘low value care’, according to the authors of the study published in the MJA.

The study authors sought to quantify the rate of inpatient rehabilitation and quantify the contribution that hospitals, surgeons and patient-related factors made to it, using five linear progression models in their retrospective analysis of 35,389 Medibank-funded surgeries at 170 private hospitals between 2009-2016.

They found the overall rate for in-patient rehabilitation jumped from 31% to 45% over that period.

This was despite consistent evidence that rehabilitation carried out in hospital was more expensive – one study calculated a mean difference of $9,500 – but no better than when done at home or in the community, and rates of use are declining overseas.

The authors found 30% of the rise was due to patient-related factors such as age, socioeconomic status and whether they lived alone. But the most important determinant of whether a patient was admitted to inpatient rehabilitation “was the hospital where the TKR procedure was undertaken”, wrote Dr Chris Schilling (PhD), Associate Director, Economics at KPMG and his co-authors.

“This factor was substantially more important than the clinical profile of the patient, that is the same patient may enter different rehabilitation pathways according to the hospital in which they were operated.”

The study’s modelling results suggested that “hospital related factors (46.9%) made the largest contribution of the factors included to variation in inpatient rehabilitation rates; together with surgeon-related factors (28.5%) and provider-related factors explained three times as much of the variation as patient-related factors (24.6%).

The authors said the private health insurance industry played a role in the rise, through offering hospitals a per-day payment for each day of in-patient rehabilitation, on top of the fee for initial surgery.

They concluded that the net result was low-value care for Australians.

“From a hospital perspective, offering a service that delivers benefits to patients for which it is well remunerated is consequently attracted. However, it is less so from a public health perspective,” they wrote, citing an editorial published in the MJA that argued inpatient rehabilitation had become an industry whose cost is not justified by better outcomes.”

The authors noted there were no clinical guidelines about best-practice rehabilitation after TKR, and no consensus on the ideal rate of inpatient rehabilitation.

“But the public health system rate in Australia of 17%, rates under 11% in the United States and Canada, and the clinical evidence discussed above suggest that the private inpatient rehabilitation rate in Australia of 45% is too high,” they wrote.

“Reducing low value care will require system-level changes to guidelines and incentives for hospitals, as hospital-related factors are the major driver in inpatient rehabilitation practices.”

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