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New knee osteoarthritis standards & why not everyone needs inpatient rehab after a knee replacement. But who decides?

Surgery should be considered a last resort for the treatment of knee osteoarthritis, under a new clinical care standard released today by the Australian Commission on Safety and Quality in Health Care.

knee standards graphicIn a media statement, the Commission’s Clinical Director Dr Robert Herkes said about 70 per cent of knee replacements were carried out on patients whose weight was contributing to their osteoarthritis.

“But fewer than 8 per cent of Australians incorporate weight loss as part of their osteoarthritis treatment,” Herkes said.

The Commission said one effect of the new standard – which has been endorsed by Arthritis Australia, the Australian Rheumatology Association, the Australian Physiotherapy Association and NPS MedicineWise – is to discourage the use of arthroscopy for patients with knee osteoarthritis. It says:

Knee arthroscopy – a procedure that involves doctors inserting a camera and surgical instruments inside a patient’s knee joint to clear out debris – is costly, may cause harm, and has repeatedly been shown to bring minimal benefit to patients with osteoarthritis, and yet it remains a common form of treatment.

Meanwhile, rehabilitation physicians Associate Professor Steven Faux and Dr Lee Laycock write in the post below how a three year study, published recently in the Journal of the American Medical Association, can help prompt a breakthrough in costly and unnecessary inpatient rehabilitation for knee replacements versus effective and targeted home-based care.

Writing on behalf of the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ), they say inpatient rehabilitation is often a “default” service model for privately insured patients – a big issue given more than half of all joint replacements take place in private hospitals.

They say there are two important issues at play. One, of course, is who decides that the patient is best managed as an in-patient in a private rehabilitation hospital or at as a private patient receiving rehabilitation in their own home.

The other is the lack of alternative and adequate funding models for rehabilitation in the home or tele-rehabilitation developed by private health funds, and how that drives patient expectations and experiences and health care costs.

Croakey readers may also be interested to read these reports from a recent Choosing Wisely event on efforts by other health services and professionals to reduce unnecessary tests and treatments.


Associate Professor Steven Faux and Dr Lee Laycock write:

There are over 50,000 total knee replacements undertaken per year in Australia and over half a million since the Australian Joint Registry commenced in 2000-1.

A 2004 study suggested that each total knee replacement costs between $25-30,000. In the public hospital system the length of stay averages 5-12 days with 33- 55 per cent of funding costs going to inpatient rehabilitation hospitals for 10-14 days of rehabilitation.

As rehabilitation physicians we know that not all patients need to be admitted to hospitals for rehabilitation and many can achieve the same outcomes through different service models including outpatient rehabilitation, day rehabilitation, rehabilitation in the home and tele-rehabilitation.

In the public sector patients can be assessed by rehabilitation physicians and allocated to the right rehabilitation, in the right setting, at the right time, with only those in under-resourced rural areas, or those with poor social supports, numerous comorbidities and/or surgical complications being admitted for inpatient rehabilitation.

However, it’s a very different array of services and resources in the private sector where over 50 per cent of all joint replacements take place.

HIHO (Hospital Inpatient v HOme) study

Few private health funds (who control access to private hospitals) have been able to develop alternative and adequate funding models for rehabilitation in the home or tele-rehabilitation. So evidence was needed to answer the question: can people who have knee replacements achieve the same or better outcomes without necessarily being admitted for inpatient rehabilitation?

In February 2017 such a study was completed at the Whitlam Orthopaedic Research in western Sydney by Associate Professor Justine Naylor and Dr Mark Buhagiar.

The HIHO (Hospital Inpatient v HOme) study was a parallel, randomised clinical trial, including a nonrandomised observational group, conducted at two public, high-volume arthroplasty hospitals in Sydney between 2012-2015.

Of 525 eligible patients, 165 were randomised either to receive inpatient hospital rehabilitation and home-based rehabilitation (known as ‘usual care’) or to receive home-based rehabilitation alone. Nearly 90 patients were enrolled in an observation group receiving usual care.

The study found no difference in outcomes among the patients: they each walked as well as one another, had the same amount of pain and regained the same amount of function in the short term (at 10 weeks) and long-term (at 6 months).

The HIHO study is to be congratulated and embraced by the rehabilitation community.  It is without doubt one of the first times rehabilitation and its role in managing people after complex surgery has been discussed in the mainstream media.

Working with PHI funds to cut unnecessary admissions

As rehabilitation physicians we have been trying to influence the health funds to enhance the service models for rehabilitation after knee replacement.

In Victoria a model for home based rehabilitation has been trialled but with poor uptake as many believe it is insufficiently funded, while in New South Wales some private hospitals have been providing an unfunded home based service because it is the right thing to do and patients want it.

Home based rehabilitation was offered in the South East Sydney Area Health Service for three years under the Gillard Government’s additions to national subacute beds with impressive cost savings and improved outcomes.

However, the problem lies in who decides that the patient is best managed in a private rehabilitation hospital or at home.

Rehabilitation physicians are trained to identify the clinically relevant services for people with newly acquired permanent or temporary disability, including difficulty walking. They have an understanding of the limitations and capacities of local hospital and outpatient rehabilitation services, both public and private, and have knowledge of the community rehabilitation services and their resources.

Of course, they work with the patient and the surgeon and take into consideration the patient’s clinical and psychological response to surgery, the complexities of the operation or complications and the patient’s desires and wants which includes where and how the rehabilitation is delivered.

So the decision is not always straightforward and requires a skilled rehabilitation physician to team up with the patient and get them walking earlier, safely independent at home and out of pain.

It must be noted that in this study patients who were obviously in need of inpatient rehabilitation were excluded and so the people who were studied were those agreeing to forego their option for hospital rehabilitation. Surely this is the population who should have a home-based therapy product adequately funded by the health insurers (it’s bound to be cheaper than paying for 14 days of hospital stay, assuming the patient lives in a well-resourced area).

It is not always easy for health insurers to discuss treatment options with rehabilitation physicians and as a result the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) is developing a working group with the Australian Private Hospital Association (APHA) to assist health funds to understand how they can provide better services and save on expensive inpatient admissions.

The crux of this initiative will be the way it is communicated to the consumer who may feel caught between a desire to get home safely as soon as possible and to take advantage of their entitlement to have inpatient rehabilitation.

The rehabilitation physician is therefore uniquely placed to work with the patient and obtain the best outcomes in the most acceptable service model.  If they are to do so, they need to have an array of service models:  inpatient, outpatient, day hospital, telehealth or in-home service models. However, more often than not, this variety of services is not available to privately insured patients who are often inconvenienced by having to use inpatient rehabilitation as a “default” service model.

Why leave many privately insured patients dissatisfied when rehabilitation physicians have the skills, expertise and experience to contribute to the development of more flexible services models?  Surely we all want the same things: high levels of patient satisfaction, service efficiency and optimal cost effectiveness?

We hope this article begins a fruitful discussion and interaction with the health insurance industry. The outcomes are likely to help all involved.

Further reading: Evaluation of the benefits and impact of subacute funding provided to services across South Eastern Sydney Local Health District (SESLHD) under two National Partnership Agreements: Rehabilitation Inpatient Programs 2009-10–2011-12:

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2013 conferences
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Closing the Credibility Gap 2013
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Racism and children/youth health symposium 2014
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Population Health Congress 2015
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