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Ong CB, Cororaton AD, Westrich GH, Cushner FD, Haas SB, Della Valle AG. COVID-19 disruptions to elective postoperative care did not adversely affect early complications or patient reported outcomes of primary TKA. Arch Orthop Trauma Surg 2023; 143:1579-1591. [PMID: 35378597 PMCID: PMC8978771 DOI: 10.1007/s00402-022-04422-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Elective orthopedic care, including in-person office visits and physical therapy (PT), was halted on March 16, 2020, at a large, urban hospital at the onset of the local COVID-19 surge. Post-discharge care was provided predominantly through a virtual format. The purpose of this study was to assess the impact of postoperative care disruptions on early total knee arthroplasty (TKA) outcomes, specifically 90-day complications, 120-day rate of manipulation under anesthesia (MUA) and 1-year patient-reported outcome measures (PROMs). MATERIALS AND METHODS Institutional records were queried to identify 624 patients who underwent primary, unilateral TKA for osteoarthritis and who were discharged home between 1/1/20 and 3/15/20. These patients were compared to 558 controls discharged between 1/1/19 and 3/15/2019. Cohort demographics and in-hospital characteristics were equivalent apart from inpatient morphine milligram equivalent (MME) consumption. Patient-reported access to PT (p < 0.001) and post-discharge care (p < 0.001) were worse among study patients. Study patients were prescribed fewer post-discharge PT sessions (19.8 vs. 23.5; p < 0.001) and utilized telehealth more frequently (p < 0.001). Mann-Whitney U, T, Fisher's Exact, and chi-squared tests were used to compare outcomes. RESULTS Ninety-day CMS complications were lower among study patients (3.5% vs. 5.9%; p = 0.05). Rates of MUA were similar between groups. Study patients reported similar PROMs and marginally inferior VR-12 mental and LEAS functional outcomes at 1 year. CONCLUSION Disruptions to elective orthopedic care in March 2020 seemed to have had no major consequences on clinical outcomes for TKA patients. Our findings question the usefulness of pre-pandemic post-discharge protocols, which may over-emphasize in-person visits and PT.
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Affiliation(s)
- Christian B. Ong
- The Department of Orthopaedic Surgery at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Agnes D. Cororaton
- The Department of Orthopaedic Surgery at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Geoffrey H. Westrich
- The Department of Orthopaedic Surgery at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Fred D. Cushner
- The Department of Orthopaedic Surgery at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Steven B. Haas
- The Department of Orthopaedic Surgery at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Barker KL, Room J, Knight R, Dutton SJ, Toye F, Leal J, Kent S, Kenealy N, Schussel MM, Collins G, Beard DJ, Price A, Underwood M, Drummond A, Cook E, Lamb SE. Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT. Health Technol Assess 2020; 24:1-116. [PMID: 33250068 DOI: 10.3310/hta24650] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. OBJECTIVES To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. DESIGN An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. SETTING The trial took place in 14 NHS physiotherapy departments. PARTICIPANTS People identified as being at high risk of a poor outcome after knee arthroplasty. INTERVENTIONS A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. MAIN OUTCOME MEASURES The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. RESULTS In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. LIMITATIONS The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. CONCLUSIONS This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. TRIAL REGISTRATION Current Controlled Trials ISRCTN13517704. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jon Room
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Fran Toye
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Seamus Kent
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Kenealy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael M Schussel
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Gary Collins
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,School of Medicine and Health, University of Exeter, Exeter, UK
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Haas R, Bowles KA, O'Brien L, Haines T. The effect of transferring weekend physical therapy services from the acute to sub-acute setting in patients following hip and knee arthroplasty: a quasi-experimental study. Physiother Theory Pract 2020; 38:648-660. [PMID: 32568601 DOI: 10.1080/09593985.2020.1777604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited. PURPOSE To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty. METHODS This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted. RESULTS The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p = .022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively). CONCLUSIONS No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients.
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Affiliation(s)
- Romi Haas
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Physiotherapy, Monash University and Monash Health Allied Health Research Unit, Frankston, Australia
| | - Kelly-Ann Bowles
- Department of Community Emergency Health and Paramedics, Monash University and Monash Health Allied Health Research Unit, Frankston, Australia
| | - Lisa O'Brien
- Department of Occupational Therapy, Monash University and Monash Health Allied Health Research Unit, Frankston, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University and Monash Health Allied, Health Research Unit, Frankston, Australia
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Immediate Physical Therapy following Total Joint Arthroplasty: Barriers and Impact on Short-Term Outcomes. Adv Orthop 2019; 2019:6051476. [PMID: 31080675 PMCID: PMC6476141 DOI: 10.1155/2019/6051476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/26/2019] [Indexed: 12/21/2022] Open
Abstract
Background Recent evidence suggests benefit to receiving physical therapy (PT) the same day as total joint arthroplasty (TJA), but relatively little is known about barriers to providing PT in this constrained time period. We address the following questions: (1) Are there demographic or perioperative variables associated with receiving delayed PT following TJA? (2) Does receiving immediate PT following TJA affect short-term outcomes such as length of stay, discharge disposition, or 30-day readmission? Methods. Primary TJA procedures at a single center were retrospectively reviewed. Immediate PT was defined as within eight hours of surgery. Demographic and perioperative variables were compared between patients who received immediate PT and those who did not. We identified an appropriately matched control group of patients who received immediate PT. Postoperative length of stay, discharge disposition, and 30-day readmissions were compared between matched groups. Results In total, 2051 primary TJA procedures were reviewed. Of these, 226 (11.0%) received delayed PT. These patients had a higher rate of general anesthesia (25.2% versus 17.8%, p=0.006), later operative start time (13:26 [11:31-14:38] versus 9:36 [8:24-11:16], p<0.001), longer operative time (1.8 [1.5-2.2] versus 1.6 [1.4-1.8] hours, p=0.002), and higher overall caseload on the day of surgery (6 [4-9] versus 5 [4-8], p=0.002). A matched group of patients who received immediate PT was identified. There were no differences in postoperative length of stay or discharge disposition between matched immediate and delayed PT groups, but delayed PT (OR 4.54; 95% CI 1.61-12.84; p=0.004) was associated with a higher 30-day readmission rate. Conclusion Barriers to receiving immediate PT following TJA included general anesthesia, later operative start time, longer operative time, and higher daily caseload. These factors present potential targets for improving the delivery of immediate postoperative PT. Early PT may help reduce 30-day readmissions, but additional research is necessary to further characterize this relationship.
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