No place like home af­ter hip or knee re­place­ment

The Hamilton Spectator - - HEALTH - JANE E. BRODY New York Times News Ser­vice

Grow­ing num­bers of Amer­i­cans are out­liv­ing their joints. More than 1 mil­lion op­er­a­tions are done an­nu­ally in the U.S. to re­place worn-out knees and hips, and that num­ber is ex­pected to sky­rocket in the com­ing decades as the pop­u­la­tion ages.

Joint re­place­ments typ­i­cally re­store lost mo­bil­ity, mak­ing it pos­si­ble for peo­ple to get health-en­hanc­ing ex­er­cise and en­joy count­less ac­tiv­i­ties that re­quire move­ment.

As some­one who has had both knees re­placed, I can at­test to the vast im­prove­ment in qual­ity of life the surgery be­stowed. I can walk and cy­cle for miles and swim daily with­out pain, and I can sit through op­eras, plays and con­certs with­out stiff­ness.

I can also un­der­score the gen­eral fu­til­ity of some pop­u­lar ef­forts to post­pone needed joint re­place­ments, in­clud­ing in­jec­tions of hyaluronic acid and cor­ti­cos­teroids, braces, shoe in­serts and opi­oid painkillers like OxyCon­tin and fen­tanyl, none of which are rec­om­mended by the Amer­i­can Academy of Or­thopaedic Sur­geons.

In a study pub­lished ear­lier this year in The Jour­nal of Arthro­plasty, med­i­cal re­searchers at the Univer­sity of Iowa and the Univer­sity of Texas re­ported that pa­tients with knee arthri­tis who use treat­ments be­fore surgery that the academy does not rec­om­mend may be in­creas­ing costs by 45 per cent. (The academy guide­lines strongly rec­om­mend only three of the eight pre­op­er­a­tive treat­ments stud­ied — phys­i­cal ther­apy, non­s­teroidal antiinflammatory drugs and the painkiller tra­madol.)

Ul­ti­mately, many, if not most, pa­tients with painful bone-on-bone arthri­tis opt for a joint re­place­ment. But as the num­ber of these re­place­ments grows (the rate nearly dou­bled from 2000 to 2010, when an es­ti­mated 693,400 to­tal knee re­place­ments were per­formed), so does the cost to the health care sys­tem, prompt­ing some experts to look for ways to min­i­mize the ex­pense of the pro­ce­dures with­out com­pro­mis­ing the well-be­ing of pa­tients who need them.

The lat­est re­search — on the value of in-pa­tient re­ha­bil­i­ta­tion for large num­bers of pa­tients — of­fers a promis­ing route to less costly care with no loss of ben­e­fit.

It may sur­prise many to learn that, even if joint re­place­ment pa­tients live alone, the over­whelm­ing ma­jor­ity re­cover equally well and may ex­pe­ri­ence fewer com­pli­ca­tions if they go home di­rectly from the hospi­tal and get out­pa­tient re­ha­bil­i­ta­tion in­stead of spend­ing days or weeks in a costly re­hab fa­cil­ity.

Based on the find­ings of re­cent well-de­signed stud­ies, Dr. Javad Parvizi, chair­man of re­search in or­tho­pe­dics at Thomas Jef­fer­son Univer­sity in Philadel­phia, main­tains that “we need to re-ex­am­ine who, if any­one, should go to a re­hab fa­cil­ity af­ter joint re­place­ment.”

Tra­di­tion­ally, Parvizi said, pa­tients who live alone, those who have both knees or both hips re­placed si­mul­ta­ne­ously, and those with a se­ri­ous un­der­ly­ing med­i­cal con­di­tion are au­to­mat­i­cally sent to a re­hab fa­cil­ity af­ter dis­charge from the hospi­tal. And to be sure, a small per­cent­age of these pa­tients — per­haps those who have both hips or, like me, both knees re­placed at once — may ben­e­fit from it.

How­ever, ac­cord­ing to the find­ings of a new Aus­tralian study, pa­tients who live alone and can per­form a home ex­er­cise pro­gram re­cover just as well with home-based re­hab as pa­tients who spend 10 days in a re­hab fa­cil­ity. In the study, 81 knee re­place­ment pa­tients were ran­domly se­lected to re­ceive 10 days of in-pa­tient re­ha­bil­i­ta­tion, fol­lowed by an eight-week home­based pro­gram; 84 pa­tients got only the home-based pro­gram; and 87 pa­tients served as a non­ran­dom­ized ob­ser­va­tion group that did only home-based re­hab.

Six months af­ter their surgery, there was no dif­fer­ence in mo­bil­ity, pain, func­tion or qual­ity of life be­tween those who got in-pa­tient re­hab and ei­ther of the two groups that got out­pa­tient re­hab.

An­other study, by Parvizi’s team, in­volved 769 pa­tients who un­der­went ei­ther a knee or hip re­place­ment for ad­vanced arthri­tis. Only 36 of these pa­tients were dis­charged from the hospi­tal to a re­ha­bil­i­ta­tion fa­cil­ity; the rest, in­clud­ing 138 pa­tients who lived alone, re­turned home to re­ceive out­pa­tient re­hab.

Based on an assess­ment of the pa­tients’ func­tion, pain relief and per­sonal sat­is­fac­tion three months af­ter their surgery, the team con­cluded, “Pa­tients liv­ing alone can ex­pect a safe re­cov­ery, equiv­a­lent to those not liv­ing alone, when dis­charged di­rectly home.”

Even if pa­tients who lived alone stayed in the hospi­tal an ex­tra day, and some of them got home health ser­vices in ad­di­tion to home-based re­hab, the cost was much less than if they had been rou­tinely dis­charged to a re­hab fa­cil­ity, they re­ported.

Dr. Wil­liam J. Hozack, an or­tho­pe­dic sur­geon at the Sid­ney Kim­mel Med­i­cal Col­lege at Thomas Jef­fer­son Univer­sity, who de­scribed the study at the an­nual meet­ing of the Amer­i­can Academy of Or­thopaedic Sur­geons last month, said, “We found that pa­tients liv­ing alone were able to safely re­cover with­out any in­crease in the rate of com­pli­ca­tions. Even more strik­ingly, pa­tients were gen­er­ally happy and con­tent be­ing in the com­fort of their own home dur­ing re­cov­ery.”

Parvizi noted, “Half or more of the cost of to­tal joint re­place­ments is in­curred in the post­op­er­a­tive pe­riod. Out­pa­tient re­hab is much less ex­pen­sive.”

Costs aside, pa­tients who go home di­rectly may be less likely to ex­pe­ri­ence what doc­tors call “ad­verse events” — com­pli­ca­tions like in­fec­tions, blood clots or worse.

Parvizi said that when pa­tients who live alone are pre­pared be­fore surgery for go­ing home di­rectly from the hospi­tal, they are much more likely to do well with home­based re­hab.

“If pa­tients are told they will be go­ing home, they can make prepa­ra­tions be­fore­hand for needed sup­port,” he said. “But if they think they will be go­ing to in-pa­tient re­hab, they ex­pect that and are not pre­pared to man­age alone.”

PAUL ROGERS, NYT

Stud­ies show that even if joint re­place­ment pa­tients live alone, the ma­jor­ity re­cover well if they get out­pa­tient re­ha­bil­i­ta­tion in­stead of spend­ing time in a costly re­hab fa­cil­ity.

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