Knee patients ‘better off at home’

In-hospital rehabilitation after knee replacements is increasing despite evidence that cheaper alternatives may be better.

“There is strong clinical evidence that home and community-based rehabilitation delivers the same health outcomes as rehabilitation in the hospital for the majority of patients,” Medibank chief medical officer Linda Swan said.

In-hospital rehabilitation after knee replacements has been increasing in Australia despite evidence that cheaper options may be better for patients.

While other countries have embraced at-home or community services after surgery, the rate of in-hospital rehabilitation in Australia increased from 31 per cent of patients in 2009 to 45 per cent in 2016 in private hospitals.

By contrast, the rate in the ­public system is only 17 per cent.

The findings, published today in the Medical Journal of Australia, suggest that following best-­practice guidelines could save $50 million in private health expenditure each year and free up 60,000 ­hospital bed days.

Researchers analysed Medibank claims data and hospital case-mix records for 35,389 patients aged 40-89 years who had not previously needed a new joint and underwent a total knee replacement in a private hospital.

Some data was unavailable; for example whether patients had obesity or were deemed capable of managing their rehabilitation out of hospital.

“Variation can be due to different health needs of patients, however when adjusted for patient characteristics — such as age, clinical profile and how the surgery went — the large variation in inpatient rehabilitation rates across hospitals persisted, suggesting that some in-hospital rehabilitation is low-value care,” said report author Chris Schilling, a KPMG health economist.

“There is a significant opportunity to reduce in-hospital rehabilitation rates, without having any detrimental effect on health outcomes. To ensure the sustainability and affordability of the healthcare system, it is important that every dollar is invested in high-value care.”

A separate study in the MJA last year found inpatient rehabilitation “did not achieve better joint-specific outcomes or health scores than alternatives”. Australia’s ageing population and an increasing obesity rate has made in-hospital rehabilitation a pressing problem.

Any unnecessary costs also help push up health-insurance premiums, a key factor in the decline in membership.

A working group under the private health ministerial advisory committee has been discussing appropriate models of care for rehabilitation and whether intervention is needed to drive best practice. At its last meeting, the working group discussed whether prehabilitation should be funded by insurers to prepare ­patients better for surgery and external rehabilitation.

Australia has one of the highest rates of knee replacements in the world. Between 2003 and 2014, the number of knee replacements performed each year increased by 97 per cent in the private sector and 71 per cent in the public sector.

Medibank chief medical officer Linda Swan said the Australian experience with rehabilitation contrasted with international trends showing inpatient rehabilitation rates decreasing as community and home-based rehabili­tation became more popular.

“There is strong clinical evidence that home and community-based rehabilitation delivers the same health outcomes as rehabilitation in the hospital for the majority of patients,” Dr Swan said.

Separate bodies of work are likely to lead to clearer guidelines for Australian clinicians.

There is growing support in the health sector, from clinicians to funders, for programs designed to reduce unnecessary, low-value, wasteful or overly risky interventions.