December 2020 correspondence

The opinions expressed by correspondents in this column are not endorsed by the editors or The Royal Australian College of General Practitioners.

Response to: Changes to rehabilitation after total knee replacement

The authors read the recent article ‘Changes to rehabilitation after total knee replacement’ by Sattler et al (AJGP September 2020)¹ with great interest. We would like to make a contribution to this article. It was pointed out that the seemingly indiscriminate use of inpatient rehabilitation following primary total knee replacement (TKR) might be considered ‘low-value care’ in Australia. In May 2019, the Rehabilitation Medicine Society of Australia and New Zealand produced a position statement with indicators for patients requiring inpatient rehabilitation following TKR.²

These indicators were based on evidence from the HIHO randomised control trial, a study that specifically excluded from its study cohort any patient who would have normally been referred to inpatient rehabilitation following primary TKR. Furthermore, a separate study, funded by Medibank Private Ltd, which mined their own data, coined the term ‘low-value care’ in order to highlight their plan to fund rehabilitation in the home, which, until late 2019, was unfunded.³ It would appear that Sattler et al failed to read all the grey literature or carefully examine the HIHO study’s inclusion criteria. Had the researchers explored all the relevant literature, they may have been more academic with their use of the term ‘indiscriminate’.

Julie Cadden MB BCh BAO, MRCPI, BSc (Pharm), MPharm
Advanced Trainee in Rehabilitation Medicine,
Eastern Suburbs Private Hospital, NSW

Steven Faux MBBS BA, FRACGP, FAFRM (RACP), FFPMANZCA
Rehabilitation and Pain Physician, Conjoint Professor, UNSW, NSW;
Adjunct Associate Professor, School of Medicine,
University of Notre Dame University, NSW;
Director, St Vincent’s Hospitals,
Departments of Rehabilitation Medicine and Pain Medicine, NSW

References

1. Sattler L, Hing W, Vertullo C. Changes to rehabilitation after total knee replacement. Aust J Gen Pract 2020;49(9):587–91. doi: 10.31128/AJGP-03-20-5297.
2. Rehabilitation Medicine Society of Australia and New Zealand Private Practice Special Interest Group. Position statement on rehabilitation following total knee replacement. North Sydney, NSW: RMSANZ, 2018.
3. Schilling C, Barker A, Wilson SF. Predictors of inpatient rehabilitation after total knee replacement: An analysis of private hospital claims data. Med J Aust 2019;210(2):101. doi: 10.5694/mja2.12065.

Reply

We appreciate the interest in our article ‘Changes to rehabilitation after total knee replacement’.¹

We acknowledge that the position statement produced by the Rehabilitation Medicine Society of Australia and New Zealand includes clinical indicators and safety standards for the assessment of suitability for home-based rehabilitation after total knee replacement (TKR). Although these consensus statements are subject to confirmation bias, they are an important step forward if they accurately reflect existing literature. Transparent guidelines that aim to assist decision making for the most appropriate discharge destination following TKR surgery are valuable tools for clinicians.

Unfortunately, despite the position statement making the recommendation for rehabilitation destination to be determined by clinical drivers, there is robust evidence that non-clinical factors are still the major determinant of discharge destination in the private sector.^2–4 In Australia, the mean rate of discharge to inpatient rehabilitation in the private sector (40%) is double that in the public sector (20%).⁵ This high variation of inpatient rehabilitation discharge rates cannot be explained by clinical factors alone, with research suggesting that hospital- and surgeon-level factors and patient preference have the strongest influence.^2–5 Accordingly, when referring to the rate of inpatient rehabilitation discharge after uncomplicated primary TKR, the authors consider the term ‘seemingly indiscriminate’ to be appropriate. With more patients discharging to inpatient rehabilitation than clinically indicated, the authors agree that the results of the HIHO trial are highly relevant, demonstrating that there is no greater functional benefit to a patient discharging to inpatient rehabilitation who would otherwise be suitable for discharge home.

Moreover, with respect to the use of the term ‘low-value care’, the authors believe the use of the term in the context of rehabilitation is appropriate within this narrative review. Four years prior to the Medibank-funded study, the Medical Journal of Australia described ‘low-value care’ as care that confers benefit that is disproportionately low when compared with its cost.⁶ The authors agree with Schilling et al that given the increased financial burden of inpatient rehabilitation without demonstration of superior outcomes, alternative models of care should be explored.⁷

Larissa Sattler MPhtySt
Assistant Professor, Physiotherapy,
Faculty of Health Sciences & Medicine, Bond University, Qld

Wayne Hing PhD
Head of Physiotherapy,
Faculty of Health Sciences and Medicine, Bond University, Qld

Christopher Vertullo MBBS, PhD, FRACS (Orth), FAOrthA
Director, Knee Research Australia, Qld

References

1. Sattler L, Hing W, Vertullo C. Changes to rehabilitation after total knee replacement. Aust J Gen Pract 2020;49(9):587–91. doi: 10.31128/AJGP-03-20-5297.
2. Halawi MJ, Vovos TJ, Green CL, Wellman SS, Attarian DE, Bolognesi MP. Patient expectation is the most important predictor of discharge destination after primary total joint arthroplasty. J Arthroplasty 2015;30(4):539–42. doi: 10.1016/j.arth.2014.10.031.
3. Sconza C, Respizzi S, Grappiolo G, Monticone M. The risk assessment and prediction tool (RAPT) after hip and knee replacement: A systematic review. Joints 2019;7(2):41–45. doi: 10.1055/s-0039-1693459.
4. Sattler LN, Hing WA, Rathbone EN, Vertullo CJ. Which patient factors best predict discharge destination after primary total knee arthroplasty? The ARISE trial. J Arthroplasty 2020;35(10):2852–57. doi: 10.1016/j.arth.2020.05.056.
5. Royal Australasian College of Surgeons. Rehabilitation pathways following hip and knee arthroplasty. North Adelaide, SA: RACS, 2018.
6. Scott IA, Duckett SJ. In search of professional consensus in defining and reducing low-value care. Med J Aust 2015;203(4):179–81. doi: 10.5694/mja14.01664.
7. Schilling C, Barker A, Wilson SF. Predictors of inpatient rehabilitation after total knee replacement: An analysis of private hospital claims data. Med J Aust 2019;210(2):101. doi: 10.5694/mja2.12065.