The role of rehabilitation for hip and knee replacement in New Zealand: a national survey

Transcription

1 The role of rehabilitation for hip and knee replacement in New Zealand: a national survey Deborah L. Snell, PhD Senior Research Fellow Department of Orthopaedic Surgery and Musculoskeletal Medicine University of Otago Christchurch

2 Acknowledgements ROR Participants ROR Research Assistant Caroline Norris Canterbury Medical Research Foundation New Zealand Joint Registry

3 Acknowledgements NZ Co-investigators: - Anne Sinnott Dip PT: Burwood Academy of Independent Living (BAIL) - Jen Dunn PT, PhD: University of Otago Christchurch - Alastair Rothwell MD, FRACS: University of Otago Christchurch - Gary Hooper MD, FRACS: University of Otago Christchurch US Co-investigators: - Jean Hsieh Dip OT, PhD: Medstar Health Research Inst.; Medstar Rehabilitation Hospital - Gerben DeJong PhD: Georgetown University, Medstar Rehabilitation Hospital, Washington DC

4 Rehabilitation and joint replacement what do we know? Joint replacement is common and effective rates are escalating worldwide Rehabilitation (esp. physio) accepted as standard Protocols vary and optimal mix of type, setting and intensity unclear Use of rehabilitation is understudied

5 Rehabilitation and joint replacement what do we know? Scoping study of the literature over 100 studies 1 Rehabilitation appears beneficial Intensity and type of therapy not associated with outcomes Setting (home vs clinic) not associated with outcomes Comorbidities and pre-surgical clinical variables associated with outcomes 1. Snell, DL, Hipango, J, Sinnott, KA, Dunn, JA, Rothwell, A, Hsieh, CJ, DeJong, G, Hooper, G. (2017). Rehabilitation after total joint replacement: a scoping study. Disability and Rehabilitation, Mar 23.

6 ROR study objectives Characterize use of rehabilitation and evaluate variation based on location and ethnicity Evaluate associations between type, setting, and intensity of rehabilitation and outcomes Evaluate role of funding source on use/access to rehabilitation services and outcomes

7 Methods Cross-sectional questionnaire-based study Recruited from the New Zealand Joint Registry (NZJR) Selection criteria were broad and inclusive Age 45 Joint replacement six months prior to recruitment Primary total hip or knee, primary uniknee Ethical approval from the University of Otago Human Ethics Committee (ref H14/070).

8 Recruiting from the NZ Joint Registry Captures >95% joint replacements PROM data (Oxford scores) for 20% Flyers with NZJR monthly mail outs between June 2015 and July 2016 Primary outcome : Pain and function (Oxford score) 6 months post-op (NZJR) Secondary outcome: Quality of Life (WHOQOL-8) 6 months post-op

9 Variables Demographic Clinical Pre-op Rehab Post-op Rehab Age Sex Ethnicity Geography Education Work Funder Comorbidities BMI Procedure type Wait-list time Oxford scores QOL Setting Type Intensity Duration Time to onset (weeks) Setting Type Intensity Duration No of surgical reviews

10 The sample Agreed to be contacted N = 768 Agreed to participate N = 662 Mean age 67.8 years 45.2% men 89.9% NZ European Returned N = 608 questionnaires

11 Ethnicity Fig. 1: ROR sample ethnicity breakdown (n = 608)

12 Geography Regional Information (total sample): Auckland: 21.9% Canterbury: 20.4% Wellington: 10.2% Fig. 2: Geographical variability of participants in the sample by DHB region (n = 608)

13 Geography Regional Information (total sample): Northland: 4.8% Taranaki: 4.4% West Coast: 1.8% Gisborne: 0.5% Fig. 2: Geographical variability of participants in the sample by DHB region (n = 608)

14 Geography Fig. 2: Geographical variability of participants in the sample (n = 608)

15 Access to rehabilitation by ethnicity and geography No differences on basis of ethnicity but Trends to greater use of rehabilitation before surgery for those living in larger urban centres

16 Funding Total Sample 36% 4% 9% 51% ACC MOH Private Insurance Other Fig. 4: Surgical funding source (n = 608)

17 Funding Compared with privately funded, MOH cases: Were older and had higher levels of comorbidity Lower outcomes post-op Waited longer for surgery and had more pre-op rehab Had less post-op rehab

18 Clinical outcomes Clinical variables (total sample): Mean waitlist time = 29 weeks Mean BMI = 26.4 ASA (comorbidity) class: 1 (14.7%) 2 (67.6%) 3 (17.5) 4 (0.2%) Figure 4: Mean (±1 SD) Oxford and WHOQOL-8 scores for the total sample and by procedure type (n = 608)

19 Rehabilitation intensity and duration Pre-op (total sample): Weeks of intervention: m = 6.9 Length of sessions: m = 50 mins Times per week: m = 2.4 Total hours: m = 5.0 Post-op (total sample): Weeks of intervention: m = 8.1 Length of sessions: m = 40 mins Times per week: m = 1.4 Total hours: m = 5.7 Time to 1st session: m = 2.7 weeks No of surgical FUs: m = 1.8 Figure 5: Percentage of participants accessing any form of rehabilitation before and after their surgery (n = 608)

20 Rehabilitation setting and type Figure 3: Percentage of participants accessing rehabilitation before and after surgery by venue and by discipline (n = 608)

21 Access to rehabilitation and outcomes Differences by procedure type Quantity and type of rehab associated with better post-op outcomes for hip replacement participants Otherwise no strong dose response relationship between use of rehabilitation and outcome

22 Free text themes Self-efficacy Importance of rehab Knowing what to do Barriers Self-directed efforts Pre-op rehab Knowing who to contact Cost Not the usual patient Post-op rehab Knowing what to expect Access Timing

23 Free text themes self-efficacy Self-directed efforts My rehab was self-induced as none was offered. But I made myself walk straight and normal. It worked I knew that the work and effort I made before and after the operation was key to how good a result I would get Not the usual patient I am not your typical hip replacement patient I maintained reasonable fitness prior to the operation I was playing B grade tennis 3-4 times a week so was fit, not overweight and my blood pressure was good

24 Free text themes importance of rehab The op is just the first part of the process, rehabilitation is a crucial part of the equation and I can t advocate strongly enough in this regard. I highly advocate exercises PRIOR to surgery. Made a huge difference in recovery both mental and physical It is of interest to note that my other knee was replaced two years before, but due to sickness, physiotherapy was delayed a month [after surgery]. There is now a marked difference between my knees (e.g. ability to bend )

25 Free text themes knowing who to contact and what to do To tell the truth, I am not finished recovering yet. But the local physio is available if I need her. I was left alone, not knowing what to do, feeling frustrated and helpless. I was not sure if I had done enough exercise or too much. Sometimes I feel I ve been abandoned and left to get on with it by myself.

26 Free text themes - barriers Cost I only went for two visits because access was difficult for me, cost $20 for transport and I didn t always have the money I went to only one postop rehab physio session, at $50 a session, I figured I d have to manage on my own Access I did not attend rehab sessions at the hospital because of transport problems I don t drive

27 Summary of findings Post-op outcomes (Oxford scores, QOL) high Rehabilitation type and intensity generally not associated with outcomes consistent with prior research Patient-specific and service variables associated with outcomes, consistent with prior research Rehab was mostly physio and clinic-based consistent with prior research Rehab was valued by participants

28 Methodological challenges Response and recruitment bias Self-report and recall bias Did we use the right outcome measures? Oxford scores lack granularity required to evaluate rehabilitation?

29 So what can we draw from the study? No associations between use of rehab and outcomes? Review outcome measures Ethnic disparities vs response bias (or both)? Need for baseline information Exploring other rehab setting and delivery options to remove access barriers

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