Comparison of 6- and 7-Day Physical Therapy Coverage on Length of Stay and Discharge Outcome for Individuals With Total Hip and Knee Arthroplasty

Transcription

1 R E S E A R C H S T U D Y Comparison of 6- and 7-Day Physical Therapy Coverage on Length of Stay and Discharge Outcome for Individuals With Total Hip and Knee Arthroplasty Catherine E. lang, MS, PT' P hysical therapy departments were traditionally considered an excellent revenue-generating source in hospitals. Physical therapy was a billable service charged sep arately from the hospital room charge prior to In 1983, Medicare switched from a fee-for-service reimbursement system to the Prospective Payment System for hospitals. Under the Prospective Payment System, physical therapy service is included in the Diagnostic-Related Group payment. Physical therapy is no longer a billable service or aute matically considered a revenue-generator by hospitals (3). Hospital and physical therapy department administrators have since been trying to decide the appropriate frequency of physical therapy service in acute care to reach the optimal quality of care at the lowest possible cost. It has been suggested that if physical therapy service is provided over weekends, this might help patients to improve faster and be discharged sooner than if they only had physical therapy service during the week (6.7, 12). Only three previous studies have addressed the effect of 7day per week physical therapy service on length of stay (6,7,12). Holden and Daniele found that the 7day per week group of orthopaedic patients Providing physical therapy service on Sundays is a much debated topic among hospital administrators. The purpose of this study was to determine if 7 days per week of physical therapy coverage results in shorter lengths of stay and differing discharge status than 6 days per week. A total of 140 subjects with hip or knee arthroplasty participated; there were 80 in the 6day groups and 60 in the 7day groups. Data on postoperative length of stay, discharge destination, and discharge disposition were collected by retrospective medical record review. The Mann- Whitney U test was used to test for differences in length of stay data, and the chi-squared test was used to test for differences in discharge disposition and discharge destination. No significant differences in postoperative length of stay, discharge destination, nor discharge disposition existed between the 6- and 7day physical therapy coverage hip or knee arthroplasty groups. However, the power of the statistical tests applied was low. This study provides no evidence that 7day per week physical therapy results in shortened postoperative length of stay, differing discharge destination, nor differing discharge disposition for patients undergoing hip or knee arthroplasty. Key Words: length of stay, discharge outcome, hip arthroplasty, knee arthroplasty ' Graduate Student, Doaoral Program in Movement Science, Depamnent of Physical Therapy, Washington University, St. Louis, MO. At the time this study was conducted, Ms. Lang was a graduate student, Master of Science Program in Physical Therapy, Universify of Vermont, Burlington, VT. This study was undertaken in partial fulfillment of the requirements for her master of science degree. Address for correspondence: 6012 McPherson Ave., St. Louis, MO had a higher percentage of consecutive daily treatments (72% vs. 42%) compared with a May per week group (6). They found no difference in the mean number of physical therapy treatments and no difference in the length of stay between the 5 and 7day per week groups. Under the conditions of the study, the physical therapy department was not allowed to increase staffing. Holden and Daniele speculated that a certain number of physical therapy treatments would be needed in order to ensure a safe discharge. They felt that no difference in length of stay was seen because the subjects in both groups received the same total number of physical therapy treatments. Holden and Daniele suggested that if they had been able to increase staffing, then the subjects in the 7day per week group could have received more treatments and thus been discharged earlier (6). Because no difference existed between groups for the total number of physical therapy treatments, valid conclusions on the effect of 7day per week therapy on length of stay cannot be made from their study. A second study was conducted by Rapoport and Judd-Van Eerd in 1989 (1 2). Retrospectively, they studied JOSPT Volume 28 Number 1 July 1998

2 RESEARCH STUDY subjects with stroke and orthopaedic disorders. Data were grouped by orthopaedic disorder or stroke and then subclassified into surgery or no surgery performed during the hospitalization. They found no difference between the 5 and 7day groups for time from admit to first physical therapy visit nor for the number of calender days on physical therapy service. They did find a significant difference level between 5- and 7day per week service in the number of physical therapy visits per patient, 6.47 and 7.47 visits, respectively. Total length of hospital stay was not statistically different between the 5 and 7day groups for subjects with orthopaedic disorders with or without surgery. Data on the stroke groups are not reported here due to variations in recovery and treatment. The most recent and wellcontrolled study was done by Hughes et al in 1993 in Canada (7). They specifically studied patients undergoing hip and knee arthroplasty; this patient population generally has a uniform hospital course. Mean postoperative length of stay was 10.6 and 12.5 days for the 7- and May per week groups, respectively, for individuals undergoing hip arthroplasty. Mean postoperative length of stay was 11.1 and 12.0 days for the 7- and May per week groups, respectively, for individuals undergoing knee arthroplasty. The hip and knee groups were both significantly different at the 0.05 level. Hughes et a1 concluded that 7day per week physical therapy service produces shorter lengths of stay than May per week service in individuals undergoing hip and knee arthroplasty (7). This study is the only one of the three that used an increase in physical therapy stafling. Comparing the site and the physical therapy practice pattern of the study by Hughes et a1 to other hospitals is necessary before generalizing their results to other sites. Patients were not started on physical therapy service until 2-4 days after surgery in Hughes et al's study (7). The ex- pected standard at our hospital is that patients with hip and knee arthroplasty are seen postoperative day one. Furthermore, their means for length of stay of the different groups ranged from 10.6 to 12.5 days; this is considerably longer than those seen in our hospital, where the expected length of stay is 5-8 days. Perhaps this difference is due to changes in health care delivery (eg., improved surgical techniques, implementation of hospital critical pathways) between the time data were collected and the present time, or perhaps it is due to an inherent difference in the way health care is delivered under the Canadian system vs. the United States system. Therefore, their results could not be easily applied to our hospital. None of the three studies examined how 7day per week physical therapy service affects discharge outcome. The purpose of this study was to determine if 7 days per week of physical therapy coverage resulted in shorter postoperative lengths of stay and differing discharge status than 6 days per week of physical therapy coverage in individuals with hip and knee arthroplasty. METHODS A trial of 7day per week physical therapy service for patients with hip or knee arthroplasty was conducted at Fletcher Allen Health Care, Medical Center Hospital of Vermont Campus, Burlington, VT. This facility is a 500-bed, acute care, tertiary, teaching center. Patients undergoing hip or knee arthroplasty are generally admitted the day of surgery, and physical therapy service is initiated the first postoperative day. Prior to this trial, individuals with hip or knee arthroplasty were generally seen twice per day on Mondays through Fridays and once per day on Saturdays. During this trial, one additional treatment session for each subject was added on Sundays. No additional staff were hired for the Sunday trial, but several therapists elected to work extra hours on Sundays. The therapists that worked on Sundays continued to work their regularly scheduled hours and were compensated for their time with additional pay. Therefore, the trial of 7day per week coverage did not change physical therapy coverage on Mondays through Saturdays. Subjects Medical records from January, 1996 to mid-march, 1996 were searched for patients undergoing hip or knee arthroplasty for the 7day per week group. Medical records from the end of March, 1996 to July, 1996 were searched for patients undergoing hip or knee arthroplasty for the May per week group. A longer period of time for the 6-day per week group was necessary because the number of arthroplasties performed at our hospital declined in the spring and early summer. Both elective and emergent surgeries were considered eligible. Exclusion criteria were: 1) more than one joint arthroplasty during their admission (eg., bilateral knee arthroplasty), 2) other sustained injuries at the time of admission (eg., multiple fractures, closed head injury), or 3) intra- or postoperative complications which required admission to the intensive care units. Fortyeight individuals with knee arthroplasty and 92 individuals with hip arthroplasty were included in the study, for a total of 140 subjects. Of the 92 individuals with hip arthroplasty, 20 had hemiarthroplasties and 72 had total hip arthroplasties. Individuals with either total hip arthroplasty or hip hemiarthroplasty were included in the hip arthroplasty group because they have the same postoperative surgical precautions and critical pathway. There were 23 subjects in the May knee group, 25 subjects in the 7day knee group, 57 Volume 28 Number 1 July 1998 JOSPT

3 RESEARCH STUDY ,.,..... Problems Goals Discharge Criteria Decreased strength of Independent with home Goals met by patient involved extremity exercise program* alone if caregiver not available at home Decreased range of Independent maintaining Goals met by patient and motion of involved applicable surgical caregiver if available extremity precautions at home Postoperative pain Independent bed mobility OR discharged to another facilityt by attending physician Impaired functional mobility and gait Independent transferst lndependent gait with assistive device on level surfaces independent on stairs if applicable * Can include: in supine, ankle pumps, quadricep and gluteal sets, heel slides, hip abduction, hip external rotation, straight leg raises, short arc quads; in sitting, knee ilexion and extension; in standing, hip abduction, hip extension, knee flexion, and hip flexion. ' A skilled nursing facility, extended care facility, or a rehabilitation center. * Includes odoh chair, toilet, shower seat, bed, and idout of car. TABLE 1. Summary from Physical Therapy Department protocols. Patient problems, goals, and discharge criteria. Note: Problems andgoab are not matched in rows. subjects in the 6-day hip group, and or knee arthroplasty, at this hospital, 35 subjects in the 7day hip group. is guided by department protocols. Department protocols have been Physical Therapy Service summarized in Table 1 and Table 2. These protocols did not change dur- Postoperative physical therapy ing the data collection period. The care for individuals undergoing hip protocols at our hospital are in gen- - TABLE 2. Summary from Phvsical Therapv Department protocols. Postoperative evaluation, precautions, and treatment. era1 agreement with the total joint replacement protocols developed by consensus by Enloe et a1 in 1996 (5). Data Collection Data were obtained from patients' medical records on the following variables: 1) age, 2) gender, 3) surgical procedure, 4) day of the week surgery was performed, 5) surgeon, 6) intra- or postoperative complications, 7) preadmission living situation, 8) discharge destination, 9) discharge disposition, 10) postop erative length of stay, and 11) total number of time units of physical therapy provided. No medical record numbers or names of subjects were recorded. Informed consent was not required in this study according to the Committee on Human Research, Guidelines for Access to Medical Records for Research Purposes, University of Vermont, Burlington, VT. Preadmission living situation was divided into three categories: I) home, 2) skilled nursing or extended care facility, and 3) other. Discharge destination from the acute care setting was divided into three categories: 1) home with home physical therapy referral, 2) skilled nursing facility, or 3) acute rehabilitation center. Discharge disposition was dichotomized into independent or not independent. Independent was operationally defined as the patient is able to do all mobility tasks with or without assistive devices but without assistance from another person. Not independent was operationally defined as the patient needs assistance from another person to complete one or more mobility tasks (eg., needs another person to move operated leg onto bed, needs guarding on stairs). If an individual did not need to be able to climb any steps or stairs at home, he or she was considered independent, regardless of his or her ability to climb stairs at the hospital. Likewise, if an individual needed to JOSIT Volume 28 Number 1 Julv

4 RESEARCH STUDY be able to climb a ramp or other architectural barrier at home, he or she needed to be independent in doing that task to be categorized as independent in this study. Postoperative length of stay was counted as the number of days from surgery to discharge from physical therapy service. Criteria for discharge from physical therapy se~vice are summarized in Table 1. For the majority of subjects, discharge from physical therapy service was the same day and time as discharge from the hospital. Number of time units of physical therapy service was collected from physical therapy billing records. One physical therapy time unit at our hospital is defined as 1-15 minutes of patient care, two time units is minutes of patient care, three time units is minutes, and so on. A time unit can include both evaluation and treatment time. Initial medical record review and initial and discharge note writing are the only nondirect patient care activities allowed as billable time units, so these were included in the time unit count. Data Analysis Data were grouped and analyzed separately for subjects with hip vs. knee arthroplasty. SPSS for Microsoft Windows, Release 6.1 (SPSS Inc., Chicago, IL), was used for data analysis. Type I error or alpha level was set at 0.05 for statistical significance. A frequency histogram was plotted for the postoperative length of stay data and the distribution was tested by a Shapiro-Wilkes test to see if the data followed a normal distribution. Because the data did not follow a normal distribution, a Mann-Whitney U test was used to test for a difference between Mays per week and 7days per week physical therapy service for length of stay. A chi-square test was used to test for a difference between Mays per week and 7days per week physical therapy service for discharge destination and for discharge disposition. Number of subjects Gender Male Female Age (X? SD) (ye_ars) Total time units (X t SD) Day of week of surgery (number of subjects) Monday Tuesday Wednesday Thursday Friday Saturday and Sunday Preadmission living situation Home SNF or ECF Other &Day Knee 7-Day Knee SNF = Skilled nursing tacilitv. ECF = Extended care facilitv. TABLE 3. Characteristics of subiezts who underwent knee arthroplasty in the 6day per week and 7day per week physical therapy service group. Three outliers occurred in the length of stay data, the 12- and 18- day subjects in the 7day knee group and the 21day subject in the 7day hip group. Analysis of the length of stay data was performed with and without these outliers. Both analysis yielded the same conclusions. Information presented here includes the outliers in the data analysis. RESULTS Results From the Knee Groups Characteristics of subjects undergoing knee arthroplasty are described in Table 3. A frequency distribution of length of stay data is provided in Figure 1. Length of stay data were not normally distributed. The range for length of stay was 3-9 days (medi- FIGURE 1. Frequency distribution for length of stay for the knee arthroplasty groups. Volume 28 Number 1 July 1998 JOSPT

5 Functional Task Ascending and descending stairs Gait Transfers Moving idout of bed Doddoff lower extremity brace on nonoperated limb All of the above tasks Numbef of Subjects With Difficulty Performing This Functional Task and Most Common Amount of Assistance Nded 27 (Stand-by and contact guard assistance) 11 (contact guard assistance) 4 (contact guard assistance) 15 (minimal assistance to move operated lower extremity idout of bed) 1 (minimal assistance to lift lower extremity into brace) 30 (varying levels of assistance) * Note that iia subject required assistance tor two oi the above iunct~onal tasks, then hdshe is included in the above count for both tasks. Stand-by assistance = Being in close proximity to the individual but not providing any hands-on assistance. Contact guard assistance = Hands on the individual with the ability to catch the individual ifhdshe should fall but not providing any other physical assistance to complete the task. TABLE 4. Reasons for nonindependence. an 5.0 days) for subjects in the May knee group. The range for length of stay was 3-18 days (median 5.0 days) for subjects in the 7day knee group. No significant difference existed between groups (P = ). The statistical power of this test was The most common discharge destination for both the May knee and 7day knee groups was home with services. Twenty subjects (87%) in the May knee group and 20 subjects (80%) in the 7day knee group went home. In the May knee group, two subjects (9%) were discharged to a skilled nursing facility and one sub ject (4%) was discharged to a rehabilitation center. In the 7day knee group, two subjects (8%) were discharged to a skilled nursing facility and three subjects (12%) were discharged to a rehabilitation center. No significant difference existed between the 6 and 7day groups (P = 0.632). Thirteen of 23 subjects (56%) in the May knee group were considered independent with all necessary mobility prior to discharge. Eighteen of 25 subjects (72%) in the 7day knee group were considered independent with all necessary mobility prior to discharge. No significant dif- ference existed between the 6 and 7day groups (p = 0.370). Reasons given for being classified as nonindependent for all four groups are given in Table 4. Results From the Hip Groups Characteristics of subjects underge ing hip arthroplasty are described in Table 5. A frequency distribution of length of stay data is provided in Figure 2. Similar to the length of stay data from the knee groups, the length of stay data from the hip groups were not normally distributed. The range for length of stay was days (median 5.0 days) for subjects in the May hip group. The range for length of stay was 2-21 days (median 5.0 days) for sub jects in the 7day hip group. No significant difference existed between groups (p = 0.649). The power of this statistical test was Discharge to home was also the most common destination for the hip groups. Forty subjects (70%) of the May hip group and 27 subjects (77%) of the 7day hip group were discharged to home with home health physical therapy referrals. Eleven subjects (19%) of the May hip group and six subjects (17%) of the 7day hip group were discharged to a skilled nursing facility, while six subjects (1 1 %) of the May hip group and two subjects (6%) of the 7day hip group were discharged to a rehabilitation center. There was no significant difference between the May hip and 7day hip groups for discharge destination (p = 0.678). Only 15 subjects (26%) of the May hip group and 14 subjects &Day Hip 7-Day Hip Number of subjects Gender Male 16 (28%) 13 (37%) Female 41 (72%) 22 (63O/0) Age (X + SD) (years) Total time units (X + SD) Day of week of surgery (number of subjects) Monday 11 9 Tuesday Wednesday 16 7 Thursday 10 5 Friday 1 1 Saturday and Sunday 4 1 Preadmission living situation Home SNF or ECF 2 2 Other 0 0 SNF = Skilled nursing iacility. ECF = Extended care facility. TABLE 5. Characteristics of subjects who underwent hip arthroplasty in the 6day per week and 7day per week physical therapy service groups. JOSPT Volume 28 Number 1 July

6 RESEARCH STUDY FIGURE 2. Frequency distribution for length of stay for the hip arthroplasty groups. (40%) of the 7day hip group were independent with all necessary mobility. No significant difference existed between groups (p = 0.248). DISCUSSION No difference in length of stay was found when physical therapy service was provided 6 vs. 7 days per week. High variability exists within the length of stay data. The high variability in this data led to poor statistical power; the risk of making a type I1 error is large because of the poor statistical power. Comparison between the power of this study and previous studies on the same topic is not possible because none of the other studies reported on the statistical power of their tests (6,7,12). In order to reach a power of 0.80, a minimum of 400 subjects in each of the hip groups and 100 subjects in each of the knee groups would be required. Our facility averaged 28.3 arthroplasties per month for the &month time period used in this study. At that rate, data collection sufficient to reach a statistical power of 0.80 would take over 35 months. Many variables, such as critical pathways, surgical techniques, and thirdparty payor pressures, could change during a %year data collection pe- riod. Undertaking a study of over 1,000 subjects is unrealistic except in a multicenter design. The p values (0.1604, 0.649) calculated from the statistical tests on length of stay were far from reaching statistical significance. In looking at the mean values for length of stay, both the 7day per week hip (5.71 days) group and the 7day per week knee group (5.88 days) had larger values than the May per week hip group (5.17 days) and the May per week knee group (4.87 days). Therefore, if the statistical analysis had revealed that a difference existed in length of stay between 6 vs. 7day per week physical therapy service, then the conclusion would have been that May per week physical therapy results in a shorter length of stay-just the opposite from the research hypothesis. Despite the low statistical power, it is safe to conclude that this study provides no evidence that 7day per week physical therapy service reduces length of stay. Part of the justification for implementing 7day per week physical therapy service was that length of stay would decrease and then hospital costs would decrease. According to our hospital's accounting department, in the fiscal year 1996, we had an average cost per day per patient of $1,374 for hip arthroplasty and $1,997 for knee arthroplasty. Average reimbursement from Medicare for the same time period was $1 1,960 per hospital admission for hip arthroplasty and $1 1,762 per hospital admission for knee arthroplasty. Because a difference did not exist between the 6 and 7day knee groups nor the 6- and 7day hip groups for length of stay, no cost savings for the hospital occurs. At our hospital, 7day per week physical therapy service does not appear to save the hospital money. Interestingly, in a recent article by Stem et al, they illustrated that 60% of the cost of knee arthroplasty admission occurs during the period of time the patient is in the operating and recovery rooms (13). Only 40% of the cost occurs postoperatively on the orthopaedic units. They suggest that cost-saving efforts should be redirected toward looking to reduce operating and recovery room costs and directed away from concern about length of stay (13). Although only 40% of the total hospital cost could be affected by changes in length of stay, small decreases in cost, multiplied by the number of hip and knee arthroplasties done per year throughout this country, could make a large impact on the cost of health care. The operational definition of length of stay in this study is the number of days from surgery to discharge from physical therapy service. Out of the 140 subjects in this study, only 15 subjects were discontinued from physical therapy 1 day prior to discharge from the hospital, two sub jects were discontinued 2 days prior, and one subject was discontinued 3 days prior to discharge from the hospital. True hospital length of stay was almost exactly the same as the operational definition of length of stay in this study. The results of this study are in conflict with those found by Hughes et al in Canada (7). Hughes et al Volume 28 Number 1. Julv 1998 JOSPT

7 RESEARCH STUDY found that 7day per week physical therapy decreased length of stay in individuals undergoing hip and knee arthroplasty (7). The comparison group in their study was seen 5 days per week by the physical therapy service. Perhaps there is a true difference in length of stay between 5 and 7 days but not between 6 and 7. The results of this study did show that the 7day per week group received one additional physical therapy treatment session. The one extra treatment on Sundays might not be enough to have an effect. However, the different results also may be due to: I) changes in health care over the 6year period from their data collection until now, 2) the shorter duration of length of stay found here, 3) the effect of implementing physical therapy postoperative day one here vs. day three or four in their study, and 4) possible differences in health care systems and health care delivery between the United States and Canada. The results of this study are similar to those of Holden and Daniele and Rapoport and Judd-Van Eerd (6,12). Results from both of those studies indicate that 7day per week physical therapy service does not reduce length of stay despite differences in study design between their studies and this one (6.12). Their studies used orthopaedic patients, but inclusion criteria were not restricted to individuals undergoing hip and knee arthroplasty as was the case in this study. Holden and Daniele did not increase staffing to provide the weekend coverage (6). Staffing was increased to provide weekend coverage in this study. Holden and Daniele and Rapoport and Judd Van- Eerd had comparison groups of May per week physical therapy service instead of May per week physical therapy service (6,l2). Despite the variations in study design, results presented here are similar to their results. The results of this study fail to show that 7day per week coverage affects discharge destination or discharge disposition. The P values ( ) comparing discharge destination and discharge disposition were far from statistical significance. Seventy to 87% of all subjects in this study went home. This agrees with the results of Peterson et a1 (82% home or home with services) who investigated geographic variations in all individuals with elective hip and knee arthroplasties in the United States in 1988 (1 1). Despite such a high percentage of subjects going home, 56-72% of the subjects in the knee groups were independent, while only 26-40% of the subjects in the hip groups were independent. Many of the subjects who were discharged to home without being independent may have had family/friend support at home. No published data exist to compare the functional level at which individuals were discharged. Due to the retrospective design and lack of reliability in using terms such as minimum assistance, moderate assistance, and maximal assistance, discharge disposition was separated into two categories, independent or not independent. The possibility exists that this dichotomy was not sensitive enough to pick up differences between the May per week groups and the 7day per week groups. Limitations One of the limitations of this study is that we are not able to draw any conclusions as to how 7day per week physical therapy service affected individual subjects. Collecting data on the subject's perceived benefit and how well a subject was truly functioning once reaching his/her discharge destination was beyond the scope of this study. Other factors that have been found to affect length of stay are: age, living situation, comorbid conditions, type of institution, use of critical pathways, and physician feedback on resource utilization (1,2,4,8-11, 14). These factors could potentially confound the results of this study. Of the above factors, a difference might have existed between groups for the factors of living situation and comorbid conditions; the other factors were consistent between groups. Living alone has been found to increase length of stay in individuals undergoing hip and knee arthroplasty (4). More than two comorbid conditions, such as diabetes and chronic obstructive pulmonary disease, also increases length of stay (9,lO). Another limitation of this study is that specific information regarding whether or not an individual lived alone and the existence of any comorbid conditions was not collected. A third limitation of this study is that the subjects are located at one site, an acute, tertiary, teaching hospital. Community and rural hospitals generally have shorter lengths of stay than urban hospitals (2). Other tertiary care sites or community hospitals may be different in their treatment of individuals with hip and knee arthroplasty. The surgeons in this teaching hospital all use the same precautions and weight-bearing rules for arthroplasties. Other surgeons at other hospitals might use different precautions and weightbearing rules that could affect the postoperative length of stay and discharge status of their patients. A fourth limitation to this study that was not controlled for was the day of the week surgeries were performed. The majority of the subjects in this study (89% of knee arthroplasty subjects and 76% of hip arthr* plasty subjects) had surgery on Monday, Tuesday, and Wednesday. If the surgery was on a Monday or Tuesday and the subject was discharged on Saturday, then it might not matter whether physical therapy service was provided on Sunday or not. Given that their surgery was on a Monday and the median length of stay was 5 days, 52% (12 of 23) of the May knee group, 40% (10 of 25) of the 7day knee group, 19% (1 1 of 57) of JOSPT Volume 28 Number 1 July 1998

8 RESEARCH STUDY the 6-day hip group, and 25% of the 7day hip group (9 of 35) would probably not have benefited from 7day per week physical therapy coverage. However, the knowledge that physical therapy would be available on Sunday could potentially change a patient's discharge plan. If surgery was on a Monday or a Tuesday and physical therapy service was to be provided on Sunday, then a patient and therapist might make the decision to delay discharge by 1 day in order to participate in the extra session of physical therapy. Unfortunately, the length of time of the 7day per week trial of physical therapy service did not allow for enough subjects to make a comparison by day of week. A follow-up study on this issue could examine how day of the week on which surgery is performed affects length of stay and whether the availability of therapy on Sunday has any effect on the decision to remain in the hospital over the weekend. Results from this study are not generalizable to other patient populations. Patients undergoing hip and knee arthroplasty represent a fairly homogenous group with a predictable postoperative course. Patients with neurological, general medicine, or general surgery diagnoses are not homogenous and do not have predictable hospital courses. Furthermore, results are not generalizable to patients with orthopaedic problems other than hip and knee arthroplasty, such as spinal surgeries or multiple fractures. Other patient populations may respond very differently to 5 vs. 6 or 7day per week physical therapy service and would need to be studied separately. CONCLUSIONS Results of this study fail to show that providing 7day per week physical therapy coverage reduces length of stay or alters discharge destination and discharge disposition. Because of the low power of the statistical tests in this study, care should be taken when attempting to apply the results from this study. The results from this study should be considered preliminary, pending further, better controlled, clinical studies. The data collected and limitations cited can aid other researchers when attempting to examine this question with a prospective randomized clinical trial design in the acute care setting. No evidence was found that 7day per week physical therapy coverage will produce cost savings for the hospital. Clinicians and administrators in physical therapy departments should not implement Sunday physical therapy coverage in order to save money. If future studies are conducted on this topic, the effect of day of the week on which the surgery is performed should be investigated. In addition to length of stay, dependent variables should include discharge disposition as measured by a standardized test of function, discharge destination, how decisions regarding day of discharge are made, and patient and therapist perception of the effects of Sunday coverage. A multicenter design should be used to obtain the large number of subjects needed for adequate statistical power. JOSPT ACKNOWLEDGMENTS I am grateful to Jean Held, EdD, PT, for her invaluable assistance with this project and to my thesis committee: Marianne Orest, MEd, PT, Samuel Feitelburg, MA, PT, and Jeanine Cam, PhD, RN. REFERENCES 1. Amadio PC, Naessens JM, Rice RL, lhtrup DM, Evans RW, Morrey BF: Effect of feedback on resource use and morbidity in hip and knee arthroplasty in an integrated group practice setting. Mayo Clin Proc 71 : , Cannoodt L1, Knickman JR: The effect of hospital characteristics and organizational factors on pre- and postoperative lengths of hospital stay. Health Serv Res 19: , Davis K: Assessing physical therapy utilization in a prospective payment environment. Clin Manage Phys Ther 4:38-43, Ende RM: The significance of selected variables in laminectomy length of stay. 1 Neurosci Nurs 18: , Enloe LJ, Shields RK, Smith K, Leo K, Miller B: Total hip and knee replacement treatment programs: A report using consensus. J Orthop Sports Phys Ther 23:3-11, Holden MK, Daniele CA: Comparison of seven- and five-day physical therapy coverage in patients with acute orthopedic disorders. Phys Ther 67: , Hughes K, Kuffner L, Dean B: Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty. Physiother Can 45: , Johnson CC, Martin M: Effectiveness of a physician education program in reducing consumption of hospital resources in elective total hip replacement. South Med J 89: , Lutjens LRJ: Determinants of hospital length of stay. J Nurs Adm 23: 14-18, Munin MC, Kwoh CK, Glynn M, Crossett L, Rubash HE: Predicting discharge outcome after elective hip and knee arthroplasty. Am ] Phys Med Rehabil 74: , Peterson MG, Hollenberg JP, Szatrowski TP, Johanson NA, Mancuso CA, Charlson ME: Geographic variations in the rates of elective total hip and knee arthroplasties among Medicare beneficiaries in the United States. I Bone Joint Surg 74A: , Rapoport], Judd-Van Eerd M: Impact of physical therapy weekend coverage on length of stay in an acute care community hospital. Phys Ther 69:32-37, Stern SH, Singer LB, Weissman SE: Analysis of hospital cost in total knee arthroplasty. Clin Orthop 32 1 :36-44, Weingarten S, Riedinger M, Conner L, Siebens H, Varis G, Alter A, Ellrodt AG: Hip replacement and hip hemiarthroplasty surgery: Potential opportunities to shorten lengths of hospital stay. Am ] Med 97: , Volume 28 Number 1 July 1998 JOSPT