HOSPITAL INPATIENT REHABILITATION VS HYBRID HOME PROGRAM FOLLOWING TKA: A RANDOMISED CONTROLLED TRIAL (HIHO)

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1 HOSPITAL INPATIENT REHABILITATION VS HYBRID HOME PROGRAM FOLLOWING TKA: A RANDOMISED CONTROLLED TRIAL (HIHO) Buhagiar M, Naylor JM, Kohler F, Harris IA, Wright R, Fortunato R, Xuan W. JAMA 2017; 317: Funding: HCF Research Foundation

2 WHY DO WE CARE?

3 WE CARE BECAUSE High volume High cost Widespread variation

4 % 100 Inpatient rehabilitation utilisation by Sector & State TKA THA Hospital EPOC, , unpublished data

5

6 WHAT DOES THE EVIDENCE SAY?

7 SETTING: INPATIENT VS NON-INPATIENT Inpatient vs Domiciliary RCT Mahomed et al 2008, JBJS n = 234 TKA and THA 17 days inpt rehab vs 8 domiciliary visits No difference in WOMAC Fn, SF-36 or satisfaction 3 months post surgery Domiciliary more cost-effective

8 AIM Using a public sector setting, we aimed to determine whether 10 days of inpatient rehabilitation followed by a hybrid home program (clinicianmonitored home program) provides superior mobility and patientreported function 6 months after TKA compared to a clinician-monitored home program alone

9 METHODS - DESIGN Multicentre RCT Multiple outcomes Primary = distance walked in 6MWT, 26 weeks 140 participants; 60 m difference (160 participants provided 90% power to detect a difference at p < 0.05) PROMS; satisfaction; return to work cost-effectiveness if Inpt rehab shown to be superior Parallel observational usual care cohort Control for preference

10 INCLUSION & EXCLUSION CRITERIA Included Undergoing primary unilateral TKA at Fairfield or Sutherland Hospitals Primary diagnosis of OA Excluded Predisposition to need, inpatient rehabilitation (clinician-determined) NES, documented dementia Unable to participate in f/u; lived outof- area Catastrophic complication acutely

11 PARTICIPANT ALLOCATION Central randomization by site (1:1 ratio) stratified for age (<70, > 70), gender, height Allocation determined days 3-5 following surgery Check consent Criteria (eg complications) Bed availability Randomisation Those who changed their mind post-surgery were invited to participate in the observational arm (clinicianmonitored home program)

12 TREATMENT ARMS Hospital Inpatient Rehabilitation (HI) Inpatient rehabilitation at for 10 days 3 hrs / day Followed by hybrid home program (clinician-monitored HP) Hybrid Home Program (HO) (usual care) (clinicianmonitored HP) Group-based exercise session in the physiotherapy depts. Home program rehearsed and individualised Weeks 2, 4 and 10 post op

13 ANALYSIS ITT and PP Primary outcome -6MW distance 26 weeks ANCOVA, treatment group as main study factor 6MWT distance at baseline, weight, co-morbidities and participant preference as covariates as were stratifying variables. Site incorporated as a random effect. Secondary outcomes (10,26, 52 weeks) a multi-level hierarchical model was used to estimate the treatment x time interaction Same covariates as above Other Health resource utilisation and return to work outcomes Observational vs HO mean 6MWT and other secondary outcomes were compared, adjusting for the aforementioned covariates.

14 RESULTS

15 Cohort ascertainment and retention 940 screened 415 ineligible (298 NES) 525 eligible 310 consented 215 declined (172 wanted to go home ASAP) 84 randomised to Home program 84 ITT (26 weeks) 9 did not adhere to protocol 165 randomised 81 randomised to Inpt Rehab 81 ITT (26 weeks) 10 did not adhere to protocol 145 not randomised (55 changed mind) 112 invited into Observational arm 87 in Observational arm 87 at 26 weeks

16 eristic rehabilitation (N=81) Home program (N=84) Observational (N=87) sex - n (%) 56 (69) 57 (68) 38 (43) ears 66.9 (8) 66.9 (9) 66.8 (9) ass index b 34.7 (7) 34.8 (7) 32.9 (7) ant co-morbidity - n (%) 61 (75) 67 (80) 63 (72) ce for inpatient rehabilitation - n (%) 46 (57) 52 (62) N/A g at time of surgery - n (%) 11 (14) 14 (17) 14 (16) ute walk test m (107.7) (108.0) (115.3) Knee Score c 17.4 (7.0) 16.7 (7.2) 17.5 (8.1) visual analogue scale e 66.3 (19.4) 64.0 (19.0 ) 64.1 (20.8) OS (19.0, 44.0) 31.0 (19.0, 43.0) 36.0 (22.0, 44.0)

17 Characteristic Inpatient rehabilitation (N=81) Home program (N=84) Observational (N=87) Outpatient PT - mean (CI) Days in inpatient rehabilitation - mean (CI) 3.02 (2.75, 3.30) 3.07 (2.81,3.34) 2.62 (2.37,2.88) 9.51 (9.10, 9.92) - - TKA-related d emergency department presentations - n (%) TKA-related hospital readmissions - n (%) Manipulations under anaesthetic - n (%) 5% 5% 6% 5% 2% 2% 5% 4% 1% Weeks taken to return to work - mean (CI) Satisfaction with rehabilitation received %(95% CI) 92% (88, 96) 83%* (79,87) -

18 6MWT distance across time: HI vs HO Distance (meters) 200 HI HO Baseline 10 weeks 26 weeks 52 weeks Analysed using ANCOVA with group as main factor, site as random variable and preference, weight, age etc as

19 20 40 Time (sec) m walk test HI HO Score Oxford Knee Score HI HO 0 Baseline 10 weeks 26 weeks 52 weeks 0 Baseline 10 weeks 26 weeks 52 weeks EQ VAS Baseline 10 weeks 26 weeks 52 weeks HI HO KOOS sum Baseline 10 weeks 26 weeks 52 weeks HI HO

20 Metres OBSERVATIONAL VS HO MWT: HO vs OBSERVATIONAL KOOS QOL: HO vs OBSERVATIONAL weeks 26 weeks 0 0 weeks 26 weeks HO OBS HO OBS OKS: HO vs OBSERVATIONAL 0 0 weeks 26 weeks

21 CONCLUSIONS Among adults undergoing uncomplicated total knee arthroplasty, the use of inpatient rehabilitation compared with a monitored home-based program did not improve mobility at 26 weeks post-surgery These findings do not support inpatient rehabilitation for this group of patients We recognise a minority of patients (excluded in this trial) may benefit from inpatient rehabilitation for social or physical reasons

22 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE Lack of superiority consistent *** with communitybased studies Hospital Supporting evidence Evidencebased policy and practice Consumer preference s PBS Matched cohort study in private patients Private health insurers Clinician preference s Geographi cal

23 6 Min Walk (m) Flexion (degrees) WOMAC Pain WOMAC Function 1-TO-1 VS GROUP VS HOME PROGRAM WOMAC Pain MHP 30 1 to Group Weeks from surgery WOMAC Function Weeks from surgery Minute Walk Test MHP 1 to 1 Group Weeks from surgery Ko et al 2013 JBJS Knee Flexion MHP to Group Weeks from surgery 50 60

24 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE Lack of superiority consistent with +++ communitybased studies Hospital Supporting evidence Evidencebased policy and practice Consumer preference s PBS Matched cohort study in private patients Private health insurers Clinician preference s Geographical

25 RESULTS, N = 258 (129 PAIRS) PRIVATE TKA RECIPIENTS No differences in OKS at Day 90 and Day 365 p No difference in EQVAS Day 35, 90 and 365 (trend in favour of no inpt gp) Significantly higher rehab provider charges for those who received inpt rehab (median diff $9500) Significantly higher community rehab provider charges (excluding inpt rehab costs) in inpt group (median diff $749) No difference in return to work outcomes

26 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE Supporting evidence New York Times 220 comments favouring both approaches Hospital Private health insurers Evidencebased policy & practice Consumer preferences Clinician preferences Understanding consumer and clinician preferences and decision making for rehabilitation following arthroplasty in the private sector Preferences go both ways Geographical

27 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE Supporting evidence Hospital Consumer preferences Evidencebased policy Private health insurers Clinician preferences Geographical State and regional differences in access to different rehabilitation

28 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE The Australian March 15 th 2017 Bupa, NiB, HCF, Medibank all supported conclusions of HIHO Supporting evidence Desire to shift consumer preferences towards non-inpt models Hospital Private health insurers Existing policies incentivise Inpt rehab choice Reluctance to change policy individually Evidencebased policy & practice Geographical Consumer preferences Clinician preferences

29 ENABLERS OF & BARRIERS TO POLICY & PRACTICE CHANGE Business model of for profit private hospital Hospital Supporting evidence Consumer preferences Access block in public system has aided service delivery efficiencies Private health insurers Evidencebased policy Clinician preferences Geographical

30 EVIDENCE INTO POLICY & PRACTICE Multipronged approach involving lots of stakeholders Education to change consumer and clinician preferences - Health insurer websites; - Models of Care; guideline generation; more research Acceptable rehabilitation alternatives offered by private health insurers provided at no gap work with clinicians and hospitals Private hospitals refer to inpatient rehab on a needs basis and encourage patients to organize social supports prior to surgery

31 ACKNOWLEDGEMENTS Our public patients and public hospitals and Hammondcare that allowed us to do this research

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Buhagiar M, Naylor J, Harris I, et al. Effect of inpatient rehabilitation vs a monitored home-based program on mobility in patients with total knee arthroplasty: the HIHO study:

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