Post-operative home care for patients who have undergone total joint replacement surgery accounts for a considerable portion of Medicare expenditures and, due to an aging population, is expected to increase in future. More cost-efficient home care delivery may be safely achieved through reducing the numbers of post-surgical visits when combined with a pre-operative home care visit.

Background: This paper reports the findings of a clinical trial of the effectiveness of two home care protocols for total joint replacement (TJR) of the hip or knee. TJR was selected because of its high prevalence in US Medicare home care users, and because it accounts for a substantial, and increasing, proportion of Medicare expenditures. The outcomes of a customary home care protocol were compared with a new treatment protocol which involved a preadmission home visit and fewer postoperative home visits for patients of a large Midwestern hospital. It was hypothesized that the preadmission visit would sensitize home care staff to potential post-discharge problems, particularly those related to the home environment and the need for modifications, and initiate early patient education and assessment with respect to post-operative diet, exercise and treatment expectations.

Method: Consenting TJR patients who were undergoing unilateral total knee replacement (TKR), bilateral TKR, or total hip replacement (THR)) were randomly assigned to the control (number=67) or intervention (number=69) protocol. Control and intervention group patients differed with respect to the number and timing of authorized nurse and physical therapist (PT) visits. Intervention protocols for THR and TKR called for an initial preoperative home visit by a nurse and PT, followed by two postoperative nurse visits and 6 (THR) or 10 (TKR) PT visits compared with 11 to 47 combined nurse/PT visits under the control protocol. All subjects were followed postoperatively for 6 months, with data collected at baseline, 1 month and 6 months post-surgery. Outcome measures included functioning, pain, self-care, quality of life, satisfaction, adverse outcomes, and the use and cost of health care.

Findings: No significant differences were seen between groups in terms of overall functional status, health-related quality of life, adverse outcomes, short-term rehabilitation hospital use, or with reported satisfaction at 6 months. Hospital readmissions did not differ by group with respect to mean days or mean reimbursement. Mean home care reimbursement was significantly lower in the intervention group, reflecting fewer visits per patient. At six months, the average reimbursement of the treatment group was approximately 55% lower than the control.

Conclusion: Few differences were found in outcomes between control and intervention groups. Although functional status, quality of life, and other satisfaction outcomes were similar for both groups, those receiving the intervention expressed higher satisfaction with access to care despite receiving fewer visits. While other health care costs remained similar between groups, intervention home health care costs were 55% lower. The findings suggest that post-surgical home care visits can be reduced without compromising outcomes in patients with TJR when provided in conjunction with a preoperative home visit. Applying these findings to a Canadian context suggests that costs may be reduced and outcomes maintained through pre-surgical home care referral and contact.

Reference: Weaver, F.M., Hughes, S.L., Almagor, O., Wixson, R., Manheim, L., Fulton, B., and Singer, S. Comparison of two home care protocols for total joint replacement. Journal of the American Geriatrics Society, 2003; 51:523-528.

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