International Journal of Technology Assessment In Health Care, 8:1 (1992), 93-101. Copyright © 1992 Cambridge University Press. Printed in the U.S.A.
HOSPITAL CARE VERSUS HOME CARE FOR REHABILITATION AFTER HIP REPLACEMENT Gudrun Moller Ian Goldie Egon Jonsson Karolinska Hospital/Institute
Abstract A pilot study was done to assess the feasibility of reducing the hospital stays of patients with total hip replacement (THR). The length of hospital stay for these patients depends largely on how rehabilitation, mostly physical therapy, is organized. This study shows that not more than a half hour per postoperative day was devoted to care services and rehabilitation activities. It is feasible and less expensive to reduce substantially hospital stay by planned physical therapy in the patient's home. These results have prompted a randomized controlled clinical trial to assess hospital versus home rehabilitation.
Large-scale assessments of alternative delivery systems are an important part of efforts to control costs and improve access to health services. However, before major changes in the system can be designed and implemented, exploratory studies are often needed to assess which types of changes are feasible and which promise the greatest benefit. The pilot study described in this paper was such a preliminary assessment. Its purpose was to lay the foundation for a much larger and more formal experiment that is now in progress. In 1987 about 400,000 total hip replacements (THR) were performed worldwide (7). Approximately 10,400 were performed in Sweden in 1989, including reoperations (10). Ninety percent of these patients continue to do well 10 years after surgery (4;8). Indications for total hip replacement surgery are: pain, both from movement and at rest, and restricted movement of the hip joint caused by osteoarthritis, rheumatoid arthritis, sequelae of femoral neck fractures, or congenital malformation. Primary hip osteoarthritis, the most common cause for THR, is rare among people under 55-60 years of age (150 cases per 10,000 inhabitants), but its frequency increases with age (11). Intensive early rehabilitation is generally regarded as important for achieving a good end result, and, for this reason, patients are often kept in the hospital to receive therapy for some days after surgery. In 1985 THR patients at the Karolinska Hospital in Stockholm generally stayed in the hospital for 12-14 days following their operation. Although the outcomes of this care have been satisfactory, such long postsurgical hospitalization creates practical problems: the costs of hospital-based rehabilitation are
93
Moller, Goldie, and Jonsson
high and the slow turnover of patients that it creates contributes to long waiting periods for patients who need surgery. Reduction of these problems might be achieved by reorganizing the rehabilitation program to provide only initial treatment in the hospital with follow-up care at home after discharge. Because most hip surgery is planned well in advance, it should be possible to plan rehabilitation at home well before the operation takes place. Encouraging evidence supporting this approach is provided by studies of hip-fracture patients (1;2). A study from Australia indicated that hip-fracture patients could leave the hospital within 5 days following surgery. A physical therapist and a nurse paid daily visits during the first week, and all of the patients were visited once by an orthopedist (9). To explore the feasibility and potential economic savings associated with substituting home-care rehabilitation for some of the services now provided in the hospital, a pilot study was conducted at the Karolinska Hospital in the autumn of 1985. The purpose was to collect preliminary data on three broad questions: 1. Can the rehabilitation services that THR patients currently receive in the hospital be delivered at home? 2. How would the projected costs of such a home-care program compare with those for a 14day period of postoperative rehabilitation in the hospital? 3. Does a relationship exist between such factors as the patients' age, medical status, and social situation and the length of their hospital stay or the setting to which they are now discharged? The study consisted of three parts: (a) a time-motion study, (b) a cost analysis, and (c) an interview with the patients. PATIENTS AND METHODS In order to find out about the specific rehabilitation services that THR patients receive, and to identify the nature of other services that are part of patient care, 12 consecutive patients were tracked during all categories of care services. The method used was that described by Kolstad and Wigren (5). Printed forms were placed at the patients' beds. All ward staff who participated directly in the care of these patients made notes on the forms, indicating their staff category, care services, and time spent (in minutes) on each service. All services were recorded, 24 hours per day, from the first day after surgery through the entire hospital stay. Data were analyzed to determine the type and length of care that each category of staff provided, and to evaluate the proportion of their services that could be provided through home visits. Examples of those different services were checking of drainage, dressing of wounds, physical therapy, training in walking, dressing, and other self-care activities. Cost projections were done for inpatient care at the orthopedic surgery department and for home care. The economic calculations were based on accounting records of actual costs at the Karolinska Hospital, the department of primary health care of the county council of Stockholm, and the local department of community health care and social services. To make the findings of the pilot study easier to interpret, the 1985 cost values have been translated into their 1990 equivalents using a formula that both adjusts for inflation and takes into account recent increases in the actual costs of hospital and health care services. The 1990 figures thus represent what equivalent services would cost in the 1990 Swedish health care market. The costs in Swedish crowns (SEK) for the year 1985 have been adjusted to SEK for the year 1990 using the different discounting rates for each year recommended by the Federation of County Councils. Com-
94
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
Rehabilitation after hip replacement
parisons have been made with previous studies concerning different types of hip surgery and similar cost studies (2;3;5;6;12). Using the accounting records for the financial year 1985, and in consultation with the hospital management, we divided the annual working costs of the orthopedic ward into three categories: 1. Transferred cost ("hotel expenditure") includes all cost items that are shared equally by all inpatients (e.g., lodging, food, heating, electricity, bedclothes, administration). 2. Cost of surgery includes costs of recurrent standard activities and procedures, such as anesthesia, surgical operations, intensive care, blood, Pharmaceuticals, x-rays, laboratory tests, ECG, and costs of implants and other materials. 3. Cost of care includes all costs of staff salaries, wages, and national insurance as well as substitutes for vacations and sick leave. Estimates of the probable costs for home-care services were based on a hypothetical program. The study of the time spent on care services indicated that most of a hospital stay beyond 5 or 6 days after surgery seemed to be devoted to rehabilitation services that could be provided at home. So an arbitrary period of care of 7 days at the hospital and 7 days at home was used in the cost calculations of early discharge. There is no specific home-care program for THR patients in Sweden. Based, however, on what was learned from the interviews and the bedside measurements, such a program could be organized. Rehabilitation at home might be provided by daily visits from a physical therapist and from the local homemakers service. An outpatient nurse's aid, following instructions from the physical therapist, could assist patients with different exercises and could also provide "hotel" services by cleaning, making the bed, shopping, etc. Dressing the wounds and giving medication could be provided by a district nurse from a community health center. One early visit by the general physician with later visits, if needed, could also be arranged. Telephone contact with the staff at the department of orthopedics and a guarantee of immediate readmission in case of complications would increase patient confidence and medical safety. Such programs have been tried in cases of hip fracture and have shown promising results (1;2;9). A Swedish study of the time spent for home care showed that the mean time spent for home care and homemakers' services for patients with femur fractures was about 10 hours per week, and about 11 hours per week for patients with other joint and back disorders (12). To avoid underestimating the needs and costs of home care, two possible alternatives were calculated —a "maximum," alternative 1, and a "minimum," alternative 2. The maximum alternative features high personnel density and a total personnel time of 37 hours at the patient's home. The minimum alternative offers 18 hours of care at home. The estimated time includes the time spent getting to and from the patient. Figures for the cost of traditional home health care services were obtained from the department of primary health care of the county council of Stockholm and the local department of community health care and social services. After consulting with them, we adopted the following assumption regarding the distribution of the costs. For patients receiving care at home, the cost of care (services provided) represents approximately 70% of the total costs, and transferred costs (hotel expenditures) make up 30% of the total. A third study was done to examine possible predictors of early rehabilitation and to gain an understanding of which medical and social factors might influence the pattern of care, length of hospital stay, and the type of facility to which the patients were discharged. Information was collected via interviews and hospital records of 18 conINTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
95
Moller, Goldie, and Jonsson
Minutes 60' —50 -
Total ^ Nurse's Aid Physical Therapist Assistant Nurse
40 -
30 "
20 -
10 -
0
OP 12
12
12
12
5 12
12
12
12
11
10 9
15 5
5
5
4
Days Number of
patients Figure 1. Mean time value of care services and rehabilitation activities by different categories of staff during a care episode of 14 days. One patient was discharged on day 8, 2 patients on day 9, 4 patients on day 10, and 1 patient on day 13.
secutive patients who had undergone THR during a 4-week period in the autumn of 1985. Six of the patients had already been operated on at the onset of the pilot study. The other 12 were admitted later, consecutively, and were observed during their entire hospital stay in the study of time spent on care services described earlier. RESULTS
The bedside care services and rehabilitation activities provided by all categories of personnel showed a clear pattern: individual patients required different intensities of rehabilitation —from 20 minutes a day to about 60 minutes. Nurses, assistant nurses, and nurse's aids checked drainage, infusion, catheters, urine, and blood pressure, dressed surgical wounds, and collected blood samples during the first 3-5 days after surgery. The first postsurgical days also included many rehabilitative activities, which were carried out by assistant nurses and physical therapists. These included helping the patient stand at the bedside and carry out mobility and endurance exercises. Later, the rehabilitative efforts involved transferring from the bed to a chair and from the bed to the bathroom. Most of the hospital stay beyond 5 days after the surgery seemed to be entirely devoted to such physical training and physical therapy treatments as motion and walking exercises, including the use of different assistive devices. The types of services provided were similar to those provided many other patients at home. The mean times devoted to specific day-by-day care services and rehabilitation activities by nurse's aids, assistant nurses, and physical therapists are shown in Figure 96
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
Rehabilitation after hip replacement
CO8T OF BUROERY COST • F CARE TRAIMBF!ERRED COST
•+.3000 5 6 7 B 9 1011 I S H3 i a
Surgery
Discharge
Figure 2. Distribution of different costs over time in a period of 14 days in the hospital, in 1990 SEK.
1. The total time devoted to care services and rehabilitation activities decreased from an average of about 1 hour per patient per day during the first 2 days after surgery to an average of about 20 minutes on the 14th day. Physical therapy services were increased on the 8th day, when intensive exercises involving walking on an even surface and climbing stairs were initiated in preparation for discharge. An average of about 4 minutes per day of the assistant nurses' time was spent on every patient with THR. The corresponding mean-time value was 12 minutes for physical therapists and 17 minutes for nurse's aids, totaling 33 minutes per day. The distribution of different costs over time during a 14-day hospital stay is shown in Figure 2. Table 1 presents the cost estimate for a 7-day care period at home for the maximum and minimum alternatives. Table 2 shows the total cost of home health care in 1985 SEK and adjusted into 1990 SEK. Costs are shown both in SEK and U.S. dollars (US$). Comparing the cost per patient day at an inpatient department of orthopedic surgery with the cost for home care shows a potential savings of US $1,337 — 1,805 per patient, from shortening the hospital stay from 14 days to 7 days (Table 3). Data from the interviews and hospital records suggested that length of hospital stay is related to age and to whether the patients live alone. There did not seem to INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
97
Moller, Goldie, and Jonsson Table 1. Cost of Care for 7 Days of Home Health Care, 2 Alternatives, in 1985 SEK
"Maximum," alternative 1 Cost/hour
Hours
95 148 84 85 77 79 67
1 1 5 5 2 2 21
Assistive device consultant General physician District nurse District physical therapist Assistant nurse Homemaker Nurse's aid, primary care Transportation service Cost of care
"Minimum," alternative 2
Cost
Hours
95 148 420 425 154 158
1,407
2 5
168 425
1 10
79 670 135
18
1,477
135 37
2,942
Cost
Table 2. Total Cost of 7 Days of Home Health Care, 2 Alternatives, in 1990 SEK and US$ (these are 1985 costs adjusted to 1990 values)
"Maximum," alternative 1
Cost of care Transferred cost Total cost
"Minimum," alternative 2
SEK
US$
SEK
us$
3,951 1,694 5,645
656 282
1,984 849
331 142
938
2,833
473
Table 3. Cost of 14 Days of Hospital Care Compared with 7 Days of Hospital Care and 7 Days of Home Care per Patient, 2 Alternatives, in 1990 SEK and US$ (these are 1985 costs adjusted to 1990 values)
14 days of hospital care
Hospital care Cost of care Cost of operation Transferred cost Home care Cost of care Transferred cost Total costs Savings
7 days of hospital care and 7 days of "maximum" home care, alternative 1
7 days of hospital care and 7 days of "minimum" home care, alternative 2
SEK
US$
SEK
US$
SEK
US$
18,662 16,053 8,681
3,110 2,676 1,447
9,331 16,053 4,341
1,555 2,676
9,331 16,053 4,341
1,555 2,676
3,951 1,694 35,370 8,026
656 282
1,984 849
331 142
5,896 1,337
32,558 10,838
5,428 1,805
43,396
7,233
724
724
be a strong relationship between length of stay and such medical factors as disability due to other causes than joint disease. Six out of the seven patients who lived with someone (spouse or relative) were discharged to their home and had an average hospital stay of 12 days. Of 11 patients living alone, 4 were discharged to their homes and 98
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Rehabilitation after hip replacement
7 were discharged to a long-term care or convalescent home. Seven of the 13 patients who had other musculoskeletal problems preoperatively, and 3 of the 5 who did not, were discharged to their homes. DISCUSSION This pilot study indicates that it might be cost-effective to shorten the length of hospital stay for patients who undergo THR in favor of early rehabilitation at home. It is difficult, however, to draw conclusions from this study on what length of hospital stay would be optimal. Individual variations will exist, depending on age, other medical complications, need for assistance, etc. However, by weighing such factors it should be possible to predict an appropriate discharge time for each individual patient. Variations in the severity of the problem, due to different diagnoses or different stages in a disease process, mean that the personnel time that is spent on specific activities also varies from case to case. This unpredictability has been shown by other studies (3). The time spent on rehabilitation activities for the patients included in this pilot study varied from about 60 minutes/day for the patient who needed the most help to about 20 minutes/day for the patient who needed the least help. This variation may have different explanations. The printed form at the bedside, used here to measure all activities, give only a rough classification of nursing care versus rehabilitative activities; a more differentiated protocol for time measures must be developed. The involvement of doctors and nurses consisted mostly of decision making, including administrative actions associated with rounds, medication, reports, medical records, etc. They did very little actual bedside activity in this pilot study. Determining the relative importance of the activities of the doctors and the nurses for the rehabilitation of the patient would also require a more elaborate protocol and controlled environment than were used here. A controlled study also would be necessary to establish the real cost differences between hospital and home care. In this analysis it is important to note the particular economic effects that may arise as a result of a shortened average length of stay. As the analysis of specific activities showed, time spent on them decreased toward the end of the hospital stay. It is likely that the same situation exists concerning general daily routines. The input from physicians and nurses is likely to be greatest during the first days (e.g., medical examination and decisions, preoperative laboratory tests, and supervision and medication during the day after surgery). Direct physician action decreases after the second and third day following surgery to more of a "medical security" role: daily rounds and availability if something unexpected happens. Thus, it is possible that the personnel density and overall staffing costs would need to increase in inpatient units if the hospital stay were shortened and the beds used by more acutely ill patients. A randomized controlled trial will be necessary to establish the relative costs and benefits of hospital care versus home care for rehabilitation after hip replacement. CONCLUSIONS The major findings of the pilot study were that: • the actual amount of time devoted to rehabilitation activities while patients are hospitalized was very limited;
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• the types of services provided were similar to those that are often provided to older patients through home-care services; • there appear to be significant potential savings in the cost of total care when home services are substituted for the last days/weeks of hospital-based care; and • availability of family support at home appears to allow early discharge home better than do other factors such as age and medical condition. While we recognized that these findings were only preliminary and based on a very small sample, the results of the pilot study generated considerable interest and created the basis for a larger study that is now in progress. The goals of the current study are: • to determine whether preoperative teaching, early hospital discharge, and rehabilitation at home by specially trained staff improves rehabilitation outcomes in terms of activities of daily living, mobility, and patient satisfaction; and • to determine whether the waiting time prior to surgery and the length of stay in the hospital after surgery can be shortened, at a lower cost per patient to society and without impairing
the quality of care. The current study is a prospective comparative study that will involve a total of 120 consecutive patients aged 50-80 years. Subjects will be randomized into two different groups: a treatment and a control group. The first group will receive a preoperative informational program, stay for 5-7 days at the department of orthopedic surgery after surgery, and receive further rehabilitation at home. The patients in this group will be equipped and trained with necessary assistive devices before going to the hospital. The control group will follow the traditional routines, pre- and postoperatively. The types of data to be collected will be considerably more varied than in the pilot study and will include measurements of the physical outcomes of care and of the patients' perceived quality of life, as well as more detailed data on patterns of service, cost of care, and the physical and social characteristics of the patients. We hope that this study will build on the work of the pilot investigation to compare the overall cost-effectiveness of different patterns of delivery of rehabilitation services, and that it also will lead to the development of guidelines that will help match individual patients to the pattern of care that is best suited to their personal needs and characteristics. REFERENCES
1. Ceder, L. Effektivt samarbete ortopedi—Oppenvard kravs for att kunna ge aldre en fullgod vard. Ldkartidningen, 1983, 80, 582-84. 2. Jarnlo, G.-B., Ceder, L., & Thorngren, K.-G. Early rehabilitation at home of elderly patients with hip fractures and consumption of resources in primary care. Scandinavian Journal of Primary Health Care, 1984, 2, 105-12. 3. Johansson, S. Hoftledsplastik. Kostnader och effekter av en ortopedisk-kirurgisk operationsmetod. Goteborg, Sweden: Goteborgs Universitet, 1983. 4. Jonsson, E. Kostnader och nytta av medicinsk teknologi- den konstgjorda hoften. Nordisk Median, 1985, 100, 2-3. 5. Kolstad, K., & Wigren, A. Costs of and needs for resources in hospital care. Scandinavian Journal of Social Medicine, 1981, 9, 11-18.5. 6. Lofstrom, A. Kostnadstackningfor utomlanspatienter vid ortoped-kirurgiska kliniker. Stockholm: Karolinska sjukhuset, 1984.
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Rehabilitation after hip replacement
7. Nilsson, B., Ahnfelt, L., Albrektsson, T., et al. Nya hoftleder: En explosionsartad utveckling. Ldkartidningen, 1988, 38, 3053. 8. Office of Health Economics. Hip replacement and the NHS. Luton, England: Office of Health Economics, 1982. 9. Sikorski, J. M., Davies, N. J., & Senior, J. The rapid transit system for patients with fractures of proximal femur. British Medical Journal, 1985, 290, 438-43. 10. Socialstyrelsen. Koer i sjukvarden 3. Stockholm: Socialstyrelsen, 1990. 11. Socialstyrelsen. Rorelseorganens sjukdomar— Problem och strategier infor 90-talet. Stockholm: Socialstyrelsen, 1983. 12. Stockholms lans landsting, Kommunforbundets lansavdelning. Sjukvard i hemmet-social Hemtjdnst. Stockholm: Liber Tryck, 1984.
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HOSPITAL CARE VERSUS HOME CARE FOR REHABILITATION AFTER HIP REPLACEMENT Gudrun Moller Ian Goldie Egon Jonsson Karolinska Hospital/Institute
Abstract A pilot study was done to assess the feasibility of reducing the hospital stays of patients with total hip replacement (THR). The length of hospital stay for these patients depends largely on how rehabilitation, mostly physical therapy, is organized. This study shows that not more than a half hour per postoperative day was devoted to care services and rehabilitation activities. It is feasible and less expensive to reduce substantially hospital stay by planned physical therapy in the patient's home. These results have prompted a randomized controlled clinical trial to assess hospital versus home rehabilitation.
Large-scale assessments of alternative delivery systems are an important part of efforts to control costs and improve access to health services. However, before major changes in the system can be designed and implemented, exploratory studies are often needed to assess which types of changes are feasible and which promise the greatest benefit. The pilot study described in this paper was such a preliminary assessment. Its purpose was to lay the foundation for a much larger and more formal experiment that is now in progress. In 1987 about 400,000 total hip replacements (THR) were performed worldwide (7). Approximately 10,400 were performed in Sweden in 1989, including reoperations (10). Ninety percent of these patients continue to do well 10 years after surgery (4;8). Indications for total hip replacement surgery are: pain, both from movement and at rest, and restricted movement of the hip joint caused by osteoarthritis, rheumatoid arthritis, sequelae of femoral neck fractures, or congenital malformation. Primary hip osteoarthritis, the most common cause for THR, is rare among people under 55-60 years of age (150 cases per 10,000 inhabitants), but its frequency increases with age (11). Intensive early rehabilitation is generally regarded as important for achieving a good end result, and, for this reason, patients are often kept in the hospital to receive therapy for some days after surgery. In 1985 THR patients at the Karolinska Hospital in Stockholm generally stayed in the hospital for 12-14 days following their operation. Although the outcomes of this care have been satisfactory, such long postsurgical hospitalization creates practical problems: the costs of hospital-based rehabilitation are
93
Moller, Goldie, and Jonsson
high and the slow turnover of patients that it creates contributes to long waiting periods for patients who need surgery. Reduction of these problems might be achieved by reorganizing the rehabilitation program to provide only initial treatment in the hospital with follow-up care at home after discharge. Because most hip surgery is planned well in advance, it should be possible to plan rehabilitation at home well before the operation takes place. Encouraging evidence supporting this approach is provided by studies of hip-fracture patients (1;2). A study from Australia indicated that hip-fracture patients could leave the hospital within 5 days following surgery. A physical therapist and a nurse paid daily visits during the first week, and all of the patients were visited once by an orthopedist (9). To explore the feasibility and potential economic savings associated with substituting home-care rehabilitation for some of the services now provided in the hospital, a pilot study was conducted at the Karolinska Hospital in the autumn of 1985. The purpose was to collect preliminary data on three broad questions: 1. Can the rehabilitation services that THR patients currently receive in the hospital be delivered at home? 2. How would the projected costs of such a home-care program compare with those for a 14day period of postoperative rehabilitation in the hospital? 3. Does a relationship exist between such factors as the patients' age, medical status, and social situation and the length of their hospital stay or the setting to which they are now discharged? The study consisted of three parts: (a) a time-motion study, (b) a cost analysis, and (c) an interview with the patients. PATIENTS AND METHODS In order to find out about the specific rehabilitation services that THR patients receive, and to identify the nature of other services that are part of patient care, 12 consecutive patients were tracked during all categories of care services. The method used was that described by Kolstad and Wigren (5). Printed forms were placed at the patients' beds. All ward staff who participated directly in the care of these patients made notes on the forms, indicating their staff category, care services, and time spent (in minutes) on each service. All services were recorded, 24 hours per day, from the first day after surgery through the entire hospital stay. Data were analyzed to determine the type and length of care that each category of staff provided, and to evaluate the proportion of their services that could be provided through home visits. Examples of those different services were checking of drainage, dressing of wounds, physical therapy, training in walking, dressing, and other self-care activities. Cost projections were done for inpatient care at the orthopedic surgery department and for home care. The economic calculations were based on accounting records of actual costs at the Karolinska Hospital, the department of primary health care of the county council of Stockholm, and the local department of community health care and social services. To make the findings of the pilot study easier to interpret, the 1985 cost values have been translated into their 1990 equivalents using a formula that both adjusts for inflation and takes into account recent increases in the actual costs of hospital and health care services. The 1990 figures thus represent what equivalent services would cost in the 1990 Swedish health care market. The costs in Swedish crowns (SEK) for the year 1985 have been adjusted to SEK for the year 1990 using the different discounting rates for each year recommended by the Federation of County Councils. Com-
94
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
Rehabilitation after hip replacement
parisons have been made with previous studies concerning different types of hip surgery and similar cost studies (2;3;5;6;12). Using the accounting records for the financial year 1985, and in consultation with the hospital management, we divided the annual working costs of the orthopedic ward into three categories: 1. Transferred cost ("hotel expenditure") includes all cost items that are shared equally by all inpatients (e.g., lodging, food, heating, electricity, bedclothes, administration). 2. Cost of surgery includes costs of recurrent standard activities and procedures, such as anesthesia, surgical operations, intensive care, blood, Pharmaceuticals, x-rays, laboratory tests, ECG, and costs of implants and other materials. 3. Cost of care includes all costs of staff salaries, wages, and national insurance as well as substitutes for vacations and sick leave. Estimates of the probable costs for home-care services were based on a hypothetical program. The study of the time spent on care services indicated that most of a hospital stay beyond 5 or 6 days after surgery seemed to be devoted to rehabilitation services that could be provided at home. So an arbitrary period of care of 7 days at the hospital and 7 days at home was used in the cost calculations of early discharge. There is no specific home-care program for THR patients in Sweden. Based, however, on what was learned from the interviews and the bedside measurements, such a program could be organized. Rehabilitation at home might be provided by daily visits from a physical therapist and from the local homemakers service. An outpatient nurse's aid, following instructions from the physical therapist, could assist patients with different exercises and could also provide "hotel" services by cleaning, making the bed, shopping, etc. Dressing the wounds and giving medication could be provided by a district nurse from a community health center. One early visit by the general physician with later visits, if needed, could also be arranged. Telephone contact with the staff at the department of orthopedics and a guarantee of immediate readmission in case of complications would increase patient confidence and medical safety. Such programs have been tried in cases of hip fracture and have shown promising results (1;2;9). A Swedish study of the time spent for home care showed that the mean time spent for home care and homemakers' services for patients with femur fractures was about 10 hours per week, and about 11 hours per week for patients with other joint and back disorders (12). To avoid underestimating the needs and costs of home care, two possible alternatives were calculated —a "maximum," alternative 1, and a "minimum," alternative 2. The maximum alternative features high personnel density and a total personnel time of 37 hours at the patient's home. The minimum alternative offers 18 hours of care at home. The estimated time includes the time spent getting to and from the patient. Figures for the cost of traditional home health care services were obtained from the department of primary health care of the county council of Stockholm and the local department of community health care and social services. After consulting with them, we adopted the following assumption regarding the distribution of the costs. For patients receiving care at home, the cost of care (services provided) represents approximately 70% of the total costs, and transferred costs (hotel expenditures) make up 30% of the total. A third study was done to examine possible predictors of early rehabilitation and to gain an understanding of which medical and social factors might influence the pattern of care, length of hospital stay, and the type of facility to which the patients were discharged. Information was collected via interviews and hospital records of 18 conINTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
95
Moller, Goldie, and Jonsson
Minutes 60' —50 -
Total ^ Nurse's Aid Physical Therapist Assistant Nurse
40 -
30 "
20 -
10 -
0
OP 12
12
12
12
5 12
12
12
12
11
10 9
15 5
5
5
4
Days Number of
patients Figure 1. Mean time value of care services and rehabilitation activities by different categories of staff during a care episode of 14 days. One patient was discharged on day 8, 2 patients on day 9, 4 patients on day 10, and 1 patient on day 13.
secutive patients who had undergone THR during a 4-week period in the autumn of 1985. Six of the patients had already been operated on at the onset of the pilot study. The other 12 were admitted later, consecutively, and were observed during their entire hospital stay in the study of time spent on care services described earlier. RESULTS
The bedside care services and rehabilitation activities provided by all categories of personnel showed a clear pattern: individual patients required different intensities of rehabilitation —from 20 minutes a day to about 60 minutes. Nurses, assistant nurses, and nurse's aids checked drainage, infusion, catheters, urine, and blood pressure, dressed surgical wounds, and collected blood samples during the first 3-5 days after surgery. The first postsurgical days also included many rehabilitative activities, which were carried out by assistant nurses and physical therapists. These included helping the patient stand at the bedside and carry out mobility and endurance exercises. Later, the rehabilitative efforts involved transferring from the bed to a chair and from the bed to the bathroom. Most of the hospital stay beyond 5 days after the surgery seemed to be entirely devoted to such physical training and physical therapy treatments as motion and walking exercises, including the use of different assistive devices. The types of services provided were similar to those provided many other patients at home. The mean times devoted to specific day-by-day care services and rehabilitation activities by nurse's aids, assistant nurses, and physical therapists are shown in Figure 96
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
Rehabilitation after hip replacement
CO8T OF BUROERY COST • F CARE TRAIMBF!ERRED COST
•+.3000 5 6 7 B 9 1011 I S H3 i a
Surgery
Discharge
Figure 2. Distribution of different costs over time in a period of 14 days in the hospital, in 1990 SEK.
1. The total time devoted to care services and rehabilitation activities decreased from an average of about 1 hour per patient per day during the first 2 days after surgery to an average of about 20 minutes on the 14th day. Physical therapy services were increased on the 8th day, when intensive exercises involving walking on an even surface and climbing stairs were initiated in preparation for discharge. An average of about 4 minutes per day of the assistant nurses' time was spent on every patient with THR. The corresponding mean-time value was 12 minutes for physical therapists and 17 minutes for nurse's aids, totaling 33 minutes per day. The distribution of different costs over time during a 14-day hospital stay is shown in Figure 2. Table 1 presents the cost estimate for a 7-day care period at home for the maximum and minimum alternatives. Table 2 shows the total cost of home health care in 1985 SEK and adjusted into 1990 SEK. Costs are shown both in SEK and U.S. dollars (US$). Comparing the cost per patient day at an inpatient department of orthopedic surgery with the cost for home care shows a potential savings of US $1,337 — 1,805 per patient, from shortening the hospital stay from 14 days to 7 days (Table 3). Data from the interviews and hospital records suggested that length of hospital stay is related to age and to whether the patients live alone. There did not seem to INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:1, 1992
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Moller, Goldie, and Jonsson Table 1. Cost of Care for 7 Days of Home Health Care, 2 Alternatives, in 1985 SEK
"Maximum," alternative 1 Cost/hour
Hours
95 148 84 85 77 79 67
1 1 5 5 2 2 21
Assistive device consultant General physician District nurse District physical therapist Assistant nurse Homemaker Nurse's aid, primary care Transportation service Cost of care
"Minimum," alternative 2
Cost
Hours
95 148 420 425 154 158
1,407
2 5
168 425
1 10
79 670 135
18
1,477
135 37
2,942
Cost
Table 2. Total Cost of 7 Days of Home Health Care, 2 Alternatives, in 1990 SEK and US$ (these are 1985 costs adjusted to 1990 values)
"Maximum," alternative 1
Cost of care Transferred cost Total cost
"Minimum," alternative 2
SEK
US$
SEK
us$
3,951 1,694 5,645
656 282
1,984 849
331 142
938
2,833
473
Table 3. Cost of 14 Days of Hospital Care Compared with 7 Days of Hospital Care and 7 Days of Home Care per Patient, 2 Alternatives, in 1990 SEK and US$ (these are 1985 costs adjusted to 1990 values)
14 days of hospital care
Hospital care Cost of care Cost of operation Transferred cost Home care Cost of care Transferred cost Total costs Savings
7 days of hospital care and 7 days of "maximum" home care, alternative 1
7 days of hospital care and 7 days of "minimum" home care, alternative 2
SEK
US$
SEK
US$
SEK
US$
18,662 16,053 8,681
3,110 2,676 1,447
9,331 16,053 4,341
1,555 2,676
9,331 16,053 4,341
1,555 2,676
3,951 1,694 35,370 8,026
656 282
1,984 849
331 142
5,896 1,337
32,558 10,838
5,428 1,805
43,396
7,233
724
724
be a strong relationship between length of stay and such medical factors as disability due to other causes than joint disease. Six out of the seven patients who lived with someone (spouse or relative) were discharged to their home and had an average hospital stay of 12 days. Of 11 patients living alone, 4 were discharged to their homes and 98
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7 were discharged to a long-term care or convalescent home. Seven of the 13 patients who had other musculoskeletal problems preoperatively, and 3 of the 5 who did not, were discharged to their homes. DISCUSSION This pilot study indicates that it might be cost-effective to shorten the length of hospital stay for patients who undergo THR in favor of early rehabilitation at home. It is difficult, however, to draw conclusions from this study on what length of hospital stay would be optimal. Individual variations will exist, depending on age, other medical complications, need for assistance, etc. However, by weighing such factors it should be possible to predict an appropriate discharge time for each individual patient. Variations in the severity of the problem, due to different diagnoses or different stages in a disease process, mean that the personnel time that is spent on specific activities also varies from case to case. This unpredictability has been shown by other studies (3). The time spent on rehabilitation activities for the patients included in this pilot study varied from about 60 minutes/day for the patient who needed the most help to about 20 minutes/day for the patient who needed the least help. This variation may have different explanations. The printed form at the bedside, used here to measure all activities, give only a rough classification of nursing care versus rehabilitative activities; a more differentiated protocol for time measures must be developed. The involvement of doctors and nurses consisted mostly of decision making, including administrative actions associated with rounds, medication, reports, medical records, etc. They did very little actual bedside activity in this pilot study. Determining the relative importance of the activities of the doctors and the nurses for the rehabilitation of the patient would also require a more elaborate protocol and controlled environment than were used here. A controlled study also would be necessary to establish the real cost differences between hospital and home care. In this analysis it is important to note the particular economic effects that may arise as a result of a shortened average length of stay. As the analysis of specific activities showed, time spent on them decreased toward the end of the hospital stay. It is likely that the same situation exists concerning general daily routines. The input from physicians and nurses is likely to be greatest during the first days (e.g., medical examination and decisions, preoperative laboratory tests, and supervision and medication during the day after surgery). Direct physician action decreases after the second and third day following surgery to more of a "medical security" role: daily rounds and availability if something unexpected happens. Thus, it is possible that the personnel density and overall staffing costs would need to increase in inpatient units if the hospital stay were shortened and the beds used by more acutely ill patients. A randomized controlled trial will be necessary to establish the relative costs and benefits of hospital care versus home care for rehabilitation after hip replacement. CONCLUSIONS The major findings of the pilot study were that: • the actual amount of time devoted to rehabilitation activities while patients are hospitalized was very limited;
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• the types of services provided were similar to those that are often provided to older patients through home-care services; • there appear to be significant potential savings in the cost of total care when home services are substituted for the last days/weeks of hospital-based care; and • availability of family support at home appears to allow early discharge home better than do other factors such as age and medical condition. While we recognized that these findings were only preliminary and based on a very small sample, the results of the pilot study generated considerable interest and created the basis for a larger study that is now in progress. The goals of the current study are: • to determine whether preoperative teaching, early hospital discharge, and rehabilitation at home by specially trained staff improves rehabilitation outcomes in terms of activities of daily living, mobility, and patient satisfaction; and • to determine whether the waiting time prior to surgery and the length of stay in the hospital after surgery can be shortened, at a lower cost per patient to society and without impairing
the quality of care. The current study is a prospective comparative study that will involve a total of 120 consecutive patients aged 50-80 years. Subjects will be randomized into two different groups: a treatment and a control group. The first group will receive a preoperative informational program, stay for 5-7 days at the department of orthopedic surgery after surgery, and receive further rehabilitation at home. The patients in this group will be equipped and trained with necessary assistive devices before going to the hospital. The control group will follow the traditional routines, pre- and postoperatively. The types of data to be collected will be considerably more varied than in the pilot study and will include measurements of the physical outcomes of care and of the patients' perceived quality of life, as well as more detailed data on patterns of service, cost of care, and the physical and social characteristics of the patients. We hope that this study will build on the work of the pilot investigation to compare the overall cost-effectiveness of different patterns of delivery of rehabilitation services, and that it also will lead to the development of guidelines that will help match individual patients to the pattern of care that is best suited to their personal needs and characteristics. REFERENCES
1. Ceder, L. Effektivt samarbete ortopedi—Oppenvard kravs for att kunna ge aldre en fullgod vard. Ldkartidningen, 1983, 80, 582-84. 2. Jarnlo, G.-B., Ceder, L., & Thorngren, K.-G. Early rehabilitation at home of elderly patients with hip fractures and consumption of resources in primary care. Scandinavian Journal of Primary Health Care, 1984, 2, 105-12. 3. Johansson, S. Hoftledsplastik. Kostnader och effekter av en ortopedisk-kirurgisk operationsmetod. Goteborg, Sweden: Goteborgs Universitet, 1983. 4. Jonsson, E. Kostnader och nytta av medicinsk teknologi- den konstgjorda hoften. Nordisk Median, 1985, 100, 2-3. 5. Kolstad, K., & Wigren, A. Costs of and needs for resources in hospital care. Scandinavian Journal of Social Medicine, 1981, 9, 11-18.5. 6. Lofstrom, A. Kostnadstackningfor utomlanspatienter vid ortoped-kirurgiska kliniker. Stockholm: Karolinska sjukhuset, 1984.
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7. Nilsson, B., Ahnfelt, L., Albrektsson, T., et al. Nya hoftleder: En explosionsartad utveckling. Ldkartidningen, 1988, 38, 3053. 8. Office of Health Economics. Hip replacement and the NHS. Luton, England: Office of Health Economics, 1982. 9. Sikorski, J. M., Davies, N. J., & Senior, J. The rapid transit system for patients with fractures of proximal femur. British Medical Journal, 1985, 290, 438-43. 10. Socialstyrelsen. Koer i sjukvarden 3. Stockholm: Socialstyrelsen, 1990. 11. Socialstyrelsen. Rorelseorganens sjukdomar— Problem och strategier infor 90-talet. Stockholm: Socialstyrelsen, 1983. 12. Stockholms lans landsting, Kommunforbundets lansavdelning. Sjukvard i hemmet-social Hemtjdnst. Stockholm: Liber Tryck, 1984.
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