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Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial

¹ Toronto Western Hospital, University Health Network, 399 Bathurst Street, East Wing 1-435, Toronto, ON M5T 2S8, Canada. E-mail address: nizar.mahomed{at}uhn.on.ca
² Division of Health Care and Outcomes Research and Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, 399 Bathurst Street, MP 11-322, Toronto, ON M5T 2S8, Canada
³ Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, 76 Grenville Street, 10th Floor, East Room 1010, Toronto, ON M5S 1B6, Canada
⁴ Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, 1-011 East Wing, Toronto, ON M5T 2S8, Canada
⁵ Department of Health Policy, Management and Evaluation, McMurrich Building, University of Toronto, Toronto, ON M5S 1A8, Canada
⁶ Department of Surgery, The Hospital for Sick Children, 1218-555 University Avenue, Toronto, ON M5G 1X8, Canada

Investigation performed at Toronto Western Hospital, University of Toronto, and North York General Hospital, Toronto, Ontario, Canada

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Physicians' Services Incorporated. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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Methods: We randomized 234 patients, using block randomization techniques, to either home-based or inpatient rehabilitation following total joint replacement. All patients followed standardized care pathways and were evaluated, with use of validated outcome measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Short Form-36, and patient satisfaction), prior to surgery and at three and twelve months following surgery. The primary outcome was the WOMAC function score at three months after surgery.

Results: The mean length of stay (and standard deviation) in the acute care hospital was 6.3 ± 2.5 days for the group designated for inpatient rehabilitation prior to transfer to that facility compared with 7.0 ± 3.0 days for the home-based rehabilitation group prior to discharge home (p = 0.06). The mean length of stay in inpatient rehabilitation was 17.7 ± 8.6 days. The mean number of postoperative home-based rehabilitation visits was eight. The prevalence of postoperative complications up to twelve months postoperatively was similar in both groups, which each had a 2% rate of dislocation and a 3% rate of clinically important deep venous thrombosis. The prevalence of infection was 0% in the home-based group and 2% in the inpatient group. None of these differences was clinically important. Both groups showed substantial improvements at three and twelve months, with no significant differences between the groups with respect to WOMAC, Short Form-36, or patient satisfaction scores (p > 0.05). The total episode-of-care costs (in Canadian dollars) for the inpatient rehabilitation and home-based rehabilitation arms were $14,532 and $11,082, respectively (p < 0.01).

Conclusions: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the group that received home-based rehabilitation and the group that had inpatient rehabilitation. On the basis of our findings, we recommend the use of a home-based rehabilitation protocol following elective primary total hip or knee replacement as it is the more cost-effective strategy.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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