Surgeon, patient preference may lead to discharge to rehabilitation facility after TKA
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Although patients may be safely discharged to home following total knee arthroplasty, published results showed patients continue to be discharged to a rehabilitation facility due to patient, physician and family preference.
“The implementation of postoperative initiatives to streamline discharge to home has been successful in large, university-based facilities; however, a paucity of knowledge as to the safety and efficacy of discharge to home following TKA in smaller community hospitals exists,” Kimona Issa, MD, orthopedic spine surgeon at Lourdes Orthopedic Sports Medicine Southside in Binghamton, New York, and colleagues wrote.
The retrospective review assessed the success of a single teaching institution’s initiative to discharge patients home instead of to a rehabilitation facility. The study included 229 patients who underwent TKA from 2015 to 2017. Among patients who were discharged to a rehabilitation facility, researchers evaluated why and stratified the reasons into four groups based on physician and occupational health team assessment, patient preference, physician preference and family or caretaker preference.
Results showed 47% of patients were discharged to home with outpatient physical therapy services and 53% of patients were discharged to a rehabilitation facility. Of the 122 patients discharged to a rehabilitation facility, researchers found this was due to physician and occupational health team assessment for 29% of these patients. Researchers also noted 25% of patients went to a rehabilitation facility due to patient preference, 26% due to surgeon preference and 20% due to family or caretaker preference.
The two groups had no differences in length of stay, gender or complication rates, although those discharged to a rehabilitation facility were older (66 years vs. 70 years; P = .0007).
“We found that the majority of our patients can be safely discharged to home following TKA. However, the majority of the patients who had underwent TKA continue to be discharged to a rehabilitation facility despite it being deemed medically unnecessary,” the authors wrote. “Although it is unclear as to all the reasons why, there was a strong prejudice by patients, physicians and family/caretakers alike for discharge to a rehabilitation facility after TKA. As such, it is crucial to implement appropriate preoperative education and postoperative patient care protocols to facilitate discharge to home in training facilities.”
Perspective
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The reduction in post-surgical expenses following total joint arthroplasty is a major aim of value-based care initiatives. Unneeded or unnecessary utilization of post-discharge care is a major expense during the episode of care. However, it must be determined that removing these care options is safe and that viable alternatives exist.
One of the major advances in value-based care cost savings has been the reduction in patient discharges to rehabilitation centers and skilled nursing facilities following elective hip and knee arthroplasty. Numerous studies have demonstrated not only the reduced cost associated with home discharge, but also the safety that goes along with this decision. This study by Kimona Issa, MD, and colleagues demonstrates that while safe discharge to home is possible, there remains significant barriers at teaching institutions with patients, families and even physicians often preferring discharge to rehabilitation.
What we have been taught and what we must implement is that significant pre-surgical education must be done in order to determine appropriate post-discharge care. Everyone on the care team (patient, family and medical team) must be on the same page and deliver a consistent message prior to the hospitalization.
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