title: Management and care of patients undergoing total knee arthroplasty: variations across different health care settings.
abstract: OBJECTIVE
  To examine variation in the process of care for total knee arthroplasty (TKA) and to highlight the need for rigorous research into the ideal management of TKA. We hypothesize that variation in the process of care for TKA across and within health care systems is associated with identifiable financial and historical factors.
  
  
  METHODS
  We compared access to TKA and typical postoperative rehabilitation management in 12 orthopedic centers in the United States (4 centers), United Kingdom (6 centers), and Australia (2 centers). We collected data from two sources: 1) Empirical data on length of stay and discharge management were collected as part of a prospective study of the outcomes of primary TKA for patients with a diagnosis of osteoarthritis; 2) Structured qualitative interviews were conducted at each of the participating centers to collect data on academic status and reimbursement structure, as well as waiting times for orthopedic consultation and TKA surgery once it had been scheduled.
  
  
  RESULTS
  We demonstrated differences in length of acute hospital stay, use of extended care facilities, home physical therapy, and outpatient physical therapy within our cohort of hospitals. The publicly funded hospitals had a significantly longer acute hospital length of stay (mean 11.8 days, SD 7.1) than the private hospitals (mean 6.6 days, SD 4.1; P < 0.0001). Variation in waiting times was associated with the method of surgeon reimbursement and whether the hospital is publicly funded or private. Patients attending private hospitals waited 1-8 weeks for the first consultation and 2-12 weeks for a surgical date after scheduling. In contrast, patients attending publicly funded hospitals waited 4-12 months for a first consultation and 12-18 months for a surgical date after scheduling.
  
  
  CONCLUSIONS
  Our observations are consistent with the hypothesis that financial reimbursement schemes influence the management of TKA. Further research needs to be done to quantify effects of varying processes of care on the outcome of TKA surgery across different health care settings. This data would elucidate the optimal management of TKA using objective evidence rather than relying on financial incentives or the preservation of historical practices.
authors.affiliation: Department of Orthopedic Research, MRB-114a, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: E A
authors.initials: EA
authors.lastname: Lingard
authors.forename: S
authors.initials: S
authors.lastname: Berven
authors.forename: J N
authors.initials: JN
authors.lastname: Katz
mesh_terms: D019645:Arthroplasty, Replacement, Knee / Q000191:economics / Q000534:rehabilitation*; D001315:Australia; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D026741:Physical Therapy Modalities; D011182:Postoperative Care / Q000379:methods*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D036301:Qualitative Research; D016059:Range of Motion, Articular; D012051:Reimbursement Mechanisms / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D006113:United Kingdom; D014481:United States; D014850:Waiting Lists