title: Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
abstract: OBJECTIVE
  To assess the effectiveness of pre- and post-operative physiotherapy at home for unilateral total knee replacement (TKR).
  
  
  METHODS
  In this pragmatic randomized controlled trial set in participants' homes (four primary care trust areas) and physiotherapy outpatients in a South Yorkshire teaching hospital trust, 160 osteoarthritis patients waiting for unilateral TKR were randomly allocated to intervention (home) group (n=80) or control (hospital outpatient) group (n=80). The intervention group had pre- and post-operative home visits for assessment and treatment by a community physiotherapist. Outcome measures were health-related quality of life (HRQoL), measured by the Western Ontario McMaster Osteoarthritis index (WOMAC) and the Short Form 36 health survey (SF-36) pre-operatively and at 12 weeks post-TKR operation; patient satisfaction; and NHS resource use.
  
  
  RESULTS
  No significant differences were observed between the two treatment groups in the primary outcome measure, the WOMAC pain score, or any other HRQoL score. The home group had a significantly greater mean number of physiotherapy sessions than the hospital group [mean difference 5.2 sessions, 95% confidence interval (CI)=-6.3 to -4.1; P=0.001]. There was no significant difference in the total NHS costs per patient between groups. However, home physiotherapy for TKR was significantly more expensive (mean difference-pound136.5, 95% CI=- pound160 to-pound113; P=0.001). Patients were equally satisfied with physiotherapy at home or in hospital; however, more of the home group would choose their location for physiotherapy again.
  
  
  CONCLUSIONS
  Although home physiotherapy was as effective and as acceptable to patients as hospital outpatient physiotherapy for unilateral TKR, it was more expensive. Additional pre-operative home physiotherapy did not improve patient-perceived health outcomes.
authors.affiliation: University of Sheffield, School of Health & Related Research (ScHARR), Institute of General Practice and Primary Care, Community Sciences Centre, Northern General Hospital, Sheffield, UK. c.mitchell@sheffield.ac.uk
authors.forename: Caroline
authors.initials: C
authors.lastname: Mitchell
authors.forename: Jane
authors.initials: J
authors.lastname: Walker
authors.forename: Stephen
authors.initials: S
authors.lastname: Walters
authors.forename: Anne B
authors.initials: AB
authors.lastname: Morgan
authors.forename: Teena
authors.initials: T
authors.lastname: Binns
authors.forename: Nigel
authors.initials: N
authors.lastname: Mathers
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation*; D003362:Cost-Benefit Analysis; D004739:England; D005260:Female; D017048:Health Care Costs / Q000145:classification / Q000706:statistics & numerical data*; D006699:Home Care Services / Q000191:economics*; D006779:Hospitals, Public; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000601:surgery*; D010044:Outpatient Clinics, Hospital / Q000191:economics*; D017060:Patient Satisfaction; D026741:Physical Therapy Modalities / Q000191:economics*; D011182:Postoperative Care / Q000191:economics*; D011300:Preoperative Care / Q000191:economics*; D011788:Quality of Life; D013222:State Medicine; D016896:Treatment Outcome