title: Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial.
abstract: BACKGROUND
  Home-based rehabilitation is increasingly utilized to reduce health-care costs; however, with a shorter hospital stay, the possibility arises for an increase in adverse clinical outcomes. We evaluated the effectiveness and cost of care of home-based compared with inpatient rehabilitation following primary total hip or knee joint replacement.
  
  
  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.
authors.affiliation: Toronto Western Hospital, University Health Network, 399 Bathurst Street, East Wing 1-435, Toronto, ON M5T 2S8, Canada. nizar.mahomed@uhn.on.ca
authors.forename: Nizar N
authors.initials: NN
authors.lastname: Mahomed
authors.forename: Aileen M
authors.initials: AM
authors.lastname: Davis
authors.forename: Gillian
authors.initials: G
authors.lastname: Hawker
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Badley
authors.forename: J Rod
authors.initials: JR
authors.lastname: Davey
authors.forename: Khalid A
authors.initials: KA
authors.lastname: Syed
authors.forename: Peter C
authors.initials: PC
authors.lastname: Coyte
authors.forename: Rajiv
authors.initials: R
authors.lastname: Gandhi
authors.forename: James G
authors.initials: JG
authors.lastname: Wright
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000534:rehabilitation*; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation*; D016009:Chi-Square Distribution; D003362:Cost-Benefit Analysis; D005260:Female; D018575:Home Care Services, Hospital-Based / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D007297:Inpatients; D008297:Male; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D016896:Treatment Outcome