Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement: randomized study of 50 patients with 6 months of follow-up. Comparison of two home care protocols for total joint replacement. Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. Early inpatient rehabilitation after elective hip and knee arthroplasty.
To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty.
                Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital.
                163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients).
                Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay.
                Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients.
                Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty. Because of current cost restrictions, we studied the effect of a shorter hospital stay on function, pain and quality of life (QOL) after total hip replacement (THR).
                50 patients from two hospitals were randomized into a study group (SG) of 27 patients receiving preoperative and postoperative education programs, as well as home visits from an outpatient team, and a control group (CG) of 23 patients receiving "conventional" rehabilitation often augmented by a stay at a rehabilitation center.
                Mean hospital stay was shorter for the SG than for the CG (6.4 days and 10 days, respectively; p < 0.001). During the 6-month study period, there were 9 non-fatal complications in the SG and 12 in the CG (p = 0.3). The difference in Oxford Hip Score between the groups was not statistically significant before the operation, but was better for the SG at 2 months (p = 0.03) and this difference remained more or less constant throughout the study. The overall score from the Nottingham Health Profile indicated a better QOL in the SG.
                Our preoperative education program, followed by postoperative home-based rehabilitation, appears to be safer and more effective in improving function and QOL after THR than conventional treatment. To examine the effect of a more-efficient home care protocol to manage total joint replacement (TJR) patients after surgery.
                A randomized trial of two home care protocols for TJR management.
                A hospital-affiliated home healthcare agency in a large midwestern city.
                Medicare-eligible individuals undergoing elective total hip or knee replacement surgery (N = 136).
                A home care protocol that included preoperative home visits by a nurse and a physical therapist and fewer postoperative visits (range of 9-12 visits) to the home than an existing protocol (range of 11-47 visits).
                Functional status, lower extremity functioning, health-related quality of life, satisfaction with care, and use and cost of healthcare services for 6 months postsurgery.
                There were no differences in functional status, health-related quality of life, or lower extremity functioning by group at 6 months. A marginally significant gain in satisfaction with access to care (P =.059) was found in the intervention group at 6 months. Home healthcare costs were 55% lower for the streamlined group (P <.001). Other costs did not differ significantly by group.
                TJR patients who received the more-efficient home care protocol experienced comparable outcomes to those who received the existing protocol. An abbreviated set of home care visits resulted in more-efficient delivery of care without compromising patient outcomes. To compare hospital at home care with inpatient hospital care in terms of patient outcomes.
                Randomised controlled trial with three month follow up.
                District general hospital and catchment area of neighbouring community trust.
                Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).
                Hospital at home care or inpatient hospital care.
                Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures-chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care.
                At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care.
                Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern. Inpatient rehabilitation after elective hip and knee arthroplasty is often necessary for patients who cannot function at home soon after surgery, but how soon after surgery inpatient rehabilitation can be initiated has not been studied.
                To test the hypothesis that high-risk patients undergoing elective hip and knee arthroplasty would incur less total cost and experience more rapid functional improvement if inpatient rehabilitation began on postoperative day 3 rather than day 7, without adverse consequences to the patients.
                Randomized controlled trial conducted from 1994 to 1996.
                Tertiary care center.
                A total of 86 patients undergoing elective hip or knee arthroplasty and who met the following criteria for being high risk: 70 years of age or older and living alone, 70 years of age or older with 2 or more comorbid conditions, or any age with 3 or more comorbid conditions. Of the 86 patients, 71 completed the study.
                Random assignment to begin inpatient rehabilitation on postoperative day 3 vs postoperative day 7.
                Total length of stay and cost from orthopedic and rehabilitation hospital admissions, functional performance in hospitals using a subset of the functional independence measure, and 4-month follow-up assessment using the RAND 36-item health survey I and the functional status index.
                Patients who completed the study and began inpatient rehabilitation on postoperative day 3 exhibited shorter mean (+/-SD) total length of stay (11.7+/-2.3 days vs 14.5+/-1.9, P<.001), lower mean (+/-SD) total cost ($25891+/-$3648 vs $27762+/-$3626, P<.03), more rapid attainment of short-term functional milestones between days 6 and 10 (36.2+/-14.4 m ambulated vs 21.4+/-13.3 m, P<.001; 4.8+/-0.8 mean transfer functional independence measure score vs 4.3+/-0.7, P<.01), and equivalent functional outcome at 4-month follow-up.
                These data showed that high-risk individuals were able to tolerate early intensive rehabilitation, and this intervention yielded faster attainment of short-term functional milestones in fewer days using less total cost.