Effectiveness and cost-effectiveness of pre- and post-operative physiotherapy at home for osteoarthritis patients undergoing unilateral total knee replacement : a randomised controlled trial

Costs and effectiveness of pre- and postoperative home physiotherapy for total knee replacement: a randomised controlled trial. Total knee replacement (TKR) is a common effective intervention for knee osteoarthritis (OA) with potential to further improve patient outcomes. There is a lack of evidence assessing physiotherapy within the TKR care pathway; previous studies lack statistical power and measures of health related quality of life (HRQoL). Pre- and postoperative home physiotherapy rehabilitation for TKR has not previously been evaluated as an alternative to NHS hospital outpatient rehabilitation. Objective To assess the costs and effectiveness of pre- and postoperative physiotherapy at home for unilateral total knee replacement (TKR). Design This was a pragmatic RCT comparing patient reported HRQoL, and NHS costs of home physiotherapy pre- and postoperatively for TKR with usual hospital outpatient postoperative physiotherapy. Setting 160 Sheffield knee OA patients awaiting TKR, randomly allocated to an intervention (home care) group (n=80) or a control (usual care) group (n=80). Intervention Individual home physiotherapy assessment and treatment; 3 sessions preoperatively, continuing for maximum 6 sessions postoperatively, supplemented by advice on self- directed exercise routines. Usual Care 8 to 10 knee classes postoperatively; average 10 patients with 2 physiotherapists and one assistant, individual treatments for up to 15 minutes and an exercise circuit in the outpatient gym, supplemented by advice on self-directed exercise routines. Outcome Measures (OCM) Western Ontario McMaster Osteoarthritis index (WOMAC) and Short Form 36 health survey (SF-36) questionnaires measured at trial entry and 12 weeks post TKR. Primary OCM; WOMAC pain dimension scores. A patient satisfaction questionnaire was used and NHS resource use also assessed. Results 116 participants completed follow up, well matched by group with a 98% questionnaire response rate. 45 (28.1%) participants withdrew, 24 (15%) due to TKR cancellation, 2 patients died. There was no significant difference in primary OCM post TKR between groups (p = 0.53) or in any other dimension of the WOMAC or SF- 36. Participants were equally satisfied with physiotherapy in both groups (86%). The home group had a significantly greater mean number of physiotherapy sessions (8.7 sessions vs 3.5 sessions, p=0.001). Home physiotherapy for TKR was significantly more expensive per patient than hospital outpatient physiotherapy (£197.9 vs £61.5, mean difference = -£136.5; p=0.001) The hospital group had additional transport costs, (mean £38.7). There was no significant difference in consumption of other NHS services or in total NHS costs per patient between groups; £5,376 (intervention group) vs £5,372 (control group). Conclusions This study demonstrated the effectiveness of home physiotherapy for TKR, but home care was more intensive and expensive than usual hospital care; additional preoperative home physiotherapy did not improve patient outcomes. The cancellation rate for TKR was high and supports the need for clearer selection criteria with greater consideration of co-morbidity and willingness to undergo surgery. Investigation of whether a less intensive individualised physiotherapy intervention at home would deliver expected patient group outcomes and individual rehabilitation goals is important if a more cost- effective home physiotherapy programme were to be provided for TKR patients.