Doctors raise concerns about MJA article

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Doctors have raised concerns about a recent article in the Medical Journal of Australia (MJA) that suggests location of knee-replacement surgery is a key indicator of where patients will be rehabilitated – either at home or in hospital.

The article, written by a researcher funded by Medibank and based on Medibank data, reports the in-patient rehabilitation rate increased from 31 percent of total knee replacement patients in 2009, to 45 percent in 2016.

They wrote that a reduction in the mean acute length of stay explained about 15 percent of the increase and about 30 percent of the increase was explained by patient-related factors. But more than half the increase was driven by neither patient-related factors nor reduced hospital stays.

The researchers said variations between hospitals suggested some in-patient rehabilitation was low value care and “could be substantially reduced to improve health care effectively without any detriment to health outcomes”.

The Australian Orthopaedic Association (AOA) said the article was simply not wide-ranging enough.

“Rehabilitation is an extremely personal and individual experience where the success, speed and length of time can be influenced by several factors including age, functional limitations, pre-existing injuries and trauma, associated co-morbidities, and whether the patient has adequate support at home,” AOA president, Dr Lawrence Malisano, said.

“The problem with recent research and analysis is that total knee replacement rehabilitation is hampered by a lack of clear, evidence-based clinical guidelines with respect to overall best practice for post-surgical rehabilitation. What we have now is that some hospitals are having more success at inpatient recovery while others are seeing more benefit using outpatient recovery programs.”

Dr Malisano also questioned the MJA’s decision to publish the article.

“In its editorial guidelines, the MJA gives low priority to research from a single institution or research that has a small sample size,” he said.

“The fact that it chooses to publish an article that only quotes from a single publicly-listed institution and that is written by consultants paid by that very same institution is concerning.

“As a profession, there is a lot of merit in developing clinical guidelines around knee rehabilitation; however, greater rigour around research, transparency and data needs to be developed to ensure effectiveness,” Dr Malisano said.

The President of the Rehabilitation Medicine Society of Australia and New Zealand, Dr Lee Laycock, said he had a number of concerns with the study, including misrepresentation of some of the literature which is not generalisable to privately insured Australian patients.

“The authors claim that the most important determinant for referral to inpatient rehabilitation ‘was the hospital where the TKR took place’. Independent researchers might be more circumspect. Considering there is no acknowledgement that Medibank Private did not fund rehabilitation in the home nationally during the study period nor whether their data included outpatient rehabilitation carried out as ‘same day rehabilitation’, usually coded as ‘inpatient’.

“With the ageing of the population and the increasing baseline disability and medical complexity of people receiving knee replacement surgery, the need for inpatient rehabilitation is to be expected to increase over the coming decades.

“Perhaps it’s a mere coincidence that Medibank has recently released a low-cost rehabilitation in the home insurance product,” Dr Laycock said.

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