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Greater Newcastle Acute Hospital Network– Physiotherapy

National Allied Health Benchmarking Consortium- Health Round Table

October 2009

Total Knee Replacement

Patient Population and Physiotherapy Management Review

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BACKGROUND

• 376 TKR patients were seen by RNC Physiotherapy as an outpatient during 2006/2007

• Number of TKR procedures in Australia has increased by 152.3% over past 12 years

33,737 performed in Australia in 2005/6 FY

• Public hospital growth rate far greater than private (14.5% vs 1.6%)

• Increasing demands upon public hospital Physiotherapy services• Evidence base for PT management of TKR is quite limited (Naylor et al 2006)

• No clinical guidelines exist for post-operative Physiotherapy• Considerable variation in Physiotherapy practice (Roos 2003)

Australian Orthopaedic Association National Joint Replacement Registry, 2007

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AIMS• To review the TKR patient population receiving

physiotherapy services at the RNC

• To review current outcome measure utilisation throughout the clinical pathway

• To review current physiotherapy management strategies and resource consumption

• To analyse clinical outcomes

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METHODOLGY• Cross-Sectional Retrospective Analysis

• TKR patients identified via PiMS and AHMIS

• Random sample of 50 records Received pre-operative, in-patient and out-patient

physiotherapy services at the RNC for primary TKR

No post-operative complication

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POPULATION CHARACTERISTICS• The RNC TKR population is similar to other reported TKR

populations in regards to age, gender and reason for arthroplasty

• Perhaps interestingly, the mean BMI in our data was found to be higher than all other reported TKR populations (by around 4 points)

• Previous research has identified that patient’s with higher BMI’s typically obtain poorer ROM (Anouchi et al 1996, Lizaur et al 1997)

• There is strong evidence that the primary patient factor influencing post-operative range of motion is pre-operative range of motion (Dennis et al 2007, Lizaur et al 1997, Parsley et al 1992, Ritter et al 2003)

• Considerable variance in the pre-operative flexion range of movement has been reported in the literature

• However the pre-operative flexion ROM in patients at the RNC approximates the central tendency of these reported figures (104.2°)

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RESOURCE CONSUMPTION• Standard practice at the RNC involves all patients attending a pre-

operative individual consultation with a physiotherapist 50% of Hospitals in Sydney South West Area Health Service provide a

similar pre-operative service

• Mean in-patient LOS was 7.46 days (95%CI 6.82 to 8.1 days)

• The last outpatient appointment was a mean of 6.86 weeks (95%CI 5.87

to7.85) from the date of surgery

• Comparable to the previously published figures for TKR patients in other Australian hospitals (Naylor et al 2006)

• A low correlation was discovered between age and duration of physiotherapy management, with younger patients attending for greater durations (r = -0.36, 95%CI –0.58 to –0.09)

• Age, Sex and BMI had no influence on any other measures of resource consumption.

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USE OF OUTCOME ASSESSMENT

Use of Outcome Assessment

0%

20%

40%

60%

80%

100%

Pre-Op Day 4 D/C (Day7.5)

OneMonth

Last OPappt

(week6.9)

Flex ROM

Ext ROM

Mob Aid

Mob Tolerance

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OUTCOME ASSESSMENT & PT MANAGEMENT • A review of literature and analysis of the data

identified an opportunity to include further outcome assessment measures Patient Perceived Function

» Eg. Lower Extremity Functional Scale

Measures of Patient-Important Function

» Eg. Timed Up and Go

Patient Satisfaction with Care/Outcome

• The nature and frequency of the interventions used at the RNC appear consistent with those reported in other sites within Australia (Naylor et al 2006, Sydney South West Area Health Service)

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PHYSIOTHERAPY MANAGEMENT

In-Patient Management

0%

20%

40%

60%

80%

100%

Mob

Pra

ctice

ROM E

x

Streng

th E

xHEP

Educa

tion

Gait R

etra

inin

gCPM Ice

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PHYSIOTHERAPY MANAGEMENT

Out-Patient Management

0%

20%

40%60%

80%

100%

HEP

Educa

tion

ROM

Ex

Streng

th E

x

Gait

Ret

raini

ng

Mob

Pra

ctice

Scar M

x

Man

ual T

hera

py Ice

Oed

ema

Mx

Heat

Ex Bike

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KNEE ROM OUTCOMES • KNEE FLEXION

A small correlation existed between pre-operative flexion ROM and final flexion ROM at the last OP appt (r=0.34)

For each 4 increase in pre-operative flexion, the predicted flexion range at the final physiotherapy appointment increases by 1

Final flexion ROM had no relationship to the number of physiotherapy OOS (r=0.1)

Those with poorer flexion ROM at their last appointment tended to have poorer extension ROM (r=0.29)

• KNEE EXTENSION No influence by age, sex or prosthesis type Interestingly, a small positive correlation was identified between BMI and pre-

operative extension ROM (r=0.37) for every increase in BMI by 5 points, the predicted pre-operative extension

improves by 2 No influence by mobility tolerance or mobility aid utilisation No relationship with the number of physiotherapy OOS

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KNEE ROM OUTCOMES• KNEE FLEXION

Paired t-test statistical analysis identified the differences in flexion range of movement scores between all of the five time periods to be significantly different (p < 0.05)

Mean Flexion ROM

0

20

40

60

80

100

120

Pre-Op Day 4 D/C (Day 7.5) One Month Last OP appt(week 6.9)

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KNEE ROM OUTCOMES• KNEE FLEXION

No influence by age, sex or BMI at any time point

No influence by prosthesis type at any time point

Flexion ROM by Prosthesis Type

020406080

100120

Pre-Op Day 4 D/C (Day7.5)

OneMonth

Last OPappt

(week6.9)

Genesis

Vanguard

PFC

LCS

NexGen

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KNEE ROM OUTCOMES• KNEE EXTENSION

No significant difference between extension ROM pre-operatively and at the final appointment (difference = 1, p=0.42)

Mean Extension Deficit ROM

02468

10121416

Pre-Op Day 4 D/C (Day 7.5) One Month Last OP appt(w eek 6.9)

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MOBILITY AID UTILISATION OUTCOMES

Mobility Aid Usage Through Clinical Pathway

0%

20%40%

60%80%

100%

Pre-Op Day 4 D/C (Day7.5)

OneMonth

Last OPappt

(week6.9)

Unaided

W/Stick

2 x W/Stick

Crutches

Frame

FASF

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Key Findings & Opportunities• Fairly consistent with other populations reported in the literature

Would seem reasonable to make comparisons Our sample had a higher BMI than other reported populations

• Similar Physiotherapy resource consumption and management strategies to comparable services

• Similar physical outcome measures to previously published reports

• Outcome Assessment Consistency throughout the clinical pathway Patient Perceived Functional Status Patient-Important Function Patient Satisfaction with Care/Outcome

• Investigation of opportunities for benchmarking

• Collaborative research initiatives

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Project Team• Judith Henderson

Area Professional Director, Physiotherapy

• Damien Smith Team Leader, Royal Newcastle Centre

• Chris Barnett Team Leader, Outpatient Physiotherapy, Royal Newcastle Centre

• Kieren Brown Team Leader, Inpatient Physiotherapy, Royal Newcastle Centre

• Veronica Parraga Physiotherapist, Royal Newcastle Centre

• Robin Haskins Physiotherapist, Royal Newcastle Centre

• Tim Lee Physiotherapist, Royal Newcastle Centre