April 06, 2019 / Judith Graham, Kaiser Health News
Older adults and their families often wonder: Where’s the best place to recover after a hip or knee replacement—at home or in a rehabilitation facility?
Increasingly, the answer appears to be home if the procedure is elective, friends and family are available to help, and the patient doesn’t have serious conditions that could lead to complications.
This trend is likely to accelerate as evidence mounts that recuperating at home is a safe alternative and as hospitals alter medical practices in response to changing Medicare policies.
The newest data comes from a March study in JAMA Internal Medicine of 17 million Medicare hospitalizations from 2010 to 2016. All the patients were older adults and went home or to a skilled-nursing facility after a medical procedure or a serious illness. Knee and hip replacements were the most common reason for these hospitalizations.
People who were sent home with home health care services demonstrated the same level of functional improvement as those who went to a SNF, the study found. Assessments examined their ability to walk and get up and down stairs, among other activities. And they were no more likely to die 30 days after surgery (a very small percentage in each group). Overall, costs were significantly lower for patients who went home, while hospital readmissions were slightly higher—a possible signal that home health care services needed strengthening or that family caregivers needed better education and training.
“What this study tells us is it’s certainly safe to send people home under many circumstances,” said Dr. Vincent Mor, a professor of health services, policy and practice at Brown University’s School of Public Health who wrote an editorial accompanying the study.
The report expanded on previous research that came to a similar conclusion. In 2017, experts from New York City’s Hospital for Special Surgery published a study that examined 2,400 patients who underwent total knee replacements and were discharged at home or to a SNF for rehabilitation between May 2007 and February 2011. There were no differences in complication rates at six months or in functional recovery and patient-reported outcomes at two years.
“As a result of these findings, we are encouraging all of our patients to consider home discharge after TKA (total knee arthroplasty),” the authors wrote.
The year before, researchers at New York University reported in JAMA Internal Medicine that from 2009 to 2012 and 2013 to 2014, discharges to rehabilitation facilities fell from 68% to 34% for patients undergoing hip and knee replacements, from 71% to 22% for patients with cardiac valve replacement surgeries, and from 40% to 30% for patients who’d had spinal fusion surgery. Instead, more people were sent home to recover. During this period, NYU Langone Medical Center assumed financial responsibility for “episodes of care” for joint replacements that include the post-hospital recovery period—a policy that Medicare is now promoting.
Diane Rubin, 67, who lives on Long Island, had a hip replacement at the NYU medical center in January. Before the surgery, she got a list of things she’d need to do to prepare for her recovery; afterward, a nurse and physical therapist visited her at home regularly for about three weeks. “I was more comfortable recuperating at home and I’ve had absolutely no complications,” she said.
How do physicians decide where to send patients? “In general, we tend to send patients to skilled-nursing facilities who are older, sicker, more deconditioned after surgery, and who have no spouse or caregiver, fewer resources and little social support,” said Dr. Leora Horwitz, a co-author of that study and associate professor of population health and medicine at NYU School of Medicine.
