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European Journal of Physical and Rehabilitation Medicine 2015 December;51(6):803-13


language: English

Clinical outcome and cost effectiveness of inpatient rehabilitation after total hip and knee arthroplasty. A multi-centre cohort benchmarking study between nine rehabilitation departments in Rhineland-Palatinate (Western Germany)

Baulig C. 1, 2, Grams M. 1, Röhrig B. 2, Linck-Eleftheriadis S. 2, Krummenauer F. 1

1 Institute of Medical Biometry and Epidemiology, Faculty of Health, Witten/Herdecke University, Witten, Germany; 2 Medical Service of the Health Care Insurance Rhineland‑Palatinate (MDK Rheinland‑Pfalz), Alzey, Germany

BACKGROUND: Rehabilitation after hip and knee replacement surgery is effective, but cost intensive. To ensure consistent cost-effectiveness across different providers prospective cohort studies on its clinical and economic outcome are recommended. Comparisons alongside suitable outcome quality indicators enable to contrast different providers and — in case of clinically or economically relevant differences — reveal constructive approaches to quality improvement.
AIM: Therefore an external benchmarking for posthospital curative treatment after hip and knee arthroplasty between nine inpatient rehabilitation departments in the German Federal Land Rhineland-Palatinate was implemented based on data acquired between 01/2007 and 12/2009.
DESIGN: Multi-centre retrospective cohort benchmarking study.
SETTING: Inpatient rehabilitation in nine rehabilitation departments
POPULATION: A total of 8672 patients after unilateral hip arthroplasty (THA) and 8180 patients after unilateral knee replacement (TKA) surgery were investigated. The median age of the patients after hip arthroplasty varied between 71 and 75 years, after knee arthroplasty between 72 and 75 years. The department-wise proportions of female patients ranged from 62% to 77% (THA) and from 70% to 81% (TKA).
METHODS: Data on clinical outcome of inpatient rehabilitation after THA and TKA were documented using the EVAReha® software. As primary indicator of clinical outcome quality the intra-individual pre-post change in the total Staffelstein Index was determined [%], as primary economic indicator the cost-normalized effect estimate (CNEE) was estimated [%/€] relating the individual Staffelstein Index change to a patient’s respective direct costs [€] paid by the statutory health insurance.
RESULTS: In the nine departments the median Staffelstein index increase after THA ranged between 18% to 31% corresponding to median CNEEs ranging from 9% to 15% Staffelstein increase per €1000 investment of the statutory health (Kruskal/Wallis P<0.001). After TKA the median Staffelstein index increase ranged between 19% to 34% corresponding to median CNEEs ranging from 9% to 16% Staffelstein increase per 1,000 € investment of the statutory health (Kruskal / Wallis P<0.001).
CONCLUSION: Inpatient follow-up treatment after hip and after knee replacement surgery demonstrated a statistically significant and both clinically and economically relevant heterogeneity between the departments. Additional exploratory analyses by means of adjustment with further predictors could not resolve these heterogeneities.
CLINICAL REHABILITATION IMPACT: Benchmark information on cost effectiveness would enable departments to learn from the “best” and to implement corresponding peer cooperation, to then identify own shortcomings and potentials, and thereby to analyze and optimize local processes.

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