Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

To the Editor: In their recent article and media release, Schilling and colleagues1 concluded that after total knee replacement (TKR) “some inpatient rehabilitation is low value care”. The research was funded by Medibank Private.

The article comes at a time of increasing interest in rehabilitation in the home (RITH) for TKR and other rehabilitation problems. Despite widely proclaimed opinions, there is limited high level evidence regarding outcomes for inpatient rehabilitation versus ambulatory rehabilitation. In research examining the benefits of RITH, higher complexity patients are often excluded from the studies.2 One of the limitations of this article is that important “patient‐related factors … including obesity, pre‐operative physical and mental health … functional performance” and others, “were not available”.

A significant gap in the current debate is an almost total absence of nuanced thinking regarding which patients are clinically indicated and safe to have RITH. The authors’ conclusion is only a relatively minor aspect of the real problem, which is to ensure the best outcome for the patient. That is, we must confidently identify the right rehabilitation program, at the right time and in the right place.

The Australasian Faculty of Rehabilitation Medicine3 is committed to ensuring high quality rehabilitation medicine services. We believe that:

• while many patients with uncomplicated TKR may be appropriate for RITH, there are many others for whom RITH is inappropriate or unsafe;
• the appropriate setting for TKR rehabilitation should be determined on evidence‐based clinical indicators and minimum safety standards;4
• all patients with TKR (apart from the most uncomplicated cases) require referral to and assessment by or on behalf of a rehabilitation medicine physician (or other appropriately trained physician); and
• some ambulatory rehabilitation programs may be appropriate for TKR and other rehabilitation, but they must be evidence‐based, interdisciplinary, led by a rehabilitation medicine physician and adequately resourced, and not simply seen as a cheaper panacea for a struggling system.

To achieve the best outcome for patients, decisions must be individualised and patient‐centred and they should start with a referral to a rehabilitation medicine physician, who can determine the right rehabilitation program, at the right time and in the right place.

There are circumstances in which RITH is an alternative to inpatient rehabilitation for appropriately selected patients.4

Let's ensure, however, that we do not throw the baby out with the bathwater.