As almost 42% of US knee replacement patients say they expect to be home same day, Jon Smith asks whether patient perceptions in the US are likely to become expectations in the UK.
We’ve spoken about same day knee replacement quite regularly on these pages. My colleague Dave Duffy reaffirmed the collective Yorkshire Knee Clinic stance on same day treatment a couple of months ago, namely that same day seems the inevitable (and entirely reasonable) direction of travel, particularly with regard to partial knee replacement. But until pathways, funding and resources are able to support pain management at home, a one night hospital stay is likely to remain the safest option, especially in most NHS trusts.
But that’s our perspective. Other knee surgeons take a different view and passionately believe in the value of same day knee replacement right now. But what do patients think?
We gained some insight when a study of US patients was published at the end of last year showing just how much traction the concept of same day knee replacement has gained with the medically savvy US public.
The research, published in the Journal of Arthroplasty, was of a fairly small sample (346 patients) following their partial knee replacement. It revealed that:
- 43% had heard of outpatient total knee replacement
- 72% thought outpatient treatment would lower costs
- 41.7% believed they would be home same day following their treatments
- Avoiding infection (57.3%), a better night’s sleep (46.9%) and a quieter recovery at home were seen as benefits of the same day process
- Pain (54.8), problems going to the bathroom (39.6%) and having a fall (39.8%) were the top disadvantages of same day as perceived by patients
Perhaps the first thing to say about these results is that the sample comprises only partial knee replacement patients. We perhaps shouldn’t be too surprised to see the idea of same day gaining traction within this group as they are already very much within the system. Wider awareness levels remain unclear.
Same day is easier to achieve in a private setting than in the NHS, but even in a private setting, same day presents pain management challenges that need resourcing. Pain is typically worse the day after an operation (once the anaesthetic has worn off). That’s why most of my private knee replacement patients will have their op on a Friday morning, get out of bed to mobilise in the afternoon, have a day of physio on Saturday and be home in time for tea. It’s a chance for us to ensure their pain is under control, a chance to control the environment for a day, and a way of reducing risk to an absolute minimum. I feel that’s worth a one night stay, and the results of the survey suggest that this attitude echoes the concerns of many patients.
But you can only do that with the right resources. In a private setting, there might be three physiotherapists to every ten patients. In an NHS setting that ratio may reduce to 1 in 12, so even a one night stay becomes a challenge, and 3 or 4 night stays are far more common, if hardly ideal.
The cost conundrum
The cost perception issue is an interesting one. It is, of course, a prime driver in the US healthcare system and – in theory – the faster you turnaround patients, the more money you could save an ailing NHS.
A hospital bed costs between £250 and £350 a night. Multiply that across every partial knee replacement patient and you could save the NHS a fortune by releasing patients home at the end of day one.
But it’s not that simple. In the UK, the Hospitals Readmission Reduction Program sees hospitals penalised where a patient is readmitted to hospital within 30 days. So if a home release results in a fall or pain the patient feels unable to manage (both perceived disadvantages of the same day system) they’ll be readmitted, and the hospital fined.
You need to have clear pathways in place for the home treatment of patients to guarantee safety and avoid the risk of cost penalties racking up.
Such things are entirely doable. But they need the financial clout, the available resource and the political will to make them happen. That’s relatively easy to achieve in a private setting, far less so in the NHS.
Perception vs reality
I’m not yet seeing a clamour for same day treatment. We still don’t have evidence of the clinical benefit of same day (although we do have evidence supporting a one or two night stay). At present, same day remains largely a marketing issue. Yet as examples hit the media with increasing regularity, that is likely to change. By the time it does, I imagine same day partial knee replacement will be a frequent event in private care. I only hope we’ll have found a way of overcoming the cost and resource limitations of the NHS to deliver similar results there.
And if you would like to explore your knee replacement options, please get in touch.
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