Elsevier

Physiotherapy

Volume 106, March 2020, Pages 1-11
Physiotherapy

Demographic and geographical variability in physiotherapy provision following hip and knee replacement. An analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

https://doi.org/10.1016/j.physio.2019.11.003Get rights and content

Abstract

Background

Total hip (THR) and knee replacement (TKR) are two of the most common elective orthopaedic procedures worldwide. Physiotherapy is core to the recovery of people following joint replacement. However, there remains uncertainty as to physiotherapy provision at a national level.

Objectives

To examine the relationship between patient impairment and geographical variation on the provision of physiotherapy among patients who undergo primary total hip or knee replacement (THR/TKR).

Design

Population-based observational cohort study.

Methods

Patients undergoing THR (n = 17,338) or TKR (n = 20,260) recorded in the National Joint Registry for England (NJR) between 2009 and 2010 and completed Patient Reported Outcome Measures (PROMs) questionnaires at Baseline and 12 months postoperatively. Data were analysed on the frequency of physiotherapy over the first postoperative year across England’s Strategic Health Authorities (SHAs). Logistic regression analyses examined the relationship between a range of patient and geographical characteristics and physiotherapy provision.

Results

Following THR, patients were less likely to receive physiotherapy than following TKR patients (‘some’ treatment by a physiotherapist within 1st post operative year: 53% vs 79%). People with worse functional outcomes 12 months postoperatively, received more physiotherapy after THR and TKR. There was substantial variation in provision of physiotherapy according to age (younger people received more physiotherapy), gender (females received more physiotherapy) ethnicity (non-whites received more physiotherapy) and geographical location (40% of patients from South West received some physiotherapy compared to 40 73% in London after THR).

Conclusions

There is substantial variation in the provision of physiotherapy nationally. This variation is not explained by differences in the patient’s clinical presentation.

Introduction

Total hip (THR) and knee replacement (TKR) are two of the most common elective surgical procedures performed worldwide [1], [2]. There were over 200,000 THR and TKR procedures carried out in England and Wales in 2017 [3]. Currently, the UK National Institute for Health and Care Excellence (NICE) recommend that THR and TKR should be offered to patients with end-stage hip or knee osteoarthritis [4]. Both procedures are successful interventions for reducing pain and increasing function [5], [6].

Physiotherapy, principally exercise prescription and gait re-education, is advocated for people after THR and TKR [7], [8]. Previous trials have demonstrated the effectiveness of physiotherapy for both groups of patients [9], [10], [11]. Westby et al. [12] recommended that patients should be provided with a minimum of six weeks physiotherapy after THR and TKR, both for those whose recovery is uneventful and for those with immediately poor outcomes following surgery. Whilst these international recommendations are clear, there remains uncertainty as to what postoperative physiotherapy provision is within healthcare services in the United Kingdom (UK). There is substantial variability in the delivery and content of physiotherapy post joint replacement [13]. This is currently being viewed by clinical commissioners in the UK who seek evidence to support or refute physiotherapy care-pathways for people following joint replacement [14].

No data have been previously reported on the provision of physiotherapy at a national level in the NHS for individuals following THR or TKR. We present the first analysis of the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man (NJR) data to determine: (objective 1) what the current level of physiotherapy provision is across England following primary THR and TKR; and (objective 2) what factors are associated with whether patients receive physiotherapy following THR or TKR.

Section snippets

Patients and methods

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed in the reporting of this comparative prospective cohort study [15].

Characteristics of the population

17,338 people following THR and 20,260 people following TKR were included in the analyses (supplementary Fig. 1). The characteristics of the cohort are presented in Table 1, Table 2.

In total, 4111 people following THR and 4537 people following TKR from the NJR longitudinal PROMs dataset were not included in the analysis due to missing data (supplementary Table 1).

Primary objective: provision of physiotherapy

Across all regions in England, physiotherapy provision was greater following TKR compared to THR (Fig. 1). Within the first

Discussion

This is the first nationwide study to report the provision of physiotherapy in England to people following primary THR and TKR. This has highlighted a difference in physiotherapy provision following THR and TKR, with variation attributed to geographic and patient characteristics. This variation is not explained by the degree of disability experienced. Health care inequality is a major challenge in primary and secondary care [23]. The variation reported in this analysis is of concern, and

Acknowledgements

We thank the patients and staff of all the hospitals in England, Wales and Northern Ireland who have contributed data to the National Joint Registry. We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Research Committee and staff at the NJR Centre for facilitating this work. The authors have conformed to the NJR’s standard protocol for data access and publication. The views expressed represent those of the authors and do not necessarily reflect those of the

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