Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT.

BACKGROUND: Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. OBJECTIVES: To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. DESIGN: An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. SETTING: The trial took place in 14 NHS physiotherapy departments. PARTICIPANTS: People identified as being at high risk of a poor outcome after knee arthroplasty. INTERVENTIONS: A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. MAIN OUTCOME MEASURES: The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. RESULTS: In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. LIMITATIONS: The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. CONCLUSIONS: This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13517704. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Knee replacement is a common treatment for knee osteoarthritis. Most people do well after surgery; however, a small group of people do not report a good outcome. One way we could try to improve this is by considering the way that rehabilitation is offered after surgery. We identified people thought to be at risk of a poor outcome after knee replacement. We compared a newly designed rehabilitation programme that was undertaken in people's own homes with physiotherapy as it is currently offered. This new programme was delivered by rehabilitation assistants under the guidance of qualified therapists. We assessed these treatments by measuring three functional tests: walking in a figure of eight, sitting and standing from a chair in 30 seconds and standing on one leg. In addition, we asked people to complete questionnaires about their knee, what activities they could perform, how physically active they were and their quality of life. We also recorded the use of health-care services, time off work and any informal care that people received. The results showed that both groups had improved by a similar amount at 6 months and 12 months after surgery. The new rehabilitation programme that was designed for the study was cheaper to deliver than standard physiotherapy, when all costs were considered. We think that future research should look at developing better tools to predict who might be at risk of not doing well after surgery, and to determine the ideal make-up of the rehabilitation team that delivers treatment after knee replacement.

Building nurse education capacity in India: insights from a faculty development programme in Andhra Pradesh.

BACKGROUND: India faces an acute shortage of nurses. Strategies to tackle the human resource crisis depend upon scaling up nursing education provision in a context where the social status and working conditions of nurses are highly variable. Several national and regional situation assessments have revealed significant concerns about educational governance, institutional and educator capacity, quality and standards. Improving educational capacity through nursing faculty development has been proposed as one of several strategies to address a complex health human resource situation. This paper describes and critically reflects upon the experience of one such faculty development programme in the state of Andhra Pradesh. DISCUSSION: The faculty development programme involved a 2 year partnership between a UK university and 7 universities in Andhra Pradesh. It adopted a participatory approach and covered training and support in 4 areas: teaching, research/scholarship, leadership/management and clinical education. Senior hospital nurses were also invited to participate. SUMMARY: The programme was evaluated positively and some changes to educational practice were reported. However, several obstacles to wider change were identified. At the programme level, there was a need for more intensive individual and institutional mentorship as well as involvement of Indian Centres of Excellence in Nursing to provide local (as well as international) expertise. At the organisational level, the participating Colleges reported heavy workloads, lack of control over working conditions, lack of control over the curriculum and poor infra-structure/resources as ongoing challenges. In the absence of wider educational reform in nursing and government commitment to the profession, faculty development programmes alone will have limited impact.

Putting post-registration nursing students on-line: important lessons learned.

A web site and discussion forum to support a part time degree course for nurses was introduced not only to support student learning but also to encourage students to use and develop their IT skills. Previous cohorts had identified that health informatics skills needed to be addressed more explicitly throughout the programme. The aims of the project were to: (i) evaluate the use of the web site and discussion forum; (ii) determine the barriers to using the web site and discussion forum; (iii) identify ways of overcoming any barriers. The first aim was addressed by analysing web page hits and contributions to the discussion forum. Students' experiences of using the web site and the discussion forum were collected using a questionnaire and followed up by a focus group made up of high and low users of the discussion forum. Students who had accessed the web site most often felt they had been able to communicate with their peers (Spearman's rho, p < 0.01) and had gained peer support by accessing the web site (Spearman's rho, p > 0.05). None of the participants in this study had used a discussion forum before and whilst some students had the skills and confidence to contribute to the on-line discussions, others 'lurked' and some did not access the discussion facility at all. Strategies for improving the engagement and quality of on-line learning are proposed from the lessons learned during this study.