Kristian Larsen

Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty.

BACKGROUND Accelerated perioperative rehabilitation protocols following total hip and knee arthroplasties are currently being implemented worldwide, but the cost-effectiveness of these protocols from a societal perspective is not known. We compared the cost-effectiveness of an accelerated perioperative care and rehabilitation protocol with that of a more standard protocol for patients treated with total hip and knee arthroplasty. METHODS A cost-effectiveness study was undertaken as a study piggybacked on a randomized clinical trial comparing early outcomes of an accelerated and intensive postoperative rehabilitation regimen with those of a more standard rehabilitation protocol. We assessed eighty-seven patients (forty-two who received the standard protocol and forty-five who received the accelerated protocol) for a total of twelve months. Costs from the time of the patients visit immediately before the operation to one year postoperatively were calculated with use of activity-based costing analysis. Postoperative quality-adjusted life-years (QALYs) were calculated from validated patient diaries and questionnaires at fifteen time points. The primary objective was to determine whether one intervention was dominant over the other during a twelve-month period or, if neither was dominant, to determine the incremental cost-effectiveness ratio. RESULTS The result of the randomized clinical trial showed the accelerated intervention to be effective, with a reduction in the length of the hospital stay and a gain in health-related quality of life at the three-month follow-up time point. The cost-effectiveness study showed the accelerated protocol to be significantly less expensive than the standard protocol (p=0.036), with an average reduction in cost of 18,880 Danish kroner (95% confidence interval, 1899 to 38,152) (approximately US

Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: A randomized clinical trial involving 87 patients with 3 months of follow-up

4000). Patients treated with the accelerated protocol following hip arthroplasty had an additional average gain of 0.08 QALY (95% confidence interval, 0.02 to 0.15) compared with the patients who received the standard protocol (p=0.006); this led to a 98% dominance of the accelerated protocol over the standard protocol. No significant or clinically relevant difference in the numbers of QALYs associated with the two protocols was observed for the patients treated with knee arthroplasty. CONCLUSIONS An accelerated perioperative care and rehabilitation protocol can be both cost-saving and clinically more effective after total hip arthroplasty, whereas it can be cost-saving with no observed significant difference in effect, from a societal perspective, after knee arthroplasty.

Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up

Background Approximately 12,000 hip and knee replacements were performed in Denmark in 2005. Accelerated perioperative interventions are currently implemented, but there is conflicting evidence regarding the effect. We therefore performed an efficacy study of an accelerated perioperative care and rehabilitation intervention in patients receiving primary total hip replacement, and both total and unicompartmental knee replacement. Methods A randomized clinical trial was undertaken in which 87 patients were randomized to either a control group receiving the current perioperative procedure, or an intervention group receiving a new accelerated perioperative care and rehabilitation procedure. Outcome measures were length of stay (LOS) in hospital, and gain in quality of life (QOL) using EQ-5D from baseline to 3-month follow-up. Results Mean LOS was reduced (p < 0.001) from 8 days (95% CI: 7.1–8.4) in the control group to 5 days (95% CI: 4.2–5.6) in the intervention group. This was accompanied by a greater gain in QOL of 0.08 (95% CI: 0.004–0.16) in the intervention group (p = 0.03). Interpretation An accelerated perioperative care and rehabilitation intervention in patients undergoing primary total hip replacement, and total or unicompartmental knee replacement is indeed effective—and of advantage to both the hospital and the patient.

Interprofessional undergraduate clinical learning: Results from a three year project in a Danish Interprofessional Training Unit

BackgroundIn Denmark, approximately 12,000 hip and knee arthroplasties were performed in 2006, and the hospital costs were close to US

The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial.

110,000,000. In a randomized clinical trial, we have recently demonstrated the efficacy of accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty compared to current intervention under ideal circumstances. We do not, however, know whether these results could be reached under usual circumstances of healthcare practice. We therefore investigated whether length of stay after implementation of accelerated perioperative care and rehabilitation after hip and knee arthroplasty could be reduced in a normal healthcare setting, and how the achieved results matched those observed during the randomized clinical trial.MethodsAn effectiveness study as a before-after trial was undertaken in which all elective primary total hip and total knee arthroplasty patients were divided into a before-implementation group receiving the current perioperative procedure, and an after-implementation group receiving the new accelerated perioperative care and rehabilitation procedures as provided by a new multi-disciplinary organization. We used the Breakthrough Series Collaborative Model for implementation. The primary outcome measure was in hospital length of stay (LOS), and the secondary outcome measure was adverse effects within 3 months postoperatively.ResultsWe included a total of 247 patients. Mean LOS was significantly (P < 0.001) reduced by 4.4 (95% CI 3.8–5.0) days after implementation of the accelerated intervention, from 8.8 (SD 3.0) days before implementation to 4.3 (SD 1.8) days after implementation. No significant differences in adverse effects were observed. LOS in this effectiveness study was significantly lower than LOS reported in the efficacy study.ConclusionAccelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty was successfully and effectively implemented. Results obtained during usual hospital circumstances matched the results achieved under ideal circumstances in this group of patients.

One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors.

On entering higher education students become professionally socialized, and parallel with this, stereotyping takes place, students developing a more positive assessment of their own roles than those of other professions. This difference between the view of their own and other professions can contribute to creating cognitive and social boundaries between professions that hinder sharing of knowledge, which can result in poor cooperation. Interprofessional training can provide students with good clinical expertise in their own profession as well as teach them about other professions encouraging more positive attitudes between the professions. This project has taken place from 2004 to 2007 in a Danish Interprofessional Training Unit manned with students from the professions occupational therapy, physiotherapy, medicine and nursing. As part of an evaluation of the project, four focus group interviews and two in-depth interviews were analysed using the technique of Systematic Text Condensation. Results show that the goals of the Interprofessional Training Unit were fulfilled because the students learned interprofessional teamwork, strengthened their own professional role and worked together in an organization for the benefit of the patient. All this took place in a secure learning environment in which new methods of coordinating and integrating clinical and theoretical interprofessional learning were developed and tested.

Difficulties in avoiding exposure to allergens in cosmetics

Study Design. Randomized controlled trial. Objective. To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice. Summary of Background Data. Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care. Methods. A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization. Results. Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences. Conclusion. In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.

Cost-effectiveness of MRI in managing suspected scaphoid fractures

Study Design. A randomized controlled trial with multivariable analyses of prognostic factors. Objective. To report the long-term outcome of McKenzie treatment compared with strengthening training. Further, to determine patient-related factors associated with poor outcome 14 months after completion of treatment. Summary of Background Data. Exercise therapy is widely recommended for patients with chronic low back pain. However, reports vary considerably concerning characteristics of patients who will not respond to treatment. Knowledge of factors associated with poor outcome may assist identification of patients requiring special attention. Methods. A total of 260 patients with chronic low back pain were included in a previously reported randomized controlled trial of McKenzie therapy versus strengthening training. Outcome variables were: functional status, pain level, work status, and use of healthcare services during follow-up. Also, factors associated with withdrawal during the intervention were sought identified. The following factors of possible prognostic significance were determined: levels of pain and disability, pain-distribution, duration of symptoms, smoking habits, leisure activities, workload, job satisfaction, treatment preference, outcome expectations, treatment modality received, compliance with home exercises during follow-up, and demographic variables such as age, gender, work status, and application for pension. Association between variables was examined by multiple logistic regression analysis and odds ratios. Results. No differences in outcomes were found between the treatment groups at 14 months of follow-up. Low level of pain intensity and disability, sick leave at entry, low pretreatment expectations of future work ability, withdrawal during treatment, and discontinuance of exercises after the end of the treatment period were associated with poor outcome. Conclusion. Poor long-term outcome of exercise therapy for chronic low back pain can be explained by a number of patient-related factors. Different prognostic factors were associated with different outcomes. These factors were more important in determining outcome than the exercise-programs studied.

The final follow-up plain radiograph is sufficient for clinical evaluation of polyethylene wear in total hip arthroplasty: A study of validity and reliability

The aim of the study is to describe the ability of patients with allergic contact dermatitis to avoid exposure to allergens in cosmetics. The study is a questionnaire survey among 382 patients with contact allergy to preservatives and fragrances, included from 3 dermatological clinics. The questionnaire included questions about the level of difficulty in reading labels of ingredients on cosmetics and about patients’ strategies to avoid substances they were allergic to. It also included questions about eczema severity as well as about educational level. 46% of the patients found it difficult or extremely difficult to read the ingredient labelling of cosmetics, and this finding was significantly related to low educational level. Patients allergic to formaldehyde and methyldibromo glutaronitrile experienced the worst difficulties, while patients with fragrance allergy found ingredient label reading easier than patients with preservative allergy. Reading of ingredient labels is a major problem for patients with contact allergy to allergens in consumer products. It is a general problem for all patients and not restricted to a small group with multiple allergies.

Hip arthroplasty patients benefit from accelerated perioperative care and rehabilitation A quasi-experimental study of 98 patients

In a cost-effectiveness study, we compared a treatment algorithm using repeated radiological examination with an algorithm using subacute MRI in patients with clinical signs of scaphoid fracture but normal initial radiography. Twenty-seven patients were included in both groups, and MRI reduced the immobilisation time from 20 days (range, 6–54) to 4 days (range, 1–19) and sick leave from 27 days (1–92) to 11 days (0–28). Use of MRI increased hospital costs by €151 (P<0.05), but reduced non-hospital costs by €2869 (P<0.05), making MRI cost-effective in the treatment of suspected scaphoid fractures.