Journal of Rehabilitation Medicine 51-10 | Page 51

Joint replacement rehabilitation and role of funding source
between 2006 and 2013, accessed from the Ministry of
Health’s national minimal dataset. They reported that
approximately 65% of TJRs were publicly funded for
the period under study and that there was evidence of
ethnic, socioeconomic and geographical inequity. For
example, the authors reported that Māori and people
in the most socioeconomically deprived groups had
the highest rates of publicly funded TJR, possibly
suggesting higher rates of privately funded procedures
in other ethnic and socioeconomic groups. They also
reported that those living in main urban centres had
lower rates of publicly funded TJR. Again, the authors
speculated that rates of privately funded TJR may be
higher in larger urban centres. However, the use of
associated services, such as rehabilitation, was not
reviewed, and the authors did not have access to data
from the private sector. This study raises questions re-
garding differences in the use of services and outcomes
after TJR on the basis of funding source, and suggests
that there may be inequities, particularly in terms of
socioeconomic factors, ethnicity and geography.
Within New Zealand the majority of surgeons work in
both public and private areas. Private surgery is funded
by a “fee for service” arrangement with the funding
agency, such as private insurance or the government-
funded Accident Compensation Corporation (ACC),
commonly by a “fixed price contract” for the whole
procedure. Public hospitals either use salaried surgeons
to perform the procedure, or outsource the procedure
through a “fixed price contract”. Within the private area
the great majority of surgeons work independently, with
no ownership of the hospital facilities. Rehabilitation
services are accessed either through the public hospital
or independent private services, which are mostly owned
and administered by physiotherapists. Often access to a
private rehabilitation service is determined by whether
the patient has funding, either from medical insurance
or ACC.
Study objectives
The objectives of this study were to examine the as-
sociations between funding source (private vs public),
use of rehabilitation, and outcomes before and after hip
or knee replacement, and how these associations varied
with education, socioeconomic status, geography and
ethnicity.
METHODS
Study design and recruitment strategy
The role of rehabilitation study is a cross-sectional questionn-
aire-based study characterizing rehabilitation therapy received
771
before and during the first 6 months following primary total
hip or knee, or unicompartmental knee replacement in New
Zealand.
Participants were recruited from the New Zealand Joint
Registry (NZJR) in order to achieve a national sample with
geographical diversity. Because of the large numbers of regis-
tered primary hip and knee replacements, the NZJR obtains
patient-reported outcome information from randomly selected
patients across the country to achieve an annual response of
20% for each group (5). This was the sampling frame for the
role of rehabilitation study. Flyers for the study were included
in NZJR mail-outs between June 2015 and July 2016, and all
patients returning flyers with their contact information were
approached and invited to participate in the study.
The study received ethical approval from the University of
Otago Human Ethics Committee (ref H14/070).
Participant selection
Patients registered and followed by the NZJR after elective
primary hip or knee joint replacement in either private or
public systems in New Zealand were eligible to participate in
the study. The New Zealand health system is not dissimilar to
that of other countries in the British Commonwealth. Selection
criteria were broad and inclusive in order to capture patient va-
riation and facilitate generalizability of findings. Thus, patients
who met the following criteria were included in the study: (i)
age 45 years or older, (ii) underwent primary unilateral total
hip replacement (THR), total knee replacement (TKR), or
unicompartmental knee replacement (UKR) for osteoarthritis
6 months prior to recruitment, (iii) agreed to participate in the
study, and (iv) received either private or public funding for
surgery. Patients with any previous operation on the index joint,
those obtaining funding under New Zealand’s public accident
and injury insurance scheme (ACC), and those who self-funded
their surgeries, were excluded.
Data collection
Details were supplied monthly by the NZJR (name, preferred
contact information) for potential participants meeting the in-
clusion criteria who had agreed to being contacted by the study
team. Potential participants were then contacted by a research
assistant to discuss the study and invite participation.
Once recruited, role of rehabilitation participants completed
questions in booklet form regarding timing, type, intensity
and duration of any rehabilitation following referral for joint
replacement (pre- and post-operatively). Demographic and
clinical questions were also included (date of birth, ethnicity,
geographical location (region and population size), funder
(public funding vs private funding), medical history). A final
text box was available for any additional comments participants
wished to add. Questionnaires were available for completion
either online (e.g. Survey Monkey™) or by post, depending on
the participant’s preference.
Additional clinical information was collected from the NZJR.
This included pain and functional outcomes at 6 months post-
operation using Oxford scores (11, 12), procedure type, date
of surgery, body mass index, and an indication of comorbi-
dity burden at time of surgery using the American Society of
Anaesthesiologists (ASA) classification (13). Access to this
clinical information minimized participant burden by avoiding
duplication of data collection from participants.
J Rehabil Med 51, 2019