Journal of Rehabilitation Medicine 51-10 | Page 56

776
D. L. Snell et al.
function and quality of life, compared with their pu-
blicly funded counterparts. No significant differences
in terms of geography and funding source were iden-
tified, although those with private funding undergoing
TKR seemed more likely to live in an urban area. It was
not possible to examine impacts of funding source and
outcomes by ethnicity because of the small numbers of
non-European participants in the study sample.
The findings of this study may reflect policy dif-
ferences between public and private funding systems
for elective surgeries. While less use of pre-surgical
rehabilitation may simply reflect faster progression to
surgery from assessment by the surgeon for privately
funded participants, the findings that privately funded
participants accessed rehabilitation for longer after
surgery is interesting. This might reflect policy and
systemic differences based on resourcing. Pressures in
the public system may mean that rehabilitation goals
and length of stay in rehabilitation are resource-driven
rather than person-driven. Anecdotally, publicly funded
physiotherapy interventions tend to focus on short-
term functional outcomes, such as reduced reliance
on walking aids. Private physiotherapy, on the other
hand, may have the flexibility to set more individuali-
zed activity and participation goals, including return
to exercise, sport and employment. Some of the free-
text comments that participants added to their ques-
tionnaires reflect these differences and also express
dissatisfaction with rehabilitation available through
the public system. For example, one participant who
was funded in the public system wrote:
“The initial 12 sessions doing exercises at the hospital gym
were fine, but only get you through those 5 weeks or so. It
takes months to build up your muscles after a hip replacement.
My thigh muscles had disappeared. If all I wanted was to be
able to walk to the letter box and make the bed, fine, but I
wanted to do weekend tramps, walk to work, cycle, sail, etc.”
Another participant expressed feelings of aban-
donment and anxiety linked to limited rehabilitation
support in the public system:
“The initial rehab did help, but now I’ve just got to keep
doing the exercises and have had no back up from physio to
see my progress … Sometimes I feel I’ve been abandoned and
left to get on with it by myself.”
A key focus of the present study was to examine
whether surgical funding source made a difference in
terms of outcomes and use of rehabilitation. All parti-
cipants, on average, reported good clinical outcomes
in terms of reduced pain and improved function and
quality of life. Privately funded patients had better
6-month outcomes in terms of pain, function, and
quality of life, which were statistically significant,
but perhaps not clinically relevant. There was a diffe-
rence of only 2 points on the Oxford and WHOQOL-8
questionnaires, respectively (16). Moreover, in the
www.medicaljournals.se/jrm
absence of pre-surgical data, it is difficult to determine
if these findings truly reflect better outcomes for the
privately funded group. Privately funded participants
were younger, had fewer comorbidities, and spent
less time waiting for their surgery. It is possible that
privately funded participants had less pain, higher
function and quality of life before their surgery than
did publicly funded participants. Without being able to
evaluate change before and after surgery, it is difficult
to determine if funding source was indeed associated
with outcomes in this study or whether other factors,
such as wait time for surgery, better explain outcomes.
Future research is needed to consider the effects of a
patient’s pre-surgical status.
While outcomes on the basis of funding source were
difficult to evaluate directly, variables known to impact
outcomes did appear to be associated with funding
source. For example, privately funded participants
reported spending less time on the surgical waiting
list and had faster access to surgical intervention. We
have shown previously that wait list times contribute
to outcomes following THR and TKR (Snell, D. Per-
sonal communication, Sep 12, 2019). There is also
growing evidence supporting the effects of psycholo-
gical factors on joint replacement outcomes, such as
illness beliefs and expectations, locus of control and
self-efficacy. Accessing surgery without a long wait
and having economic resources to do so may enhance
self-efficacy, satisfaction with joint replacement and
outcomes (17, 18). For example, free-text comments
from participants reflected the importance of timely
access to surgery:
“I think the replacement operation can happen too late for
some people. Pain and not being able to do things get people
down and the recuperation takes longer; I didn’t want to have
to wait until I couldn’t move to have the operation.”
The findings of the current study also resonate with
previous research considering equity of access to joint
replacement surgery. For example, in the systematic
review by Mújica Mota and colleagues (8), socio-eco-
nomic circumstances, such as being in paid employment
and having health insurance, impacted on surgery up-
take, and higher levels of education were associated with
motivation to seek timely surgical interventions. Prior
studies evaluating equitable access to joint replacement
surgery in the UK (7) and New Zealand (10) suggested
there were geographical differences, with those in urban
centres having lower rates of publicly funded joint re-
placement. This suggests there are relationships between
socio-economic and geographical factors, although these
studies did not conduct comparisons between privately
and publicly funded cases. However, the current study
did not find systematic differences in rates of joint re-
placement or use of rehabilitation services on the basis
of geographical location.