Improved Outcome Quality Following Total Knee and Hip Arthroplasty in an Integrated Care Setting: Results of a Controlled Study

Objective: In Germany, the introduction of the Law on integrated care (IC) ( 140 a-d SGB V) opened up the possibility of cross-sectional health care settings and new forms of remuneration, and improved the conditions for a closer cooperation between health care providers. Patients awaiting a hip or knee arthroplasty expect a higher benefit from such an intensified cooperation of operating hospital and rehabilitation centre. However, to date there is no study that investigated the anticipated effects on functional outcomes. Therefore, the aim of our study was the efficacy evaluation of an arthroplastic IC model in comparison with usual care. Methods: The controlled multicentre trial included pensioners who received an arthroplasty following gonarthrosis or coxarthrosis. Implantation of the arthroplasty was accomplished in 11 hospitals. Participants of the intervention group (IG; 3 hospitals) were treated within an IC model, participants of the control group (CG; 8 hospitals) were treated within conventional care. Primary outcome were the functional complaints measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results: 481 patients attended the study (IG: n=249; KG: n=232). Response at end of treatment was 85.9% (n=413), response after 4 months was 89.4% (n=430) and after 1 year 85.9% (n=413). Multivariate analyses confirmed a reduction of treatment time by 4 days (b= -3.964; 95% CI: -5.833 to -2.094; p<0.001) and improved functional outcomes on the WOMAC (4 months: b=-7.219; 95% CI: -11.184 to -3.254; p<0.001; 12 months: b=-8.070; 95% CI: -12.101 to -4.039; p<0.001). Patients of the IG rated the process better (e.g. cooperation between hospital and rehabilitation centre: b=0.672; 95% CI: 0.401 to 0.943; p<0.001); reported a better self-rated health after 1 year (b=4.418; 95% CI: 0.050 to 8.786; p=0.047), and were physically more active (b=1.603; 95% CI: 0.655 to 2.551; p=0.001). Conclusion: The IC setting improved coordination and communication at the interface between hospital and rehabilitation centre (internal patient orientation). Higher patient satisfaction and better outcome quality (external patient orientation) are not only achievable by improved medical devices but also by innovative communicative and organisational structures bringing along an improved process quality.