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The societal value of rehabilitation and evidence-based policy data

Primary osteoarthritis is a degenerative joint disease caused by the breakdown of cartilage, causing progression over time and increasing with age. The more a society ages, the more joint replacement surgeries are performed by orthopedic surgeons at the end stage of the disease, when considerable pain and the relative dysfunction make the activities of daily living (ADL) hard to bear. Just as in the Bone and Joint Decade (Lidgren, 2003), the need for prevention, treatment and care of people with musculoskeletal disorders continues to be a high priority. 

Joint replacement surgeries for hip and knee osteoarthritis are planned, making integrated perioperative programs like Fast-Track and Enhanced Recovery After Surgery better able to prepare patients and caregivers for all stages of treatment. This in turn helps to reduce the length of hospital stays and improve outcomes, by adopting nutritional and pre-habilitation protocols, minimally invasive surgeries, reducing blood loss, providing educational material and, procuring crutches and walking aids on time (Pennestrì et.al., 2019; Pennestrì et.al., 2023; Vanni et al., 2020). Patients who are able to bear an accelerated pathway can be discharged home, where they perform rehabilitation exercises as prescribed and visit the surgeon only for follow-up controls. 

However, many patients are affected by more than one (usually chronic) disease at a time and various risk factors such as potential cognitive dysfunction and some extent of social vulnerability (isolation, living with barriers) that make early hospital discharge unsafe. As these problems increase with age, the impact on hospitals, society and families can be seen in the following ways: 

  • Hospitals need to ensure longer stays in the surgical ward, and eventually provide transfer to rehabilitation wards, to make space for other surgeries to reduce waiting lists. 
  • Society has to endure the continuous rising costs of surgery and inpatient rehabilitation, which comes to be around 15.000 € per patient before discharge (based on the Diagnosis Related Group system).
  • Family burden increases due to the care needed by patients when discharged home.

This is why the classification of patients based on baseline and postoperative characteristics – such as social, functional and clinical data –ultimately helps stakeholders (doctors, patients, families and policy makers) plan the perioperative journey to maximise efficiency, which in turn, maximises equity being that: 

  1. more hospitals beds are freed to treat other patients, 
  2. inpatient rehabilitation is covered by the Italian NHS (unlike home physical therapy which for practical reasons is largely out of pocket).

IRCCS Ospedale Galeazzi Sant’Ambrogio (OGSA) is a high-volume orthopedic hospital that provides both surgery and inpatient rehabilitation via two dedicated facilities. As a part of the PREPARE consortium, the hospital is interested in adopting predictive models based on AI to estimate the length of inpatient rehabilitation stay and optimise perioperative care consequently, including planned discharge. As part of our clinical records we can collect routine information about the societal capital of patients at baseline (e.g., age, profession, who the patient lives with), the clinical and functional characteristics they show before and after surgery, the length of inpatient rehabilitation stay and the social outcomes of rehabilitation. Considering the inpatient rehabilitation program as substantially standard while training a predictive model with additional data from almost two thousand patients per year, can provide useful information in advanced on the expected rehabilitation stay, resulting in organisational, societal and possibly financial benefits as a consequence. This is in light of the four value principles of the Expert Panel on effective ways of investing in Health (EXPH) of the European Commission, personal, technical, allocative and societal value (European Commission, 2019). 

Italy’s recent investments on digitalisation, innovation and community care enhancement (Pennestrì & Banfi, 2023) make OGSA’s involvement in the PREPARE project a perfect opportunity to adopt tools and protocols that fit in perfectly with National and Regional policies (such as Community Hospitals, Community Clinics and Local Operations Centers), that would benefit significantly from the evidence-based information coming one of the highest specialistic hospitals in Italy and the area. For instance, by: 

  • Anticipating the volume of patients requiring postoperative inpatient care that can be released from acute hospitals, providing appropriate care as close to home as possible;  
  • Considering whether home discharge is safe, based on the burden of care needed by each patient and the people they live with;  
  • And evaluating the autonomy of patients in terms of essential functions such as walking and ADL. 

Aging, digitalisation and community care enhancement represent crucial challenges which go well beyond Italian borders. This means providing evidence for policy arrangements is a scientific and organisational priority at the international level. Considering rehabilitation as a complex, multidisciplinary set of interventions as a primary focus (Negrini et al., 2022), including such data and information aims to take clinical decisions to the next level. 

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Author: Federico Pennestrí, IRCCS Ospedale Galeazzi Sant’Ambrogio