Prädiktoren des Rehabilitationsergebnisses bei Patienten nach Hüft- und Knieendoprothetik - Eine Multiebenenanalyse

Zusammenfassung

Studienziel: Die Bestimmung von patientenbezogenen und klinikbezogenen Prädiktoren des kurz- und mittelfristigen Outcomes einer Rehabilitationsmaßnahme nach Hüftendoprothese (HTEP) und Knieendoprothese (KTEP). Methode: In 32 orthopädischen Rehabilitationskliniken wurden Patienten konsekutiv in die Studie eingeschlossen, bis eine Fallzahl von ca. 200 Patienten pro Klinik erreicht war. Insgesamt waren darunter n = 1954 HTEP-/KTEP-Patienten. Eingesetzt wurden ein Patientenfragebogen zur Selbsteinschätzung des somatischen, funktionalen und psychosozialen Status sowie ein Arztbogen, der u. a. der Erfassung von Komorbidität, Diagnose und Reha-Motivation dient. Als Outcomeparameter werden Mobilität, Schmerzen und vitale Erschöpfung betrachtet. Ergebnisse: Kurzfristig werden geringe bis mittelhohe Effekte erzielt. 6 Monate nach Beendigung der Rehabilitationsmaßnahme sind nur die Verbesserungen bezüglich Mobilität deutlich ausgeprägt. Bedeutsame patientenbezogene Prädiktoren des Outcomes sind der jeweilige Aufnahmewert des Outcomeparameters, die funktionale und psychische Belastung bei Reha-Beginn, Komorbidität, Geschlecht, Alter und soziale Probleme. Klinikbezogene Einflussfaktoren erweisen sich als relevant für die Rehabilitationseffekte bezüglich Mobilität und vitaler Erschöpfung, nicht aber für die Schmerzreduktion. Umfangreiche Erfahrungen einer Einrichtung mit somatisch und funktional stark belasteten Patienten wirken sich förderlich aus auf die Reha-Effekte im funktionalen und psychosozialen Bereich. Schlussfolgerung: Neben patientenbezogenen Prädiktoren des Rehabilitationsoutcomes existieren auch medizinisch relevante, klinikbezogene Einflussfaktoren, die mit Hilfe von Multiebenenanalysen identifiziert werden können.

Abstract

Aim: The determination of patient-related and clinic-related predictors of the short- and medium-term outcome of rehabilitation after total hip arthroplasties (THA) and total knee arthroplasties (TKA). Method: N = 1.954 THA/TKA patients were included in the study. Use was made of a patient questionnaire for self-assessment of somatic, functional and psychosocial status. Additionally we applied a documentation sheet completed by the physicians. Multilevel analysis using hierarchical linear modelling was employed. Results: In the short-term slight to medium effects are achieved. Six months after the end of rehabilitation only the improvements with regard to mobility are clearly obvious. Significant patient-related predictors of outcome are the value of the outcome parameter at admission, the functional restrictions and psychological stress at the start of rehabilitation, comorbidity, gender, age and social support. Centre-related influencing factors prove to be relevant for the effects of rehabilitation with regard to mobility and vital exhaustion, but not for the reduction in pain. Extensive experiences of a centre with somatically and functionally greatly affected patients have a beneficial effect on the results of rehabilitation in the functional and psychosocial area. Conclusion: In addition to patient-related predictors of outcome of rehabilitation there are also medically relevant, centre-related influencing factors that can be identified with the aid of multi-level analyses.

Schlüsselwörter

Hüft- und Knieendoprothetik - Rehabilitationsergebnis - Prädiktoren des Outcomes - Multiebenenanalysen

Key words

Arthroplasty - replacement - rehabilitation outcome - predictors of outcome - multi-level analysis

Literatur

• 1 Altman D G. Systematic reviews of evaluations of prognostic variables.  British Medical Journal. 2001;  323 224-228
• 2 Farin E, Follert P, Gerdes N, Jäckel W H, Thalau J. Quality assessment in rehabilitation centres: the indicator system „Quality Profile”.  Disability & Rehabilitation. 2004;  26 (18) 1096-1104
• 3 Parent E, Moffet H. Preoperative Predictors of Locomotor Ability Two Months After Total Knee Arthroplasty for Severe Osteoarthritis.  Arthritis & Rheumatism. 2003;  15 36-50
• 4 Sharma L, Sinacore J, Daugherty C. et al . Prognostic factors for functional outcome of total knee replacement: a prospective study.  Journals of Gerontology: Biological Sciences and Medical Sciences. 1996;  51A (4) M152-M157
• 5 Waldrop D, Lightsey jr O R, Ethington C A, Woemmel C A, Coke A L. Self-efficacy, optimism, health competence, and recovery from orthopedic surgery.  Journal of Counseling Psychology. 2001;  48 (2) 233-238
• 6 Ritter M A, Harty L D, Davis K E, Meding J B, Berend M E. Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis.  Journal of Bone & Joint Surgery. 2003;  85A (7) 1278-1285
• 7 Brander V A, Stulberg S D, Adams A D. et al . Predicting Total Knee Replacement Pain. A Prospective, Observational Study.  Clinical Orthopaedics and related Research. 2003;  416 27-36
• 8 Holtzman J, Saleh K, Kane R. Effect of Baseline Functional Status and Pain on Outcomes of Total Hip Arthroplasty.  Journal of Bone & Joint Surgery. 2002;  84A (11) 1942-1948
• 9 Fortin P R, Clarke A E, Joseph L. et al . Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery.  Arthritis & Rheumatism. 1999;  42 1722-1728
• 10 Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year.  Osteoporosis International. 1993;  3 148-153
• 11 Chen C C, Heinemann A W, Granger C V, Linn R T. Functional gains and therapy intensity during subacute rehabilitation: A study of 20 facilities.  Archives of Physical Medicine and Rehabilitation. 2002;  83 1514-1523
• 12 Nilsdotter A K, Lohmander L S. Age and waiting time as predictors of outcome after total hip replacement.  Rheumatology. 2002;  41 1261-1267
• 13 Schoppen T, Boonstra A, Groothoff J W, Vries J de, Göeken L N, Eisma W H. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees.  Archives of Physical Medicine and Rehabilitation. 2003;  84 803-811
• 14 Nilsdotter A K, Petersson I F, Roos E M, Lohmander L S. Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.  Annals of Rheumatic Diseases. 2003;  62 923-930
• 15 Svensson O, Strömberg L, Öhlén G, Lindgren U. Prediction of the outcome after hip fracture in elderly patients.  Journal of Bone & Joint Surgery, British Volume. 1996;  78-B 115-118
• 16 Heinemann A W, Linacre J M, Wright B D, Hamilton B B, Granger C V. Prediction of rehabilitation outcomes with disability measures.  Archives of Physical Medicine and Rehabilitation. 1994;  75 133-143
• 17 Jones C A, Voaklander D C, Suarez-Almazor M E. Determinants of function after total knee arthroplasty.  Physical Therapy. 2003;  83 (8) 696-706
• 18 Svensson O, Strömberg L, Öhlén G, Lindgren U. Prediction of the outcome after hip fracture in elderly patients.  Journal of Bone & Joint Surgery, British Volume. 1996;  78-B 115-118
• 19 Greenfield S, Apolone G, McNeill B, Cleary P D. The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement. Comorbidity and outcomes after hip replacement.  Medical Care. 1993;  31 141-154
• 20 Heruti R J, Lusky A, Barell V, Ohry A, Adunsky A. Cognitive status at admission: Does it affect the rehabilitation outcome of elderly patients with hip fracture?.  Archives of Physical Medicine and Rehabilitation. 1999;  80 432-436
• 21 Landi F, Bernabei R, Russo A, Zuccalà G, Onder G, Carosella L. et al . Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital.  Journal of the American Geriatric Society. 2002;  50 679-684
• 22 Brewer B W, Raalte J L van, Cornelius A E, Petitpas A J, Sklar J H, Pohlmann M H. et al . Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction.  Rehabilitation Psychology. 2000;  45 (1) 20-37
• 23 Harden R N, Bruehl S, Stanos S P. et al . Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study.  Pain. 2003;  106 393-400
• 24 Keefe F J, Caldwell D S, Martinez S, Nunley J, Beckham J, Williams D A. Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery.  Pain. 1991;  46 153-160
• 25 Kendell K, Saxby B, Farrow M, Naisby C. Psychological factors associated with short-term recovery from total knee replacement.  British Journal of Health Psychology. 2001;  6 (1) 41-52
• 26 Grahn B, Ekdahl C, Borgquist L. Motivation as a predictor of changes in quality of life and working ability in multidisciplinary rehabilitation: A two-year follow-up of a prospective controlled study in patients with prolonged musculoskeletal disorders.  Disability & Rehabilitation. 2000;  22 (15) 639-654
• 27 Mahomed N N, Liang M H, Cook E F. et al . The importance of patient expectations in predicting functional outcomes after total joint arthroplasty.  Journal of Rheumatology. 2002;  29 1273-1279
• 28 Mutran E J, Reitzes D C, Mossey J, Fernandez M E. Social support, depression, and recovery of walking ability following hip fracture surgery.  Journals of Gerontology Series B Psychological Sciences and Social Sciences. 1995;  50B (6) S354-S361
• 29 Jones C A, Voaklander D C, Johnston W C, Suarez-Almazor M E. The Effect of Age on Pain, Function, and Quality of Life After Total Hip and Knee Arthroplasty.  Archives of Internal Medicine. 2001;  161 (3) 454-460
• 30 Goldstein F C, Strasser D C, Woodard J L, Roberts V J. Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit.  Journal of the American Geriatric Society. 1997;  45 35-42
• 31 MacWilliam C H, Yood M U, Verner J J. et al . Patient-related risk factors that predict poor outcome after total hip replacement.  Health Services Research. 1996;  31 623-638
• 32 Aarons H, Hall G, Hughes S, Salmon P. Short-term recovery from hip and knee arthroplasty.  Journal of Bone & Joint Surgery, British Volume. 1996;  78 555-558
• 33 Munin M C, Kwoh C K, Glynn N, Crossett L, Rubash H E. Predicting discharge outcome after elective hip and knee arthroplasty.  Arch Phys Med Rehabil. 1995;  74 294-301
• 34 Farin E, Glattacker M, Follert P, Kuhl C, Jäckel W H. Effekte und Prädiktoren des Outcomes in der Rehabilitation muskuloskeletaler Erkrankungen.  Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. 2004;  14 123-133
• 35 Raudenbush S W, Bryk A S. Hierarchical linear models. Applications and data analysis methods (2^nd ed). Thousand Oaks, CA; Sage 2002
• 36 Duncan C, Jones K, Moon G. Context, composition and heterogeneity: Using multilevel models in health research.  Social Science and Medicine. 1998;  46 97-117
• 37 Carey K. A multilevel modelling approach to analysis of patient costs under managed care.  Health Economics. 2000;  9 435-446
• 38 Greenfield S, Kaplan S H, Kahn R, Ninomiya J, Griffith J L. Profiling care provided by different groups of physicians: Effects of patient case-mix (bias) and physician-level clustering on quality assessment results.  Annals of Internal Medicine. 2002;  136 (2) 111-121
• 39 Gerdes N, Jäckel W H. Der IRES-Fragebogen für Klinik und Forschung.  Rehabilitation. 1995;  34 XIII-XXIII
• 40 Raudenbush S W, Bryk A, Congdon R. HLM Hierarchical Linear and Nonlinear Modeling 2001 (Version 5.05). 2001
• 41 Dickstein R, Heffes Y, Shabtai E I, Markowitz E. Total Knee Arthroplasty in the Elderly: Patients' Self-Appraisal 6 and 12 Months Postoperatively.  Gerontology. 1998;  44 204-210
• 42 Kirschner S, Walther M, Bohm D. et al . German short musculoskeletal function assessment questionnaire (SMFA-D): comparison with the SF-36 and WOMAC in a prospective evaluation in patients with primary osteoarthritis undergoing total knee arthroplasty.  Rheumatology International. 2003;  23 (1) 15-20
• 43 Saunders D. Coping with Chronic Pain: What can we learn from pain self-efficacy beliefs?.  Journal of Rheumatology. 2004;  31 (6) 1032-1034
• 44 Wilcox V L, Kasl S V, Berkman L F. Social support and physical disability in older people after hospitalization.  Health Psychology. 1994;  13 170-179
• 45 Farin E, Follert P, Jäckel W H. Die Therapiezielfestlegung bei Patienten mit psychischen Belastungen in der orthopädischen und kardiologischen Rehabilitation.  Die Rehabilitation. 2002;  41 (6) 389-400
• 46 Losina E, Barret J, Mahomed N N, Baron J A, Katz J N. Early failures of total hip replacement. Effect of surgeon volume.  Arthritis & Rheumatism. 2004;  50 (4) 1338-1343
• 47 Williams O D. Quality of care versus provider volume (Editorial).  Medical Care. 2003;  41 (10) 1127-1128
• 48 Iezzoni L I. Risk adjusting rehabilitation outcomes. An overview of methodologic issues.  American Journal of Physical Medicine and Rehabilitation. 2004;  83 316-326
• 49 Sager M A, Dunham N C, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurement of activities of daily living in hospitalized elderly: a comparison of self-report and performance-based methods.  Journal of the American Geriatrics Society. 1992;  40 (5) 457-462
• 50 Orbell S, Johnston M, Rowley D, Espley A, Davey P. Cognitive representations of illness and functional and affective adjustment following surgery for osteoarthritis.  Social Science and Medicine. 1998;  47 (1) 93-102

1 Falls das jeweils betrachtete Kriterium als Skala der jeweiligen Unterdimension zugeordnet ist (wie z. B. beim Kriterium „Vitale Erschöpfung”, das eine Skala der Unterdimension „Psychische Belastung” bildet), wurde aus dem Prädiktor der Einfluss des Kriteriums zuvor regressionsanalytisch eliminiert.