Understanding factors influencing the choice of discharge destination by older patients post total lower limb replacement: A qualitative study

Abstract

Background: In Singapore, the clinical pathway for total knee replacement was introduced in 1997 to streamline multidisciplinary care and reduce length of stay for patients in acute hospitals. However, patients who chose to be discharged to a community hospital for rehabilitation currently have a longer length of stay due to the higher demand and longer waiting time for beds in these step-down care facilities. To our knowledge, no qualitative studies have been done in Singapore to investigate the post-discharge issues faced by these patients. This study aims to understand how decisions about discharge were being made among elderly patients post-discharge. Design: Grounded theory qualitative methodology was applied. Method: Data was collected from nine inpatients who recently underwent total knee replacement or total hip replacement surgery in a tertiary hospital in Singapore by in-depth interviews conducted between October 2012 and July 2013. Data was analyzed using thematic analysis. Findings: Three major themes emerged from the interviews when participants were asked about the reasons for choosing a community hospital instead of going home after discharge. The themes were: perceived lack of caregiver; lack of confidence; and services provided in the community hospitals. Conclusion: This study showed that factors related to perceived unavailability of caregivers, low level of confidence and accessibility of comprehensive community rehabilitation services were important considerations among elderly patients when choosing their discharge destinations and care. Relevant stakeholders can then explore solutions to these problems so as to correctly site patients.

Barriers, enablers and acceptability of home-based care following elective total knee or hip replacement at a private hospital: A qualitative study of patient and caregiver perspectives

“…Theoretical domains relating to these enablers included 'beliefs about capabilities', 'skills', 'procedural knowledge' and 'social influences. ' The key barrier and enabler themes identified in our study converged with themes identified in qualitative studies conducted in multiple countries, hospital settings (public and private) and with different aims [13][14][15][16][17]. For example, a perceived lack of caregiver support and lack of confidence to cope with daily activities emerged as a barrier for home discharge in a study that examined patients' choice of discharge destination in Singapore [16].…”

“…The key barrier and enabler themes identified in our study converged with themes identified in qualitative studies conducted in multiple countries, hospital settings (public and private) and with different aims [ 13 – 17 ]. For example, a perceived lack of caregiver support and lack of confidence to cope with daily activities emerged as a barrier for home discharge in a study that examined patients’ choice of discharge destination in Singapore [ 16 ]. ‘Paying for health insurance’ that emerged as a barrier to home-based care in our study is consistent with findings from a previous Australian study where patients’ perceived sense of entitlement influenced the discharge destination towards inpatient rehabilitation [ 17 ].…”

“…Qualitative research can provide an understanding of factors influencing implementation and acceptability of home-based care services by giving insights into people's perceptions that cannot be achieved by other research methods [12]. Previous qualitative studies have provided some understanding of these factors within the context of different countries [13][14][15][16] but these may not be applicable to private hospital settings in Australia. One previous qualitative study exploring clinician and patient decision-making for rehabilitation following THR and TKR in private hospital settings in Australia identified patient preference for inpatient rehabilitation as a key barrier to home discharge [17].…”

Post-acute Transitional Journey: Caring for Orthopedic Surgery Patients in the United States

“…Furthermore, in postmenopausal women and middle-aged men, decreased sex hormones and increased iron levels account for bone loss (32). Gender also affects post-surgical destinations—females who underwent THA or TKA were more likely to be discharged to IRFs (33). Cherian et al found that while there was no significant difference between men and women in implant survivorship and Knee Society Scores after TKA, men experienced significantly better functional outcomes (34).…”