Additional saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation: a prospective cohort study

Rehabilitation aims to improve the functional status of people with health conditions leading to impairments, activity limitations or participation restrictions [1]. Multidisciplinary rehabilitation (including physical therapy (PT) and occupational therapy (OT)) optimizes patient outcomes, and is beneficial for geriatric patients [2], people following hip fracture [3, 4] and those with Parkinson’s Disease [3] amongst other conditions. The Australasian Faculty of Rehabilitation Medicine [5] and the Consultative Committee on Private Rehabilitation [6] recommends that rehabilitation should extend to weekends.

Randomised controlled trials have shown improvement in functional independence and health related quality of life with Saturday PT only [7] and for multidisciplinary (OT and PT) rehabilitation [8] compared to Monday to Friday rehabilitation. Additionally, although reductions in hospital length of stay (LOS) of 3.2 days (95% CI -0.5 to 6.9) have been reported for the PT only intervention [7] and 2.0 days (95% CI 0–4; p = 0.1) for the multidisciplinary intervention [8]; these findings have not always been statistically significant. However, the external validity of randomised controlled trials that strictly control intervention delivery could be questioned [9]. More recently, a systematic review combining weekend rehabilitation delivered over six and seven days has highlighted reductions in LOS [10]. One reason for the inconsistent effect on reduction in LOS maybe in the referral of a heterogeneous mix of patients for rehabilitation. Pragmatic implementation of a Saturday OT and PT rehabilitation service in an inpatient clinical setting would likely prioritise patients likely to benefit from [11‐13] and be motivated to engage in additional rehabilitation [14, 15].

Providing weekend rehabilitation will likely incur additional staffing, hospital overhead and ward costs for facilities. However, economic evaluations have suggested that multidisciplinary Saturday rehabilitation may reduce costs per quality-adjusted life year gained [16, 17] with potential reductions also found in incremental cost-effectiveness ratios at 30 days [16] and 12 months [17] post discharge. The aims of this study were two-fold. Firstly, this study aimed to evaluate the efficacy of a pragmatic implementation of four hours of Saturday OT in addition to PT in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday OT service in addition to PT resulted in a net cost savings for the rehabilitation facility.

There was no statistically significant difference between the Saturday OT service in addition to PT (intervention) and Saturday PT service (control) groups in age, sex, medical diagnosis, acute inpatient care, or discharge destination (see Table 1). Table 1 presents the average number and duration of sessions undertaken by patients on a Saturday, as well as the average number of occasions of service completed by the Saturday service for both intervention and control groups. The percentage of patients attending Saturday rehabilitation was 11% (83% vs 72%, p < 0.01) greater for the intervention group compared to the control group. In the intervention period, six participants received only OT, 63 participants received only PT and 91 participants received both OT and PT on a Saturday during their rehabilitation stay. The intervention group attended 0.7 (p < 0.01) more Saturday sessions, received 72 (p < 0.01) more minutes of therapy and 7.1 (p < 0.01) more occasions of Saturday service during their rehabilitation stay, including 1.5 (p < 0.01) more occasions of PT service. While there was no statistically significant difference in LOS for the acute admission, the average LOS in the rehabilitation unit was 2.4 (p < 0.01) days less for the intervention group compared to the control group.

Table 2 compares outcomes at admission and discharge for the control and intervention groups. On admission, the intervention group had higher motor (3.3, p = 0.06), cognitive (2.3, p < 0.01), and total (5.3, p = 0.01) FIM scores, as well TUG (6.7, p = 0.07), FR (5.6, p < 0.01), FTEC (2.8, p = 0.08) and BOOMER (2.64, p < 0.01) test scores compared to the control group. The last column (Table 2) reports the difference in the relative improvement for each measure of recovery. Participants in the intervention group had smaller increases in their motor (-3.0, p < 0.01), cognitive (-1.1, p < 0.01) and total (-3.9, p < 0.01) FIM scores when compared with the control group. The intervention group also had a larger decrease in their TUG test scores (7.9, p < 0.01) compared to the control group. There were no other statistically significant differences in the indicators of recovery between the control and intervention groups (see last column Table 2).

This paper used a pragmatic prospective cohort study design to analyse the effect of Saturday OT service in addition to a PT service on patient outcomes admitted to a 20-bed rehabilitation ward in a private hospital located in Brisbane, Australia. The aim was two-fold. The first to analyse the impact on LOS and functional status, and second to conduct an economic evaluation from the perspective of the healthcare provider. Outcome measures of functional status included functional independence, gait and balance. LOS and hospital cost data were obtained for the economic evaluation.

Controlling for age, sex and admitting diagnosis identified minor improvements in cognition and the composite balance measure (BOOMER) scores. After controlling for admission FIM, age, sex and days of admission and discharge, LOS for the intervention group was estimated to be 1.39 days less than the control group. This estimate corroborates results published by earlier research [7, 8]. Published costs per rehabilitation bed-day [32], and treatment cost estimates obtained from the hospital billing accounting department, identified potential cost savings of AUD1,536 per patient in the intervention group. This Saturday rehabilitation service consisting of OT and PT met the published Standards for the Provision of Inpatient Adult Rehabilitation Medicine Services in Public and Private Hospitals [5] providing rehabilitation a minimum of five days per week. However, the service did not meet the Guidelines for Recognition of Private Hospital Based Rehabilitation Services [6] which state that specialist rehabilitation services should be provided seven days per week [6]. While the benefits of additional rehabilitation services outside of usual business hours seems established, [34] Australian guidelines provide inconsistent advice for service providers. Providing rehabilitation therapy across six days (at least in stroke populations) appears to result in better patient outcomes compared to seven-day rehabilitation, [35] though few studies have specifically investigated these models. Additionally, providing rehabilitation across six days seems to be prevalent in Australian rehabilitation facilities [14, 36]. This current study adds to the evidence that rehabilitation six days a week is beneficial for patients and service providers alike.

Interestingly, greater reductions in LOS have previously been found with facilities providing PT [7, 37] compared to multidisciplinary weekend services [8, 13, 38, 39]. While this current study reports similar reductions in LOS as another Australian study [8] also providing Saturday OT and PT rehabilitation, the Saturday OT and PT rehabilitation service provision model warrants further pragmatic investigation to determine if these results are reproducible in different service models and settings. This reduction in LOS may have implications, not just for patient outcomes and health service costs, but also in terms of improved patient flow through both rehabilitation units and hospitals. Certainly, allied health managers perceive improved patient flow and quality of care are benefits associated with weekend services, at least in acute care [40]. An associated increase in throughput occurred in this rehabilitation unit with approximately 10% more patients admitted during the intervention period compared to the control period. This may have led to an improved flow of patients through the hospital and possibly reduced rehabilitation waiting lists.

Participants in the intervention group in this current study had higher scores on some measures of functional independence, and some balance measures on admission. It is unclear why this was the case. The participating facility had no change in admission criteria or admission processes. Our regression models for LOS (Table 4) did control for FIM_Motor on admission but did not explicitly control for other measures of balance. It is therefore possible that our estimates slightly overestimated reduced LOS. At discharge, largely both groups had similar functional independence, balance and gait and both groups improved performance met minimum clinical important differences. It is reasonable to suggest that discharge is likely determined by patient readiness, functional performance, and preparedness of the home environment [40]. Previous studies have reported similar discharge function from inpatient rehabilitation [11, 41]. Interestingly differences in cognitive function were noted between the two groups at discharge. The intervention group had better cognitive function at discharge compared to the control group, though both groups’ scores suggest discharge home would be likely. Results obtained from observational data are always subject to the ceteris paribus caveat, and causal inferences should be drawn with caution. Although our statistical models have controlled for some important observed differences between the control and the intervention groups, it is always possible that unobserved differences could confound our results.

Potential cost savings identified in the economic evaluation corroborate an evolving literature that suggests the provision of weekend rehabilitation services may deliver an economic dividend [7, 8, 16, 17]. Previous randomised controlled trials have reported that weekend rehabilitation may reduce hospital LOS [7, 8]. A cost utility analysis has also reported probable cost effectiveness at 30 days [16] and 12 months [17] post-discharge. We found that rehabilitation LOS reduced on average by 1.39 days, with long-stay inpatients appearing to benefit most from the intervention. It is worth noting that patients in the intervention group experienced a shorter length of stay and demonstrated smaller improvements in most functional measures compared to those in the control group. In the context of the economic evaluation conducted in the current study, this suggests that the potential cost savings may be at the expense of functional improvement. However, it is likely that patients in both groups were discharged when a minimum threshold for safe discharge home, of approximately 110 on the FIM, was met. This reduced functional gain in the intervention group is likely due to higher admission FIM scores compared to the control group. Diagnosis also appeared to be important with sub-analyses confirming larger LOS reductions for neurological and orthopaedic patients. It is perhaps not surprising that those who stay longer and have complex conditions would show greater benefit from the additional therapy offered through a Saturday OT and PT rehabilitation service compared to a PT only service; perhaps further validating the need for this service.

The provision of a multidisciplinary Saturday rehabilitation service comprising OT and PT leads to a greater reduction in LOS compared a to a Saturday PT service, even when controlling for discrepancies in admission function. Providing a Saturday OT and PT rehabilitation service resulted in more patients receiving weekend therapy compared to Saturday physiotherapy only rehabilitation. The provision of a Saturday OT and PT rehabilitation service is potentially cost reducing for the treating hospital.