Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia.
Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia.
JAMA Netw Open. 2020 Dec 1;3(12):e2028328. doi: 10.1001/jamanetworkopen.2020.28328.
Hip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown.
To evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty.
DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8.
Eligible patients were randomized evenly to receive usual care (n = 153) or remote monitoring (n = 147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge.
The primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations.
A total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P = .01).
In this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team.
ClinicalTrials.gov Identifier: NCT03435549.
髋关节和膝关节置换术是美国医疗保险受益人的最常见住院手术程序，其成本和质量存在很大差异。远程监测是否可以利用行为科学的见解来帮助改善结果并提高护理价值仍不得而知。
评估活动监测和双向短信对接受髋关节或膝关节置换术的患者出院率和临床结果的影响。
设计、地点和参与者：这是一项于 2018 年 2 月 7 日至 2019 年 4 月 15 日期间在一个学术医疗系统的 2 家城市医院进行的随机临床试验。参与者为年龄在 18 至 85 岁之间、风险评估和预测工具评分在 6 至 8 分之间、计划接受髋关节或膝关节置换术的患者。
符合条件的患者被平均随机分为接受常规护理（n = 153）或远程监测（n = 147）。愿意接受远程监测的干预组患者会收到一个可穿戴活动监测器，用于跟踪步数、术后目标和里程碑的信息、疼痛评分跟踪以及根据需要与临床医生联系。被分配接受监测的患者进一步平均随机分为远程监测、远程监测与游戏化和社会支持相结合。远程监测在手术前开始，在出院时开始，并在出院后持续 45 天。
主要结果是出院状态（居家与熟练护理机构或住院康复）。预先指定的次要结果包括平均每日步数的变化和再入院情况。
共有 242 名患者进行了分析（常规护理组 124 名，干预组 118 名）；中位年龄为 66 岁（四分位距，58-73 岁）；78.1%为女性，45.5%为白人，43.4%为黑人；干预组中有 81.4%的患者同意接受监测。常规护理组（57.3%；95%置信区间，48.5%-65.9%）和干预组（56.8%；95%置信区间，47.9%-65.7%）的出院率没有显著差异，与单独接受远程监测相比，接受远程监测加游戏化和社会支持的患者的步数没有显著增加。与常规护理组（12.2%；95%置信区间，6.4%-18.0%）相比，干预组（3.4%；95%置信区间，0.1%-6.7%）的再入院率有统计学显著降低（P = .01）。
在这项研究中，远程监测计划并没有增加髋关节或膝关节置换术后的出院率，游戏化和社会支持也没有增加活动水平。接受干预的患者再入院率显著降低，这可能是由于设定了目标并与护理团队建立了联系。
ClinicalTrials.gov 标识符：NCT03435549。
