Compliance with Australian Orthopaedic Association guidelines does not reduce the risk of venous thromboembolism after total hip and knee arthroplasty.

Preventing avoidable venous-thrombo-embolism (VTE) is a priority to improve patient and service outcomes after total hip and total knee arthroplasty (THA, TKA), but compliance with relevant clinical guidelines varies. This study aims to determine the degree to which prophylaxis was compliant with Australian Orthopaedic Association (AOA) VTE prophylaxis guidelines and whether non-compliance is associated with increased risk of VTE. A prospective multi-centre cohort study of adults with osteoarthritis undergoing primary TKA/THA was completed at 19 high-volume public and private hospitals. Data were collected prior to surgery and for one-year post-surgery. Logistic regression was undertaken to explore associations between non-compliance with AOA VTE prophylaxis guidelines and symptomatic 90-day VTE outcomes. Data were analysed for 1838 participants from 19 sites. The rate of non-compliance with all clinical guideline recommendations was 20.1% (N = 369), with 14.1% (N = 259) non-compliance for risk-stratified prophylaxis, 35.8% (N = 658) for duration, and 67.8% (N = 1246) for other general recommendations. Symptomatic VTE was experienced up to 90-days post-surgery by 48 people (2.6%). Overall guideline non-compliance (AOR = 0.93, 95%CI = 0.4 to 1.3, p = 0.86) was not associated with a lower risk of symptomatic 90-day VTE. Results were consistent when people with high bleeding risk were excluded (AOR = 0.94, 95%CI = 0.44 to 2.34, p = 0.89). Non-compliance with the AOA VTE prophylaxis guidelines was not associated with risk of 90-day VTE after arthroplasty. This counterintuitive finding is concerning and necessitates a rigorous review of the AOA VTE prevention clinical guideline.

Comparative effectiveness of aspirin for symptomatic venous thromboembolism prophylaxis in patients undergoing total joint arthroplasty, a cohort study.

BACKGROUND: This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA). METHODS: Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student's t and Fisher's exact tests (unadjusted) and multivariable regression (adjusted). RESULTS: There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration < 14 days (OR = 6.7, 95% CI 3.5-13.1, p < 0.001) and history of previous VTE (OR = 2.4, 95% CI 1.1-5.8, p = 0.05). There were no significant differences in the primary or secondary outcomes between prophylaxis groups. CONCLUSIONS: Aspirin may be suitable for VTE prophylaxis following THA and TKA. The comparatively low unadjusted 90-day VTE rate in the aspirin group may have been due to selective use in lower-risk patients. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, trial number NCT01899443 (15/07/2013).

Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study.

OBJECTIVE: Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations. METHODS: Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling. RESULTS: A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. CONCLUSION: Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study.

BACKGROUND: Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery. METHODS: This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs. RESULTS: The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (ß = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (ß = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (ß = - 0.02 SE = 0.008, p = 0.011) and 365-days (ß = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: ß = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: ß = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: ß = - 0.06, SE = 0.41, p = 0.880 EQ-5D: ß = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect. CONCLUSIONS: Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Timing and duration of antibiotic prophylaxis is associated with the risk of infection after hip and knee arthroplasty.

AIMS: Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA. METHODS: A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery. RESULTS: In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours. CONCLUSION: Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252-260.

Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery.

BACKGROUND: Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications. METHODS AND FINDINGS: A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68-3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59-5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17-3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85-10.00, p = 0.15). CONCLUSIONS: We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines.

Association between pre-operative anxiety and/or depression and outcomes following total hip or knee arthroplasty.

PURPOSE: While elective primary total hip (THA) and knee (TKA) arthroplasty are effective procedures for addressing the symptoms associated with advanced osteoarthritis, there is evidence to suggest that patient anxiety and depression are linked to poorer outcomes following surgery. METHODS: A secondary analysis of prospectively-collected data of people undergoing primary elective THA or TKA for osteoarthritis across 19 hospitals was performed. We assessed outcomes at 1 year post-surgery for people with and without medically treated anxiety and/or depression at the time of surgery (A/D and no-A/D). We used unadjusted and adjusted analyses to compare improvement in Oxford Hip or Knee Scores, the incidences of major post-operative complications, satisfaction and index joint improvement by A/D status. RESULTS: 15.2% (254/1669) of patients were identified with anxiety and/or depression at time of surgery. In the unadjusted analysis, the A/D group had greater mean Oxford score improvement by 2.1 points (95% CI 0.8 to 3.4, p = 0.001), increased major complications (OR 1.39, 95% CI 1.05 to 1.85, p = 0.02), were less likely to report a "much better" global improvement for index joint (OR 0.56, 95% CI 0.38 to 0.83, p = 0.003), and there was no statistically significant difference in the rate of satisfaction with the results of surgery (OR 0.64, 95% CI 0.37 to 1.10, p = 0.10). The adjusted analysis found no significant associations between A/D vs. no-A/D and any of the reported outcomes. CONCLUSION: After adjustment for confounding variables, people with anxiety and/or depression pre-operatively, compared to those without, have similar outcomes following hip or knee arthroplasty.

Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments.

OBJECTIVE: The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. METHODS: Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. RESULTS: Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21). CONCLUSIONS: The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.

Patient satisfaction and perception of success after total knee arthroplasty are more strongly associated with patient factors and complications than surgical or anaesthetic factors.

PURPOSE: A proportion of TKA recipients following TKA are dissatisfied with their outcome. Our hypothesis is that patient satisfaction with TKA and perception of success of surgery are associated with patient comorbidities and overall health status, surgical and anaesthetic techniques as well as processes of post-operative care after TKA. The aims were to (i) measure the incidence of patient unfavourable outcomes-defined as dissatisfaction with the surgery or lack of joint-specific global improvement-1 year after TKA, and to explore the differences between these two outcomes of interest; (ii) assess the relationship between the development of these unfavourable outcomes and patient-reported knee function and overall quality of life; (iii) explore the associations between pre- and peri-operative variables and the development of these unfavourable outcomes 1 year after TKA. METHODS: This study includes analysis of data from a prospective cohort of 1017 TKA recipients. Pre-operative patient variables, surgical and acute-care data were collected. The Oxford knee score and the global perception of improvement were used to assess satisfaction and success 365 days post-surgery. RESULTS: From 1017 patients (56% female), mean age 68 years and BMI 32, 68 pts (7%) were dissatisfied with the outcome of surgery, 141 pts (14%) believed surgery was unsuccessful 1 year after TKA. A negative outcome was noted in 151 (15%) patients for either satisfaction or success, and 58 (6%) of patients reported neither good satisfaction nor success after surgery. Dissatisfied patients reported worse mean OKS (26.4 [SD 8.03] vs 42.3 [SD 5.21], p < 0.001) and mean EQ VAS (64.9 [SD 19.49] vs 81.8 [SD 14.38], p < 0.001) than satisfied patients. Patients who reported unsuccessful surgery also showed significantly lower mean OKS (30.9 [SD 9.29] vs 42.9 [SD 4.39], p < 0.001) and mean EQ VAS (68.2 [SD 18.61] vs 82.7 [SD 13.77], p < 0.001). Univariate analysis of predictors of unfavourable outcome post-TKA showed that financial status, obstructive sleep apnoea (OSA), ASA class > 2 and not resurfacing the patella were factors associated with the development of dissatisfaction with TKA and with patient perceived unsuccessful results of TKA. Multivariable logistic regression of patient satisfaction and success of TKA showed that compensation cases (OR 26.91, p < 0.001 for dissatisfaction and OR 11.49, p = 0.001 for unsuccessful TKA), obstructive sleep apnoea (OR 2.18, p = 0.04 for dissatisfaction and OR 1.82, p = 0.04 for unsuccessful TKA), ASA grade > 2 (OR 1.83, p = 0.04 for dissatisfaction and OR 1.57, p = 0.03 for unsuccessful TKA)and the development of a complication after TKA (OR 3.4, p < 0.001 for dissatisfaction and OR 2.39, p < 0.001 for unsuccessful TKA) were associated with the development of a negative outcome in both groups. Patella preservation (OR 1.96, p = 0.03) was associated with dissatisfaction, whereas the use of cruciate retaining femoral prosthesis was associated with less successful results of TKA (OR 1.78, p = 0.009). CONCLUSIONS: An unfavourable outcome occurs in approximately 7-15% of patients following TKA. The incidence varies with how an unfavourable result is defined and many factors are associated with this outcome though prosthetic design or patella resurfacing do not appear to be important.

Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR.

OBJECTIVES: To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. METHOD: Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. RESULTS: Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2-9). A median of 5 (IQR = 2-9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age-adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2-84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. CONCLUSION: Paediatric intubation in Australasian EDs is rare from a departmental and individual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications.

Validity of patient-reported complications after total hip and knee arthroplasty.

BACKGROUND: Evaluating the effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) often relies on accurate patient reporting of postoperative complications. Despite this, there is little research regarding the accuracy of patient reports. We aimed to determine the accuracy of patient-reported significant complications after THA and TKA. METHODS: Patients were recruited prior to undergoing primary hip or knee arthroplasty at 19 high-volume hospitals. After surgery, follow-up of patients via telephone interviews at 35, 90 and 365 days recorded surgical outcomes including readmission, reoperation and venous thromboembolism (VTE). Patient-reported complications were verified via medical record audits and liaison with surgeons, general practitioners or other health professionals. Surgical and demographic information and patient-reported and verified complications were entered into a database. Patient-reported and verified complications were compared for readmission, reoperation and VTE. RESULTS: The sample included 150 of 1811 patients who reported a total of 242 significant complications. Of the 242 patient-reported complications, 224 (92.6%) were correct (true positive). The type of complication had variable levels of accuracy in patient reports. Readmission to hospital was accurately reported by 90.2% (129/143) of patients. Reoperation (including any manipulations under anaesthesia, joint washouts, reductions of dislocated joints and revisions) was accurately reported by 98.7% (75/76) of patients. VTE was accurately reported by 86.7% (20/23) of patients. CONCLUSION: A high level of accuracy in patient-reported experience of complications was demonstrated following THA and TKA. Patient-reported complications may be reliably used for post-operative surveillance of joint replacement surgery.

Evidence base and practice variation in acute care processes for knee and hip arthroplasty surgeries.

BACKGROUND: Lack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence. METHODS: Part 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients. RESULTS: Continuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely. CONCLUSION: Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.

Is Satisfaction with the Acute-Care Experience Higher amongst Consumers Treated in the Private Sector? A Survey of Public and Private Sector Arthroplasty Recipients.

BACKGROUND: Consumer satisfaction with the acute-care experience could reasonably be expected to be higher amongst those treated in the private sector compared to those treated in the public sector given the former relies on high-level satisfaction of its consumers and their subsequent recommendations to thrive. The primary aims of this study were to determine, in a knee or hip arthroplasty cohort, if surgery in the private sector predicts greater overall satisfaction with the acute-care experience and greater likelihood to recommend the same hospital. A secondary aim was to determine whether satisfaction across a range of service domains is also higher in the private sector. METHODS: A telephone survey was conducted 35 days post-surgery. The hospital cohort comprised eight public and seven private high-volume arthroplasty providers. Consumers rated overall satisfaction with care out of 100 and likeliness to recommend their hospital on a 5-point Likert scale. Additional Likert-style questions were asked covering specific service domains. Generalized estimating equation models were used to analyse overall satisfaction (dichotomised as ≥ 90 or < 90) and future recommendations for care (dichotomised as 'definitely recommend' or 'other'), whilst controlling for covariates. The proportions of consumers in each sector reporting the best Likert response for each individual domain were compared using non-parametric tests. RESULTS: 457 survey respondents (n = 210 private) were included. Less patient-reported joint impairment pre-surgery [OR 1.03 (95% CI 1.01-1.05)] and absence of an acute complication (OR 2.13 95% CI 1.41-3.23) significantly predicted higher overall satisfaction. Hip arthroplasty [OR 1.84 (1.1-2.96)] and an absence of an acute complication [OR 2.31 (1.28-4.17] significantly predicted greater likelihood for recommending the hospital. The only care domains where the private out-performed the public sector were hospitality (46.7 vs 35.6%, p <0.01) and frequency of surgeon visitation (76.4 vs 65.8%, p = 0.03). CONCLUSIONS: Arthroplasty consumers treated in the private sector are not more satisfied with their acute-care experience nor are they more likely to recommend their hospital provider. Rather, avoidance of complications in either sector appears to result in improved satisfaction as well as a greater likelihood that patients would recommend their hospital provider.

The provision of brain injury rehabilitation services for people living in rural and remote New South Wales, Australia.

OBJECTIVES: The objectives of this research were to investigate the equity of brain injury rehabilitation services to rural and remote areas of the state of New South Wales (NSW), Australia, and to describe the experience of people who access and who deliver these services. METHODS: Semi-structured interviews were used to gather information from people with acquired brain injury (ABI), their families and rural and remote NSW health, rehabilitation and support services staff who worked with people with a brain injury. Data analysis was guided by an interpretative phenomenological analysis approach. FINDINGS: Fifty-nine service providers representing 35 organizations, six people with ABI and seven family members participated in the research. Three key issues emerged from the data: (1) Limited access to appropriate brain injury rehabilitation; (2) Difficulties funding, recruiting and retaining appropriately skilled health, rehabilitation and support staff; and (3) Inadequate current services resulting in a number of unmet needs. CONCLUSION: Current models of practice for ABI rehabilitation are not appropriate to address the significant inequalities and gaps in available services for people with brain injury in rural and remote NSW. Alternative innovative models are needed to reduce the disparity of access and outcomes for these people.