greatest among patients discharged with home care. Our study should be seen as one important stepping stone towards a full economic evaluation of the continuum of care for
patients. q 2000 Elsevier Science B.V. All rights reserved.
JEL classification: I10; C10 Keywords: Costing episodes-of-care; Joint replacements; Home care; Rehabilitation; Readmission rates
1. Introduction
Musculoskeletal disorders affect a significant proportion of the population Ž
. Ž
. Statistics Canada, 1993 , their prevalence increases with age Badley et al., 1994
Ž and they are a leading cause of disability McAlindon et al., 1992; Verbrugge,
. 1991 Once arthritis affects the joints, patients suffer pain, they often lose function
Ž and their quality of life is adversely affected Hadler, 1985; Kramert et al., 1983;
Liang et al., 1984; McAlindon et al., 1992; Moskowitz et al., 1992; Peyron and .
Altman, 1992; Pincus et al., 1989; Verbrugge, 1991 . In individuals for whom Ž
. medical therapy has failed, joint replacement JR surgery has been shown to be a
cost-effective intervention resulting in pain relief, enhancing function and improv- Ž
ing the quality of life Harris and Sledge, 1990; Jonsson and Larsson, 1991; .
Laupacis et al., 1993; Liang et al., 1986; Rorabeck et al., 1994; Scott et al., 1988 . In the last 5 years, the number of JRs performed in Ontario has increased at an
average annual rate of 9.0, with hip replacement surgery increasing at a slower Ž
. annual rate, 5.0, than knee replacement surgery, 14.6 Coyte et al., 1996a,b .
While JRs are cost-effective from the viewpoint of patients and the health system Ž
. Laupacis et al., 1993; Liang et al., 1984, 1986; Rorabeck et al., 1994 , they
represent a significant expense to hospitals. Thus, as hospitals strive to contain costs, limits may be placed on access to JRs by budget restrictions for prosthetic
devices, reductions in operating room time and by bed closures. Besides restrictions to the availability of JRs, health system restructuring has
significantly reduced the number of days of inpatient care for JR patients, and, simultaneously, has altered discharge patterns. Indeed, the propensity to imple-
ment early discharge programs for JR patients and to discharge these patients to Ž
. either a rehabilitation hospital or to home with or without home care services has
increased. However, little is known about the effect of these modified patterns of practice on health system costs, health outcomes and the extent to which the
burden of care has shifted from acute care institutions to patients, families and
Ž .
community agencies Coyte and Young, 1997a,b; Parr, 1996; Welch et al., 1996 . Ž
While it is clear that expenditures on community-based care have increased Parr, .
1996; Welch et al., 1996 , this increase has occurred without compelling evidence Ž
of service cost-effectiveness FederalrProvincialrTerritorial Working Group on Home Care, 1990; Hollander, 1994; Parr, 1996; Price Waterhouse, 1989; Weissert,
. 1991; Weissert et al., 1988; Welch et al., 1996 . Moreover, there is a growing
perception that unless these services are targeted, they will not represent a Ž
cost-effective alternative to acute care Weissert, 1985, 1991; Weissert et al., .
1980, 1988; Welch et al., 1996 . Ž
This paper employs an episode-of-care approach Gonnella et al., 1984; Horn- .
brook, 1995; Hornbrook et al., 1985 to estimate the impact of alternative
discharge strategies following JR surgery on the total cost of a continuum of care and on acute care readmission rates after adjusting for potential assignment bias.
The paper contributes to the literature by developing a continuum of care methodological framework for cost–outcome studies that explicitly adjusts for
Ž potential assignment bias by using a propensity score Rosenbaum and Rubin,
. 1983, 1984 . The potential to control for possible selection biases in a non-rando-
mized comparison of the costs and outcomes of clinical practice expands the scope of health services research.
2. Methods
