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journal-of-nursing-sciences/2352-0132

Original Article

The effect of post-discharge telephone intervention on

rehabilitation following total hip replacement surgery

Lun-Lan Li a,*, Yu-Yun Gan b, Li-Na Zhang b, Ya-Bing Wang b, Fan Zhang b, Jin-Mei Qi b
a
Nursing Department, The First Hospital Affiliated to An’hui Medical University, He’fei, China
b
Orthopedics Department, The First Hospital Affiliated to An’hui Medical University, He’fei, China

article info abstract

Article history: Purpose: To determine the effect of post-discharge telephone intervention with both pa-
Received 23 January 2014 tients and family caregivers on patient compliance with doctors’ advice and rehabilitation
Received in revised form progress in total hip replacement patients.
16 April 2014 Methods: In total, 249 participants were assigned to either the control or telephone inter-
Accepted 23 April 2014 vention group according to the discharge date. The patients in the intervention group were
Available online 9 May 2014 contacted by phone three to seven days after discharge, at one month, and at three months
post-discharge. Their family caregivers received were contacted by phone twice a month.
Keywords: Content of the telephone intervention included discussion of exercise, cautions in daily
Arthroplasty life, and regular examination. The patients in the control group received routine health
Hip education and follow-up. All participants were evaluated by the questionnaire of compli-
Patient compliance ance with doctors’ advice when they were discharged at one, three, and six months after
Patient education discharge. The Harris Hip Score of patients was assessed on discharge day and six months
Replacement after discharge.
Rehabilitation Results: There was no significant difference between the patients’ compliance scores in the
two groups on discharge day or one month after discharge. Three and six months after
discharge, the scores in the intervention group were significantly higher than the control
group (p < 0.05). There was no significant difference between the groups in the Harris Hip
Score on discharge day. Six months after discharge, the Harris Hip Score in the intervention
group was significantly higher than the control group (p < 0.05).
Conclusion: Telephone intervention with patients and family caregivers improved patient
compliance with doctors’ advice and promoted functional hip joint rehabilitation.
Copyright ª 2014, Chinese Nursing Association. Production and hosting by Elsevier
(Singapore) Pte Ltd. All rights reserved.

* Corresponding author.
E-mail address: lilunlan@aliyun.com (L.-L. Li).
Peer review under responsibility of Chinese Nursing Association

Production and hosting by Elsevier

http://dx.doi.org/10.1016/j.ijnss.2014.05.005
2352-0132/Copyright ª 2014, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. All rights reserved.
208 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 2 0 7 e2 1 1

nurses, four supervisor nurses, and six senior nurses with

1. Introduction professional training, including four orthopedic specialists.
The members of this group had more than three years of
Total hip replacement (THR) is a type of reparative surgery experience in orthopedic care, with abundant experience
where an artificial joint prosthesis is used to replace a partial or caring for patients with THR. The associate chief nurses su-
total impaired hip joint in order to improve motor function. It is pervised the intervention process. The remaining nurses
an important method for the treatment of such diseases as trained THR patients’ supervisors, implemented the inter-
femoral head ischemic necrosis, traumatic arthritis, rheuma- vention, and instructed THR patients on how to complete
toid arthritis, and femoral neck fracture [1e3]. Patients who questionnaires. All group members received unified training,
undergo THR experience a reduction in hip joint pain, an including rehabilitation knowledge about THR patients at
improvement in self-care ability, and increased quality of life. different stages after discharge, skills of telephone interven-
Key components for successful recovery of hip joint function tion, and guidance of filling in questionnaire. All members
myodynamia following THR surgery are early rehabilitation were eligible for participation in this study after qualifications
and continuity of care after discharge [4,5]. However, lack of were tested.
patient understanding regarding the importance of post-
operative rehabilitation, patient fear of pain, and insufficient 2.2.2.2. Selection and training of THR patient supervisor. Re-
professional guidance and effective social support system may searchers selected one suitable family supervisor per THR
lead to poor compliance of doctor’s advice following discharge. patient during hospitalization. Inclusion criteria included: a
In this study, we evaluated the benefit of regular telephone lineal relative who lived with the patient for a long time (such
follow-ups by nurses with a family caregiver of patients after as spouse or child); a sense of responsibility, love, and
THR surgery. These follow-ups were associated with signifi- patience; education level above Primary school; and informed
cant long-term improvement of patient compliance and consent. The supervisors were told the purpose and method of
functional recovery of the hip joint. the study. After informed consent was obtained, the patient
supervisors received on-site training where they were told the
specific function, purpose, and role of supervisors and issued
2. Methods a THR family supervisor manual. In order to maintain contact
and reduce loss of patients during follow-up, all supervisors
2.1. Participants registered detailed contact information.

The participants were recruited from the orthopedic ward of 2.2.2.3. Intervention procedures. (1) The patients in the inter-
the First Affiliated Hospital of Anhui Medical University in vention group were contacted by telephone three to seven
China between March 2012 and May 2013. Inclusion criteria days after discharge and one and three months after
for this study were the ability to correctly answer questions discharge. The nurses of the intervention group implemented
without cognitive dysfunction and volunteering for the study. the telephone follow-up combined with the manual of THR
Exclusion criteria included severe cardiopulmonary disease patient care. Depending on joint and muscle function at
[6] and living alone after discharge from hospital. In total, 249 different stages, patients received individualized health edu-
participants were assigned to either the control or the inter- cation and guidance including exercise, cautions in daily life,
vention group according to the discharge date. During the and regular examination accordingly. Each call lasted
study, seven cases in the control group and five cases in the 20e30 min. (2) Researchers communicated with supervisors
intervention group were excluded due to loss of contact. via telephone twice a month to understand the patient’s
functional exercise and daily life self-management, with
2.2. Interventions emphasis on the importance and necessity of compliance of
the discharge instructions. By doing so, the quality of the su-
2.2.1. Control group pervisors and the compliance of discharge instructions were
The patients in the control group received conventional monitored.
discharge guidance and follow-up. Discharge guidance
included the explanation and demonstration with images, 2.3. Outcome measures
audio, video, and real products of functional exercises to both
patients and families. All participants were issued a THR pa- Before being discharged from the hospital, patients were is-
tient care manual containing information about hip replace- sued the Harris scale and THR patient medical behavior
ment surgery, diet, rehabilitation training, and hip protection questionnaire in person, and they were required to complete
technology. All participants received routine out-patient the survey immediately. One, three, and six months after
follow-up at one, three, and six months after discharge. discharge the THR patient medical behavior questionnaire
was completed again, and at six months patients were phys-
2.2.2. Intervention group ically reexamined at the hospital. The Harris Hip Score was
In addition to conventional nursing guidance, the interven- also assessed at six months after discharge. Patients who were
tion group received the following interventions. not reexamined in person on time were investigated by re-
searchers via telephone and required to fill in the question-
2.2.2.1. Establishment of intervention group. The nurses naire. Eventually, 237 patients completed the study and all the
leading the intervention group included two associate chief questionnaires were completed.
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 2 0 7 e2 1 1 209

mean
standard deviation and analyzed using t test and

Table 1 e Comparison of general information between
repeated measures analysis of variance. Categorical data were
two groups (n [ 237).
analyzed with the chi-square test. p < 0.05 was considered
Parameter Intervention Control c2/t p
statistically significant.
group group
Gender 1.271 >0.05
Male 46 53
Female 54 84
3. Results
Age ðyear; x
sÞ 66.2
15.5 67.3
16.7 0.535 >0.05
Etiology 0.043 >0.05 3.1. Comparison of general information between two
Femoral head 29 35 groups (Table 1)
ischemic necrosis
Femoral neck fracture 40 51
Osteoarthritis 12 15
Others 25 30 3.2. Comparison of compliance between two groups
Operating method 1.482 >0.05
One-side femoral 3 7 Although there was no statistical difference in compliance
head replacement behavior between the two groups at discharge and one month
One-side total hip 79 96 after discharge (p > 0.05), compliance behavior was signifi-
replacement
cantly different at three and six months post-discharge
Two-sides total hip 21 26
replacement
(p < 0.05) (Table 2). The patients’ compliance behavior score
Others 1 3 decreased over time in both groups but less so in the inter-
vention group relative to the control group.

2.3.1. Harris rating scale 3.3. Comparison of Harris score between two groups
Harris Rating Scale [7] is the most common clinical post-
operative hip joint function evaluation tool in patients with The Harris score for both groups at discharge and six months
THR. It includes seven domains: pain degree (44 points), post-discharge are shown in Table 3. Upon discharge from the
instrumental activities of daily living (14 points), gait (11 hospital, the percentage of patients with excellent, good, or
points), walking aids (11 points), walking distance (11 points), medium hip joint function was 2.0%, 13.0%, and 46.0%,
malformation (4 points), and range of activity (5 points). respectively, in the intervention group and 2.2%, 12.4%, and
Regarding score, total score of 90e100 was considered 43.0%, respectively, in the control group. Six months after
optimal, 80e90 was good, 70e80 was moderate, and less than discharge, the percentage in the intervention group was 8.0%,
70 was poor. 41.0% and 25.0%, respectively, and 5.1%, 25.5%, and 35.8%,
respectively, in the control group.
2.3.2. THR patient medical behavior questionnaire
This questionnaire was designed by the researchers
following thorough review of the relevant literature, consul- 4. Discussion
tation with orthopedic specialist nurses, and revision by five
expert specialists in a related area. It included three main 4.1. Compliance behavior
aspects; functional exercise, behavior, and regular examina-
tions with a total of 27 items. Items were scored using a four- The implementation of telephone follow-up for continuous
point Likert scale from “never” to “always”. The items about care has been rising due to its conciseness, cost-effectiveness,
doctor’s advice of taboo behaviors were scored reversely. A and ease of use [8]. Studies have shown that telephone
full score of 108 and higher indicated improved medical intervention could improve medication compliance, improve
behavior. self-care ability, reduce readmission rate, and reduce medical
cost [9e11].The use of a family supervisor is also widely uti-
2.4. Statistical analysis lized in public health research, e.g. in the management of
tuberculosis patients [12e15].
All data was recorded into EpiData3.1 (Odense, Denmark) and The recovery time following THR surgery for rebuilding
statistically analyzed using SPSS package version 14.0 (Chi- limb function is quite long, usually 6 months [14]. One and 3
cago, IL, USA). Continuous data are presented as the months post-discharge are two key time points during

Table 2 e Comparison of compliance score between the two groups at discharge and 1, 3, and 6 months after discharge (±s)
Item n Discharge 1 month after discharge 3 months after discharge 6 months after discharge
Intervention group 100 67.78
14.51 67.25
14.66 64.93
15.38 62.28
14.64
Control group 137 68.67
13.49 62.86
13.58 56.40
14.92 50.61
16.23
t 1.833 0.540 2.074 2.549
p 0.077 0.594 0.047 0.017

ANOVA for repeated measurement, Fgroup ¼ 32.32, P < 0.001; Ftime ¼ 4.639, P < 0.05; Finteraction ¼ 3.594, P < 0.05.
210 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 1 ( 2 0 1 4 ) 2 0 7 e2 1 1

between the groups in the Harris score at discharge, but by six

Table 3 e Comparison of Harris score between the two
months after discharge, the intervention group exhibited
groups at 6 months after intervention (±s)
significantly higher Harris scores relative to control, indicating
Item n Discharge 6 months
better overall hip joint function.
after discharge
Telephone follow-up is an economic, concise, and feasible
Intervention group 100 52.67
10.78 86.38
14.91
way to implement continuous health care, and the family
Control group 137 51.34
13.58 72.50
20.19
supervisor is an easy-access source of social support. This
t 7.343 9.338
p 0.176 0.003 study found that telephone follow-up and use of a family
supervisor as a nursing intervention for THR patients after
discharge improved compliance and hip joint function
rehabilitation where implementation of nursing intervention recovery.
can have significant therapeutic benefit. In this study, the
research team made a comprehensive and scientific tele-
phone follow-up plan to target the THR patients’ rehabilita-
tion characteristics. Each phone call was approximately
Conflicts of interest
30 min in order to provide effective nursing intervention and
None
obtain patients’ overall rehabilitation information. Family
supervisors oversaw and encouraged patients in daily exer-
cises and provided powerful support for rehabilitation
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