Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review

Stratification of Outpatient Physical Therapy Following Total Knee Arthroplasty: Knee Arthroplasty Physical Therapy Pathways (KAPPA) Nonrandomized Controlled Trial

BACKGROUND

Outpatient physical therapy following total knee arthroplasty (TKA) is often considered crucial for an effective recovery. However, recent evidence suggests that a self-directed pathway may yield similar benefits to supervised care. Despite this, there appear to be no established criteria to determine who can successfully self-direct their rehabilitation versus those who would benefit from outpatient physical therapy. This study aimed to determine if early postoperative criteria can stratify TKA patients into a self-directed or supervised physical therapy pathway without compromising outcomes.

METHODS

Overall, 60 TKA patients were initially allocated to a self-directed, unsupervised protocol for their postoperative rehabilitation. Baseline demographics, along with functional and self-reported outcomes, were assessed preoperatively and at 2 weeks, 6 weeks, and 4 months following surgery. Patients were referred to supervised outpatient physical therapy if they met any of the following Knee Arthroplasty Physical Therapy Pathways (KAPPA) criteria: (1) knee flexion range of motion <90 degrees; (2) knee extension range of motion lacking >10 degrees; or (3) dissatisfaction with the progress of their rehabilitation.

RESULTS

At 2 weeks post-TKA, 28 participants met the KAPPA criteria for supervised physical therapy for reasons of knee flexion <90 degrees (61%), a lack of knee extension >10 degrees (36%), or not being satisfied with the progress of their recovery (3%). The remaining 32 participants continued with a self-directed rehabilitation pathway. All outcomes assessed favored the self-directed group at 2 weeks, however, after an average of 4 supervised physical therapy sessions at 4 months there were no longer any differences between the 2 groups.

CONCLUSIONS

Over half of the included participants could self-direct their rehabilitation following TKA without supervised physical therapy while also maintaining excellent clinical outcomes. For those who met KAPPA criteria at 2 weeks post-TKA, 4 supervised physical therapy sessions appeared to be beneficial when outcomes were reassessed at 4 months.

Factors Associated With Higher Utilization of Outpatient Physical Therapy for Patients Who Have Undergone Primary Total Joint Arthroplasty: A Retrospective Cohort Study

Background

Research has identified predictive factors for inpatient complications and short-term recovery following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Predictors that may influence length of care in outpatient physical therapy (PT) have yet to be examined. Doing so may improve the quality and efficiency of PT care following TKA and THA.

Purpose

The aim of this study was to determine factors associated with a higher utilization of outpatient PT visits for patients who have had primary THA or TKA.

Methods

A retrospective cohort study was performed using a population of 5147 patients who underwent THA and TKA between January 2017 and October 2022. Demographic and clinical factors were analyzed to determine which factors influenced PT utilization.

Results

Our multivariable linear regression model revealed that female sex, need for inpatient PT visits, and TKA as opposed to THA were significantly associated with an increase in outpatient PT visits. Older age, number of telerehabilitation visits, and history of depression were associated with fewer outpatient PT visits while accounting for all other variables.

Conclusions

The results of this retrospective analysis may help to identify some potential factors including TKA vs THA, patient age, and a history of depression that can be evaluated prospectively in future studies to determine whether they predict subsequent outpatient PT utilization.

Racial/Ethnic Disparities in Physical Therapy Utilization After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities.

METHODS

TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses.

RESULTS

Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each).

DISCUSSION

In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately.

LEVEL OF EVIDENCE

Level III.

The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement

Background

One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.

Methods

This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015–2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.

Results

The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.

Conclusions

This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.

Association between weather and utilisation of physical therapy in patients with osteoarthritis: a case-crossover study

Background

During varied weather conditions, patients with osteoarthritis experience different severity of symptoms and signs. However, weather may also cause barriers or incentives for patients to seek medical services. These factors may result in changes in medical utilisation; however, no studies have investigated whether the probability of physical therapy utilisation among patients with osteoarthritis is associated with changes in meteorological factors.

Method

By using a secondary data of NHID in Taiwan, we conducted a population-based, retrospective study with case-crossover design for patients initially diagnosed with osteoarthritis between 2000 and 2013. The meteorological factors of months with the lowest treatment rate were used as patients’ own control periods and compared with the parameters of months with high treatment frequency. The risk of exposure to different meteorological factors, including mean temperature, daily highest temperature, daily minimum temperature, diurnal temperature range, relative humidity, and barometric pressure, was estimated and represented by odds ratios (ORs) and 95% confidence intervals (CIs).

Results

A total of 8,130 patients were recruited. Regardless of univariate or multivariable analysis, increased daily highest temperature enhanced the frequency of physical therapy (OR: 1.04; 95% CI: 1.02–1.05; p < 0.01; OR: 1.07; 95% CI: 1.04–1.10; p < 0.01). When the weather was hotter (> 23 °C), higher diurnal temperature range and humidity resulted in an increase in the utilisation of physical therapy. However, when the weather was colder (< 23 °C), reverse effects were observed.

Conclusions

An increase in temperature increases the probability of physical therapy resource use. Therefore, temperature, along with other meteorological factors, may play a key role in the utilization of physical therapy among patients with osteoarthritis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05233-9.