Delivery of physical therapy in the acute care setting: a population-based study

Physical therapy provision for patients with pneumonia in US hospitals

BACKGROUND

Physical therapy (PT) appears beneficial for hospitalized patients. Little is known about PT practice patterns and costs across hospitals.

OBJECTIVE

To examine whether receiving PT is associated with specific patient and hospital characteristics for patients with pneumonia. We also explored the variability in PT service provision and costs between hospitals.

METHODS

We included administrative claims from 2010 to 2015 in the Premier Healthcare Database, inclusive of 644 US hospitals. We examined associations between receiving at least one PT visit and patient (age, race, insurance, intensive care utilization, comorbidity status, and length of stay) and hospital (academic status, rurality, size, and location) characteristics. Exploratory measures included timing and proportion of days with PT visits, and per-visit and per-admission costs.

RESULTS

Of 768,010 patients, 49% had PT. After adjustment, older age most significantly increased the probability of receiving PT (+38.0% if >80 vs. ≤50 years). Higher comorbidity burden, longer length of stay, and hospitalization in an urban setting were also associated with higher probability. Hospitalization in the South most significantly decreased the probability (-9.1% vs. Midwest). Patients without Medicare and Non-White patients also had lower probability. Median (interquartile range) days to first visit was 2 (1-4). Mean proportion of days with a visit was 35% ± 20%. Median per-visit cost was $88.90 [$56.70-$130.90] and per-admission was $224.00 [$137.80-$369.20].

CONCLUSION

Both clinical (intensive care utilization and comorbidity status) and non-clinical (age, race, rurality, location) factors were associated with receiving PT. Within and between hospitals, there was high variability in the number and frequency of visits, and costs.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy

INTRODUCTION

The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization.

METHODS

The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits.

RESULTS

In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization.

CONCLUSION

PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Mobility status and acute care physical therapy utilization: The Moderating roles of age, significant others, and insurance type

OBJECTIVE

To investigate whether a direct measure of need for PT, mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex; age; significant other; minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics.

SETTING

Five regional hospitals from one health system.

PARTICIPANTS

60,459 adults admitted between 2014 and 2018 who received a PT evaluation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Received acute care PT; Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measure of mobility.

RESULTS

Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who 1) were younger; 2) had significant others; and 3) had private insurance (vs. public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT.

CONCLUSIONS

The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide studies targeting equitable distribution of beneficial PT services.

Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

IMPORTANCE

Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied.

OBJECTIVE

To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type.

PARTICIPANTS

A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation.

INTERVENTION

None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity.

RESULTS

Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance.

CONCLUSIONS AND RELEVANCE

Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

IMPORTANCE

Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied.

OBJECTIVE

To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type.

PARTICIPANTS

A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation.

INTERVENTION

None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity.

RESULTS

Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance.

CONCLUSIONS AND RELEVANCE

Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

A comparative approach to quantifying provision of acute therapy services

This study aims to compare delivery of acute rehabilitation therapy using metrics reflecting distinct aspects of rehabilitation therapy services. Seven general medical-surgical hospitals in Illinois and Indiana prospectively collected rehabilitation therapy data. De-identified data on all patients who received any type of acute rehabilitation therapy (n = 35,449) were extracted and reported as aggregate of minutes of therapy services per discipline. Metrics included therapy types, total minutes, and minutes per day (intensity), as charted by therapists. Extended hospital stay was defined as a length of stay (LOS) longer than Medicare's geometric mean LOS. Discharge destination was coded as postacute care or home discharge. Substantial variability was observed in types, number of minutes, and intensity of therapy services by condition and hospital. The odds of an extended hospital stay increased with increased number of minutes, increased number of therapy types, and decreased with increased rehabilitation intensity. This comparative approach to assessing provision of acute therapy services reflect differential effects of service provision on LOS and discharge destination. Investigators, policymakers, and hospital administrators should examine multiple metrics of rehabilitation therapy provision when evaluating the impact of health care processes on patient outcomes.

The Relationship Between Fall Risk and Hospital-Based Therapy Utilization Is Moderated by Demographic Characteristics and Insurance Type

OBJECTIVE

To investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type).

DESIGN

Secondary analysis of electronic health records data.

SETTING

Five acute care hospitals.

PARTICIPANTS

Adults (N=110,209) admitted to 5 regional hospitals between 2014 and 2018.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics.

RESULTS

Greater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk.

CONCLUSIONS

Patients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.

Adopting Population Health Frameworks in Physical Therapist Practice, Research, and Education: The Urgency of Now

Chronic, noncommunicable diseases have replaced acute, infectious diseases as the leading causes of global mortality and morbidity. Efforts among physical therapists to address noncommunicable diseases have primarily focused on the promotion of healthy behaviors among individual clients. However, the strongest predictors of chronic disease are tied to where we live, work, learn, and play, our families, and our communities. Population health frameworks can help us better understand the complex interrelations between individuals' health condition and their social and physical environment over time and also inform the development of effective programs and policies that improve the health of individuals and communities. The objectives of this article are to: (1) define population health, prevention, and health promotion; (2) provide a current perspective on the utility of population health frameworks in physical therapy; and (3) identify opportunities for the expanded use of population health frameworks in physical therapist practice, research, and education.

Variation in Hospital-Based Rehabilitation Services Among Patients With Ischemic Stroke in the United States

BACKGROUND

Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke.

OBJECTIVE

The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke.

DESIGN

This was a retrospective, cohort design.

METHODS

The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes.

RESULTS

Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes.

LIMITATION

The findings are limited to patients with ischemic stroke.

CONCLUSION

Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee Replacement: A Randomized Clinical Trial

IMPORTANCE

Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

OBJECTIVES

To compare the effectiveness of later-stage exercise programs after TKR and to explore heterogeneity of treatment effects.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm single-blind randomized clinical trial (January 7, 2015, to November 9, 2017) using an intent-to-treat approach with follow-ups at 3 months and 6 months. The setting was Allegheny County, Pennsylvania (an outpatient physical therapy clinic and 4 community centers). Participants had primary TKR performed more than 2 months previously, were 60 years or older, experienced moderate functional limitations, and were medically cleared to exercise.

INTERVENTIONS

Clinic-based physical therapy exercise (physical therapy arm), community-based group exercise (community arm), and usual care (control arm). The control arm continued their usual care, whereas the exercise arms participated in supervised exercise programs lasting 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was arm differences in the Western Ontario and McMaster Universities Osteoarthritis Index-Physical Function (WOMAC-PF) at 3 months. The secondary outcomes included performance-based tests germane to knee replacement and additional surveys of physical function. Data were analyzed by linear mixed models and responder analysis.

RESULTS

A total of 240 participants (mean [SD] age, 70 [7] years; 61.7% female) were allocated to physical therapy (n = 96), community exercise (n = 96), or control (n = 48). All 3 arms demonstrated clinically important improvement. At 3 months, between-arm analyses for the WOMAC-PF demonstrated no differences between physical therapy and community (-2.2; 98.3% CI, -4.5 to 0.1), physical therapy and control (-2.1; 98.3% CI, -4.9 to 0.7), and community and control (0.1; 98.3% CI, -2.7 to 2.9). Performance-based tests demonstrated greater improvement in the physical therapy arm compared with both the community (0.1 z score units; 98.3% CI, 0.0-0.2) and control (0.3 z score units; 98.3% CI, 0.1-0.4) arms and the community arm compared with the control arm (0.2 z score units; 98.3% CI, 0.0-0.3). The physical therapy arm had more than 17.7% responders than the community arm and more than 19.0% responders than the control arm. There was no difference in responder rates between the community and control arms.

CONCLUSIONS AND RELEVANCE

Based on the primary outcome, participation in late-stage exercise programs after TKR offered no benefit over usual care. The benefits of physical therapy identified by the secondary outcomes and responder analysis require confirmation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02237911.

Use of Hospital-Based Rehabilitation Services and Hospital Readmission Following Ischemic Stroke in the United States

OBJECTIVE

To examine the association between hospital-based rehabilitation service use and all-cause 30-day hospital readmission among patients with ischemic stroke.

DESIGN

Secondary analysis of inpatient Medicare claims data using Standard Analytical Files.

SETTING

Acute hospitals across the United States.

PARTICIPANTS

From nationwide data, Medicare fee-for-service beneficiaries (N=88,826) aged 66 years or older hospitalized for ischemic stroke between January to November 2010.

INTERVENTIONS

Hospital-based rehabilitation services were quantified using Medicare inpatient claims revenue center codes for evaluation (occupational therapy [OT] and physical therapy [PT]), as well as the number of therapy units delivered. Therapy minutes for both OT and PT services were categorized into none, low, medium, and high.

MAIN OUTCOME MEASURES

All-cause 30-day hospital readmission. A generalized linear mixed model was used to examine the effect of hospital-based rehabilitation services on 30-day hospital readmission, after adjusting for patient and hospital characteristics.

RESULTS

In fully adjusted models, compared to patients who received no PT, we observed a monotonic inverse relationship between the amount of PT and hospital readmission. For low PT (30 minutes), the odds ratio (OR) was 0.90 (95% confidence interval [CI], 0.83-0.96). For medium PT (>30 to ≤75 minutes), the OR was 0.89 (95% CI, 0.82-0.95). For high PT (>75 minutes), the OR was 0.86 (95% CI, 0.80-0.93).

CONCLUSION

Hospital-based PT services were associated with lower risk of 30-day hospital readmission in patients with ischemic stroke.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE

This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out-of-pocket costs under proposed therapy caps.

METHOD

This retrospective, population-based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out-of-pocket costs.

RESULTS

Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12-14 visits.

DISCUSSIO

. Wide variation exists in potential patient out-of-pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.

Individual and Regional Determinants for Physical Therapy Utilization in Germany: Multilevel Analysis of National Survey Data

BACKGROUND

Physical therapy is included in many clinical guidelines and is a commonly used health service. However, access to its benefits should not strongly depend on social or demographic factors.

OBJECTIVE

The present study used the Andersen model to explain to what extent physical therapy utilization in Germany depends on factors beyond medical need.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS, 2008-2011; target population, 18-79 years) is part of the German health-monitoring system. Two-stage stratified cluster sampling resulted in a sample of 8152 participants. Data were matched with district-related information on social structures and service supply. Following Andersen's Behavioral Model of Health Services Use, this study identified predisposing, enabling, and need factors for physical therapy utilization using multilevel logistic regression analyses.

RESULTS

Physical therapy was used by 23.4% (95% CI: 22.0-24.8) of the German population within one year, with a higher proportion of females (26.8%; 95% CI: 25.1-28.6) than males (19.9%; 95% CI: 18.1-21.8) and an increase with age. Beyond medical need, physical therapy utilization depended on higher education, migrant background, nonsmoking (predisposing), social support, higher income, private health insurance, and gatekeeping service contact (enabling). Variation among districts partly reflected regional supply.

LIMITATIONS

Because the present study was cross-sectional, its findings provide representative information on physical therapy use but do not establish final causal links or identify whether utilization or supply in certain districts or population groups is adequate.

CONCLUSIONS

Whether certain regions are under- or overserved and whether further regulations are needed is of political interest. Physicians and therapists should develop strategies to improve both adherence of hard-to-reach groups and supply in low-supply regions.

Use of post-acute care after hospital discharge in urban and rural hospitals

OBJECTIVES

Geographic variation in the use of post-acute care (PAC - skilled nursing facility and home health care) after hospital discharge is substantial, but reasons for this remain largely unexplored. PAC use in urban hospitals compared to rural hospitals may be one key contributor. We aimed to describe PAC use, explore substitution of one type of PAC for another, and identify how PAC use varies by diagnosis in urban and rural settings.

STUDY DESIGN

Secondary analysis of the 2012 National Inpatient Sample including adult discharges to PAC after a hospitalization.

METHODS

We adjusted for differences in patient demographics, comorbidities, hospital care provided, and hospital information, comparing use of PAC in urban and rural settings in multivariable logistic regression.

RESULTS

Rural patients discharged from rural hospitals constituted 188,137 (12.1%) of the 1.56 million discharges in the sample. Rural discharges received less home health care (0.85; 0.80-0.90) than urban discharges, resulting in less rural PAC use overall (0.95; 0.91-0.99). Rural discharges received more overall PAC for stroke (OR 1.11; 95% CI 1.03-1.19) and less PAC for sepsis (0.92; 0.86-0.98), hip fracture (0.82; 0.70-0.96), and elective joint arthroplasty, where rural discharges had 41% lower odds of receiving PAC (0.59; 0.49-0.71).

CONCLUSIONS

The striking differences in receipt of post-acute care in urban and rural patients may constitute a disparity. Evaluation of costs and outcomes of PAC use in these settings is urgently needed as Medicare expands bundled payments for this care.

Experiences of Physical Therapists Working in the Acute Hospital Setting: Systematic Review

BACKGROUND

Physical therapists working in acute care hospitals require unique skills to adapt to the challenging environment and short patient length of stay. Previous literature has reported burnout of clinicians and difficulty with staff retention; however, no systematic reviews have investigated qualitative literature in the area.

PURPOSE

The purpose of this study was to investigate the experiences of physical therapists working in acute hospitals.

DATA SOURCES

Six databases (MEDLINE, CINAHL Plus, EMBASE, AMED, PsycINFO, and Sociological Abstracts) were searched up to and including September 30, 2015, using relevant terms.

STUDY SELECTION

Studies in English were selected if they included physical therapists working in an acute hospital setting, used qualitative methods, and contained themes or descriptive data relating to physical therapists' experiences.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction included the study authors and year, settings, participant characteristics, aims, and methods. Key themes, explanatory models/theories, and implications for policy and practice were extracted, and quality assessment was conducted. Thematic analysis was used to conduct qualitative synthesis.

RESULTS

Eight articles were included. Overall, study quality was high. Four main themes were identified describing factors that influence physical therapists' experience and clinical decision making: environmental/contextual factors, communication/relationships, the physical therapist as a person, and professional identity/role.

LIMITATIONS

Qualitative synthesis may be difficult to replicate. The majority of articles were from North America and Australia, limiting transferability of the findings.

CONCLUSIONS

The identified factors, which interact to influence the experiences of acute care physical therapists, should be considered by therapists and their managers to optimize the physical therapy role in acute care. Potential strategies include promotion of interprofessional and collegial relationships, clear delineation of the physical therapy role, multidisciplinary team member education, additional support staff, and innovative models of care to address funding and staff shortages.

Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission

BACKGROUND

Little is known about the use of rehabilitation in the acute care setting and its impact on hospital readmissions.

OBJECTIVE

The objective of this study was to examine the association between the intensity of rehabilitation services received during the acute care stay for stroke and the risk of 30-day and 90-day hospital readmission.

DESIGN

A retrospective cohort analysis of all acute care hospitals in Arkansas and Florida was conducted.

METHODS

Patients (N=64,065) who were admitted for an incident stroke in 2009 or 2010 were included. Rehabilitation intensity was categorized as none, low, medium-low, medium-high, or high based on the sum and distribution of physical therapy, occupational therapy, and speech therapy charges within each hospital. Cox proportional hazards regression was used to estimate hazard ratios, controlling for demographic characteristics, illness severity, comorbidities, hospital variables, and state.

RESULTS

Relative to participants who received the lowest intensity therapy, those who received higher-intensity therapy had a decreased risk of 30-day readmission. The risk was lowest for the highest-intensity group (hazard ratio=0.86; 95% confidence interval=0.79, 0.93). Individuals who received no therapy were at an increased risk of hospital readmission relative to those who received low-intensity therapy (hazard ratio=1.30; 95% confidence interval=1.22, 1.40). The findings were similar, but with smaller effects, for 90-day readmission. Furthermore, patients who received higher-intensity therapy had more comorbidities and greater illness severity relative to those who received lower-intensity therapy.

LIMITATIONS

The results of the study are limited in scope and generalizability. Also, the study may not have adequately accounted for all potentially important covariates.

CONCLUSIONS

Receipt of and intensity of rehabilitation therapy in the acute care of stroke is associated with a decreased risk of hospital readmission.

A randomized trial to compare exercise treatment methods for patients after total knee replacement: protocol paper

Background

Although the outcome of total knee replacement (TKR) is favorable, surgery alone fails to resolve the functional limitations and physical inactivity that existed prior to surgery. Exercise is likely the only intervention capable of improving these persistent limitations, but exercises have to be performed with intensity sufficient to promote significant changes, at levels that cannot be tolerated until later stages post TKR. The current evidence is limited regarding the effectiveness of exercise at a later stage post TKR. To that end, this study aims to compare the outcomes of physical function and physical activity between 3 treatment groups: clinic-based individual outpatient rehabilitative exercise during 12 weeks, community-based group exercise classes during 12 weeks, and usual medical care (wait-listed control group). The secondary aim is to identify baseline predictors of functional recovery for the exercise groups.

Methods/Design

This protocol paper describes a comparative effectiveness study, designed as a 3-group single-blind randomized clinical trial. Two hundred and forty older adults who underwent TKR at least 2 months prior will be randomized into one of the three treatment approaches. Data will be collected at baseline, 3 months, and 6 months. The wait-listed control group will be randomized to one of the 2 exercise groups after 6 months of study participation, and will complete a 9-month follow-up. Primary outcome is physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale (WOMAC-PF). Physical function is also measured by performance-based tests. Secondary outcomes include performance-based tests and physical activity assessed by a patient-reported survey and accelerometry-based physical activity monitors. Exploratory outcomes include adherence, co-interventions, attrition, and adverse events including number of falls. Linear mixed models will be fitted to compare the changes in outcome across groups. Logistic regression will identify patient characteristics that predict functional recovery in the exercise groups. Instrumental variable methods will be used to estimate the efficacy of the interventions in the presence of non-compliance.

Discussion

Results will inform recommendations on exercise programs to improve physical function and activity for patients at the later stage post TKR and help tailor interventions according with patients’ characteristics.

Trial registration

ClinicalTrials.gov Identifier NCT02237911.

Student perceptions and understanding of client-therapist interactions within the inpatient acute care environment: qualitative study

BACKGROUND

Physical therapists practicing in inpatient acute care settings in the United States work in a 21st century health care system that requires professional competence in clinical reasoning and decision making. For doctor of physical therapy (DPT) students, the development of confidence in the patient evaluation and the professional skills necessary for managing the inpatient environment can be challenging.

OBJECTIVE

The study's purpose was to understand whether the early exposure of students to inpatient settings informed their understanding of the thought processes and actions of experienced clinicians during client interactions.

DESIGN

A qualitative design was used.

METHODS

Thirty-three DPT students working in inpatient settings were recruited from 15 unique inpatient hospital (acute care and rehabilitation) facilities with a convenience sampling technique. Reflective data were collected for 1 month with clinician-facilitated discussion boards.

RESULTS

Four themes emerged: environment, communication, evaluation, and client-therapist interaction. The themes informed a conceptual model depicting the observation by DPT students of factors that influenced interactions between clients and experienced clinicians in inpatient settings. Reflection on the what, the how, and the why that informed clinical decisions enabled students to recognize the situated nature of evaluation and treatment approaches.

LIMITATIONS

The use of a sample from 1 year of a DPT program at one university reduced the generalizability of the results.

CONCLUSIONS

Limited research has examined student perceptions of the interactions of experienced clinicians with clients in inpatient acute care settings. More research is needed to understand the impact of exposing students to the thoughts and actions of therapists working in such settings earlier within DPT curricula.

Factors associated with utilization of preoperative and postoperative rehabilitation services by patients with amputation in the VA system: an observational study

BACKGROUND

The Department of Veterans Affairs (VA) and the Department of Defense published evidence-based guidelines to standardize and improve rehabilitation of veterans with lower limb amputations; however, no studies have examined the guidelines' impact.

OBJECTIVES

The purposes of this study were: (1) to describe the utilization of rehabilitative services in the acute care setting by people who underwent major lower limb amputation in the VA from 2005 to 2010, (2) to identify factors associated with receipt of rehabilitation services, and (3) to examine the impact of the guidelines on service receipt.

DESIGN

A cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005, to December 31, 2010, was conducted. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases.

METHODS

Rehabilitation services were categorized as physical therapy, occupational therapy, and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined the impact of guideline implementation and identified factors associated with service receipt.

RESULTS

Patients were 1.45 and 1.73 times more likely to receive preoperative physical therapy and occupational therapy and 1.68 and 1.79 times more likely to receive postoperative physical therapy and occupational therapy after guideline implementation. Patients in the Northeast had the lowest likelihood of receiving preoperative and postoperative rehabilitation services, whereas patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified.

LIMITATIONS

The sample included only veterans who had surgeries at VA Medical Centers and cannot be generalized to veterans with surgeries outside the VA or to nonveteran patients and settings.

CONCLUSIONS

Further quality improvement efforts are needed to standardize delivery of rehabilitation services for veterans with amputations in the acute care setting.

[Utilization of physiotherapy services for traumatic disorders of the lower extremity in ambulatory care]

INTRODUCTION

Limited information is available on physiotherapy treatment of lower extremity injuries.

AIM

The purpose of this study included analysis of the utilization of outpatient physiotherapy services in case of injuries of the lower extremity.

METHOD

Data derived from the database of the National Health Insurance Fund Administration, Hungary. The number of cases undergoing physiotherapy activities after lower extremity injuries were determined.

RESULTS

In 2009 the average number of cases undergoing physiotherapy activities following lower extremity injuries per 10,000 persons were the following: "hip and thigh injuries" 249.75 male cases and 443.7 female cases; "knee and leg injuries" 927.64 male cases and 668.25 female cases, and "ankle and foot injuries" 307.58 male cases and 245.75 female cases.

CONCLUSIONS

According to this study, the number of physiotherapy activities for patients with injuries of the lower extremity showed significant differences between genders.

The acute care physical therapy HIV/AIDS patient population: a descriptive study

This study was based on an analysis of an existing database compiled from 475 medical records of people living with HIV/AIDS admitted to an acute-care hospital in New York City in 2004. The characteristics of patients with HIV infection that received physical therapy were determined. Differences between patients with HIV infection that did and did not receive physical therapy, as well as predictors of receipt of physical therapy, were identified. The physical therapy subgroup (n = 69) had a mean age of 48.3 years, consisted of more men than women, and was predominately black, with public health insurance. Admissions were commonly due to non-AIDS-defining illness as the primary diagnoses, accompanied by several comorbidities. Admissions often presented with functional deficits, incurred a prolonged length of stay, and required assistance at discharge. Differences existed between the physical therapy subgroup and the non-physical therapy subgroup (n = 406). Predictors of receipt of physical therapy were functional status on admission and length of stay.