BACKGROUND:Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the ...effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA.
METHODS:At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar digitally simulated coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis.
RESULTS:Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval CI, −1.68 to 3.23) and 12 weeks (difference, −2.33; 90% CI, −4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, −2.60 to 12.25).
CONCLUSIONS:Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA.
LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Managing noncommunicable diseases through primary healthcare has been identified as the key strategy to achieve universal health coverage but is challenging in most low- and middle-income countries. ...Stroke is the leading cause of death and disability in rural China. This study aims to determine whether a primary care-based integrated mobile health intervention (SINEMA intervention) could improve stroke management in rural China.
Based on extensive barrier analyses, contextual research, and feasibility studies, we conducted a community-based, two-arm cluster-randomized controlled trial with blinded outcome assessment in Hebei Province, rural Northern China including 1,299 stroke patients (mean age: 65.7 SD:8.2, 42.6% females, 71.2% received education below primary school) recruited from 50 villages between June 23 and July 21, 2017. Villages were randomly assigned (1:1) to either the intervention or control arm (usual care). In the intervention arm, village doctors who were government-sponsored primary healthcare providers received training, conducted monthly follow-up visits supported by an Android-based mobile application, and received performance-based payments. Participants received monthly doctor visits and automatically dispatched daily voice messages. The primary outcome was the 12-month change in systolic blood pressure (BP). Secondary outcomes were predefined, including diastolic BP, health-related quality of life, physical activity level, self-reported medication adherence (antiplatelet, statin, and antihypertensive), and performance in "timed up and go" test. Analyses were conducted in the intention-to-treat framework at the individual level with clusters and stratified design accounted for by following the prepublished statistical analysis plan. All villages completed the 12-month follow-up, and 611 (intervention) and 615 (control) patients were successfully followed (3.4% lost to follow-up among survivors). The program was implemented with high fidelity, and the annual program delivery cost per capita was US$24.3. There was a significant reduction in systolic BP in the intervention as compared with the control group with an adjusted mean difference: -2.8 mm Hg (95% CI -4.8, -0.9; p = 0.005). The intervention was significantly associated with improvements in 6 out of 7 secondary outcomes in diastolic BP reduction (p < 0.001), health-related quality of life (p = 0.008), physical activity level (p < 0.001), adherence in statin (p = 0.003) and antihypertensive medicines (p = 0.039), and performance in "timed up and go" test (p = 0.022). We observed reductions in all exploratory outcomes, including stroke recurrence (4.4% versus 9.3%; risk ratio RR = 0.46, 95% CI 0.32, 0.66; risk difference RD = 4.9 percentage points pp), hospitalization (4.4% versus 9.3%; RR = 0.45, 95% CI 0.32, 0.62; RD = 4.9 pp), disability (20.9% versus 30.2%; RR = 0.65, 95% CI 0.53, 0.79; RD = 9.3 pp), and death (1.8% versus 3.1%; RR = 0.52, 95% CI 0.28, 0.96; RD = 1.3 pp). Limitations include the relatively short study duration of only 1 year and the generalizability of our findings beyond the study setting.
In this study, a primary care-based mobile health intervention integrating provider-centered and patient-facing technology was effective in reducing BP and improving stroke secondary prevention in a resource-limited rural setting in China.
ClinicalTrials.gov NCT03185858.
Worldwide, stroke is prevalent, costly, and disabling in >80 million survivors. The burden of stroke is increasing despite incredible progress and advancements in evidence-based acute care therapies ...and despite the substantial changes being made in acute care stroke systems, processes, and quality metrics. Although there has been increased global emphasis on the importance of postacute stroke care, stroke system changes have not expanded to include postacute care and outcome follow-up. Our objectives are to describe the gaps and challenges in postacute stroke care and suboptimal stroke outcomes; to report on stroke survivors' and caregivers' perceptions of current postacute stroke care and their call for improvements in follow-up services for recovery and secondary prevention; and, ultimately, to make the case that a paradigm shift is needed in the definition of comprehensive stroke care and the designation of Comprehensive Stroke Center. Three recommendations are made for a paradigm shift in comprehensive stroke care: (1) criteria should be established for designation of rehabilitation readiness for Comprehensive Stroke Centers, (2) The American Heart Association/American Stroke Association implement an expanded Get With The Guidelines-Stroke program and criteria for comprehensive stroke centers to be inclusive of rehabilitation readiness and measure outcomes at 90 days, and (3) a public health campaign should be launched to offer hopeful and actionable messaging for secondary prevention and recovery of function and health. Now is the time to honor the patients' and caregivers' strongest ask: better access and improved secondary prevention, stroke rehabilitation, and personalized care.
Abstract Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review. Objectives To summarize the efficacy of postacute ...rehabilitation and to outline future research strategies for increasing knowledge of its effectiveness. Data Sources English-language systematic reviews that examined multidisciplinary therapy-based rehabilitation services for adults, published in the last 25 years and available through Cochrane, Medline, or CINAHL databases. We excluded multidisciplinary biopsychosocial rehabilitation programs and mental health services. Study Selection Using the search term rehabilitation , 167 records were identified in the Cochrane database, 1163 meta-analyses and reviews were identified in Medline, and 226 in CINAHL. The Medline and CINAHL search was further refined with 3 additional search terms: therapy , multidisciplinary , and interdisciplinary . In summary, we used 12 reviews to summarize the efficacy of multidisciplinary, therapy-based postacute rehabilitation; the 12 covered only 5 populations. Data Extraction Two reviewers extracted information about study populations, sample sizes, study designs, the settings and timing of rehabilitation, interventions, and findings. Data Synthesis Based on systematic reviews, the evidence for efficacy of postacute rehabilitation services across the continuum was strongest for stroke. There was also strong evidence supporting multidisciplinary inpatient rehabilitation for patients with rheumatoid arthritis, moderate to severe acquired brain injury, including traumatic etiologies, and for older adults. Heterogeneity limited our ability to conclude a benefit or a lack of a benefit for rehabilitation in other postacute settings for the other conditions in which systematic reviews had been completed. The efficacy of multidisciplinary rehabilitation services has not been systematically reviewed for many of the diagnostic conditions treated in rehabilitation. We did not complete a summary of findings from individual studies. Conclusions Given the limitations and paucity of systematic reviews, information from carefully designed nonrandomized studies could be used to complement randomized controlled trials in the study of the effectiveness of postacute rehabilitation. Consequently, a stronger evidence base would become available with which to inform policy decisions, guide the use of services, and improve patient access and outcomes.
Abstract
Translation of evidence refers to widespread dissemination, adoption and implementation of interventions that can have a significant effect on population health. However, effective ...translation has been slow; significant lags and inconsistent uptake impede intended benefits for older adults. In response, interest and investments in implementation science as the study of methods to promote the adoption and integration of evidence into real-world settings have rapidly increased. By definition, the methodology applies to evidence-based practices, interventions, and policies. But the process of evidence generation can still be prolonged. This paper introduces a framework being tested at the Duke Roybal Center that integrates a model for behavioral intervention development and testing with principles of implementation science in order to accelerate translation across all phases of behavioral research. Attendees will first learn about the NIH Stage Model supported by NIA that guides researchers to identify, define, and clarify an array of activities across six stages of behavioral intervention development. These stages define components of intervention generation, pilot and then efficacy testing, effectiveness research and ultimately implementation of potent theory-driven interventions that improve health and well-being. With this foundation, the Duke framework will be presented to illustrate how concepts of several common implementation science frameworks and models can be integrated within the different stages. Interactive case studies will be used to illustrate application of this new integrated framework for evidence generation, accelerated implementation and scale-up, and pathways for translation. Integrating the Stage Model with principles from implementation science can accelerate translation.
Abstract
Objective
The purpose of this study was to describe the process and cost of delivering a physical therapist–guided synchronous telehealth exercise program appropriate for older adults with ...functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline.
Methods
Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant.
Results
A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the “value proposition” of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved.
Conclusions
The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a “blue print” for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine.
Impact
As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study’s experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.
Aims
Stroke is affecting an increasing number of young and middle‐aged adults. Given the substantial diversion from anticipated life trajectories that younger stroke survivors experience as a result ...of their stroke deficits, their health‐related quality of life (HRQOL) is likely to be negatively impacted during the immediate post‐acute recovery period. The aim of this study was to generate a comprehensive understanding of the influences on HRQOL and acute recovery during the first three months following stroke for younger adults using a socio‐ecological perspective.
Design
Longitudinal, convergent mixed methods design.
Methods
HRQOL survey data, assessed using the Patient Generated Index (N = 31), and qualitative interview data about survivors’ recovery experiences (N = 20) were collected. Simple linear regression and effect size results were integrated with themes and sub‐themes identified from conventional content analysis using joint data displays.
Results
Depression and fatigue negatively affected recovery at the individual level. At the family and societal level, family functioning, social support including being married, having insurance, working, adequate income and being unemployed post‐stroke all positively impacted recovery. Qualitative findings revealed determination, coping, and accessing healthcare to positively affect recovery though a meta‐inference could not be drawn as no quantitative data addressed these concepts.
Conclusion
A variety of factors intersecting across socio‐ecological levels were perceived by young stroke survivors to influence acute recovery experiences and outcomes.
Impact
This study identified individual‐, family‐ and societal‐level factors in younger adults’ environments that may affect the acute stroke recovery experience. Findings underscore the need for research and clinical approaches that consider environmental factors at multiple levels of influence when supporting stroke recovery for younger adults.
Home rehabilitation requests subject to review by health authorities, restricted to patients with significant new-disability and limited caregiver support. (Provision of healthcare is regulated and ...reimbursed regionally.) Tanzania Local only Containment and mitigation: public gatherings ban, 30-day closure of schools, universities, training institutions, health screening at points of entry, 14-day quarantine for travellers from high-risk countries. Local KCMC. Example: care for older adults suspended unless an emergency, outpatient block appointments, reduced elective surgeries and prioritised emergency surgeries. Shift in rehabilitation hospital beds to maximise inpatient capacity; shift in rehabilitation personnel to provide greater acute hospital and community service support. CDC, Centers for Disease Control and Prevention; KCMC, Kilimanjaro Christian Medical Center.
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