Total joint arthroplasty: practice variation of physiotherapy across the continuum of care in Alberta.

BACKGROUND: Comprehensive and timely rehabilitation for total joint arthroplasty (TJA) is needed to maximize recovery from this elective surgical procedure for hip and knee arthritis. Administrative data do not capture the variation of treatment for rehabilitation across the continuum of care for TJA, so we conducted a survey for physiotherapists to report practice for TJA across the continuum of care. The primary objective was to describe the reported practice of physiotherapy for TJA across the continuum of care within the context of a provincial TJA clinical pathway and highlight possible gaps in care. METHOD: A cross-sectional on-line survey was accessible to licensed physiotherapists in Alberta, Canada for 11 weeks. Physiotherapists who treated at least five patients with TJA annually were asked to complete the survey. The survey consisted of 58 questions grouped into pre-operative, acute care and post-acute rehabilitation. Variation of practice was described in terms of number, duration and type of visits along with goals of care and program delivery methods. RESULTS: Of the 80 respondents, 26 (33 %) stated they worked in small centres or rural settings in Alberta with the remaining respondents working in two large urban sites. The primary treatment goal differed for each phase across the continuum of care in that pre-operative phase was directed at improving muscle strength, functional activities were commonly reported for acute care, and post-acute phase was directed at improving joint range-of-motion. Proportionally, more physiotherapists from rural areas treated patients in out-patient hospital departments (59 %), whereas a higher proportion in urban physiotherapists saw patients in private clinics (48 %). Across the continuum of care, treatment was primarily delivered on an individual basis rather than in a group format. CONCLUSIONS: Variation of practice reported with pre-and post-operative care in the community will stimulate dialogue within the profession as to what is the minimal standard of care to provide patients undergoing TJA.

Web-Based System to Capture Consistent and Complete Real-world Data of Physical Therapy Interventions Following Total Knee Replacement: Design and Evaluation Study.

BACKGROUND: Electronic health records (EHRs) have the potential to facilitate consistent clinical data capture to support excellence in patient care, quality improvement, and knowledge generation. Despite widespread EHR use, the vision to transform health care system and its data to a "learning health care system" generating knowledge from real-world data is limited by the lack of consistent, structured clinical data. OBJECTIVE: The purpose of this paper was to demonstrate the design of a web-based structured clinical intervention data capture system and its evaluation in practice. The use case was ambulatory physical therapy (PT) treatment after total knee replacement (TKR), one of the most common and costly procedures today. METHODS: To identify the PT intervention type and intensity (or dose) used to treat patients with knee arthritis following TKR, an iterative user-centered design process refined an initial list of PT interventions generated during preliminary chart reviews. Input from practicing physical therapists and national and international experts refined and categorized the interventions. Next, a web-based, hierarchical structured system for intervention and intensity documentation was designed and deployed. RESULTS: The PT documentation system was implemented by 114 physical therapists agreeing to record all interventions at patient visits. Data for 161 patients with 2615 PT visits were entered by 83 physical therapists. No technical problems with data entry were reported, and data entry required less than 2 minutes per visit. A total of 42 (2%) interventions could not be categorized and were recorded using free text. CONCLUSIONS: The use of user-centered design principles provides a road map for developing clinically feasible data capture systems that employ structured collection of uniform data for use by multiple practitioners across institutions to complement and augment existing EHRs. Secondarily, these data can be analyzed to define best practices and disseminate knowledge to practice.

Patient and Caregiver Perspectives on an eHealth Tool: A Qualitative Investigation of Preferred Formats, Features and Characteristics of a Presurgical eHealth Education Module.

INTRODUCTION: Total hip and total knee replacement (THR and TKR) are suggested for reducing joint pain resulting from hip and knee osteoarthritis (OA), especially when other interventions have not resulted in desired outcomes. Providing prehabilitation education can improve patients' psychological and physical well-being before and after surgery. The use of electronic health (eHealth) tools can be considered an effective method to increase patients' access to prehabilitation, particularly for those facing barriers to attending diagnosis-specific in-person education sessions. However, limited attention is paid to both caregiver and patient perspectives regarding the delivery formats, features, and characteristics of eHealth tools. METHOD: Patients with hip (n = 46) and knee OA (n = 14) and their family caregivers (n = 16) participated in in-person focus groups or phone interviews. Participants were shown a mock-up of an eHealth module, and asked to share their preferences regarding the formats, features, and characteristics of the eHealth prehabilitation tool. Data was transcribed verbatim and coded using primary thematic and secondary content analyses. RESULT: Analyses revealed 3 main themes: 1. "easier to understand" emphasizes patients' preferences on delivery formats and features; 2. "what does that mean?" highlights requests for clear and simple information; and 3. "Preparation, right?" shows patients' perspectives on the best time to have access to the eHealth tool. DISCUSSION: Participants' preferences for prehabilitation tools included offering eHealth tools in multiple mediums of delivery (eg, written materials, pictures, videos). Participants preferred simplified information that emphasized the key points and rationale for the knowledge. There were differences in preferred timeline for having access to prehabilitation education, such as some participants wanting to receive prehabilitation well in advance, while others stated just before surgery was adequate. Our findings provide novel and actionable information about patient and caregiver perspectives on features and characteristics of prehabilitation education for patients with hip and knee OA.

Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group study.

BACKGROUND: There is worldwide variation in rehabilitation practices after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and no agreement on which interventions will lead to optimal short and long term patient outcomes. As a first step in the development of clinical practice guidelines for post-acute rehabilitation after THA and TKA, we explored experiences and attitudes about rehabilitation practices and outcomes in groups of individuals identified as key stakeholders. METHODS: Separate focus groups and interviews were conducted with patients (THA or TKA within past year) and three health professional groups: allied health professionals (AHPs), orthopaedic surgeons, and other physicians, in Canada and the United States. Pairs of moderators led the focus groups using a standardized discussion guide. Discussions were audiotaped and transcribed verbatim. A content analysis within and across groups identified key themes. RESULTS: Eleven focus groups and eight interviews took place in six sites. Patients (n = 32) varied in age, stage of recovery, and surgical and rehabilitation experiences. Health professionals (n = 44) represented a range of disciplines, practice settings and years of experience. Six key themes emerged: 1) Let's talk (issues related to patient-health professional and inter-professional communication); 2) Expecting the unexpected (observations about unanticipated recovery experiences); 3) It's attitude that counts (the importance of the patient's positive attitude and participation in recovery); 4) It takes all kinds of support (along the continuum of care); 5) Barriers to recovery (at patient, provider and system levels), and 6) Back to normal (reflecting diversity of expected outcomes). Patients offered different, but overlapping views compared to health professionals regarding rehabilitation practices and outcomes following THA and TKA. CONCLUSION: Results will inform subsequent phases of guideline development and ensure stakeholders' perspectives shape the priorities, content and scope of the guidelines.

Canadian physiotherapists' views on certification, specialisation, extended role practice, and entry-level training in rheumatology.

BACKGROUND: Since the last decade there has been a gradual change of boundaries of health professions in providing arthritis care. In Canada, some facilities have begun to adopt new arthritis care models, some of which involve physiotherapists (PT) working in extended roles. However, little is known about PTs' interests in these new roles. The primary objective of this survey was to determine the interests among orthopaedic physiotherapists (PTs) in being a certified arthritis therapist, a PT specialized in arthritis, or an extended scope practitioner in rheumatology, and to explore the associated factors, including the coverage of arthritis content in the entry-level physiotherapy training. METHODS: Six hundred PTs practicing in orthopaedics in Canada were randomly selected to receive a postal survey. The questionnaire covered areas related to clinical practice, perceptions of rheumatology training received, and attitudes toward PT roles in arthritis care. Logistic regression models were developed to explore the associations between PTs' interests in pursuing each of the three extended scope practice designations and the personal/professional/attitudinal variables. RESULTS: We received 286 questionnaires (response rate = 47.7%); 258 contained usable data. The average length of time in practice was 15.4 years (SD = 10.4). About 1 in 4 PTs agreed that they were interested in assuming advanced practice roles (being a certified arthritis therapist = 28.9%, being a PT specialized in rheumatology = 23.3%, being a PT practitioner = 20.9%). Having a caseload of > or = 40% in arthritis, having a positive attitude toward advanced practice roles in arthritis care and toward the formal credentialing process, and recognizing the difference between certification and specialisation were associated with an interest in pursing advanced practice roles. CONCLUSION: Orthopaedic PTs in Canada indicated a fair level of interest in pursuing certification, specialisation and extended scope practice roles in arthritis care. Future research should focus on the effectiveness and cost-effectiveness of the emerging health service delivery models involving certified, specialized or extended scope practice PTs in the management of arthritis.

Emerging Role of Quality Indicators in Physical Therapist Practice and Health Service Delivery.

Quality-based care is a hallmark of physical therapy. Treatment effectiveness must be evident to patients, managers, employers, and funders. Quality indicators (QIs) are tools that specify the minimum acceptable standard of practice. They are used to measure health care processes, organizational structures, and outcomes that relate to aspects of high-quality care of patients. Physical therapists can use QIs to guide clinical decision making, implement guideline recommendations, and evaluate and report treatment effectiveness to key stakeholders, including third-party payers and patients. Rehabilitation managers and senior decision makers can use QIs to assess care gaps and achievement of benchmarks as well as to guide quality improvement initiatives and strategic planning. This article introduces the value and use of QIs to guide clinical practice and health service delivery specific to physical therapy. A framework to develop, select, report, and implement QIs is outlined, with total joint arthroplasty rehabilitation as an example. Current initiatives of Canadian and American physical therapy associations to develop tools to help clinicians report and access point-of-care data on patient progress, treatment effectiveness, and practice strengths for the purpose of demonstrating the value of physical therapy to patients, decision makers, and payers are discussed. Suggestions on how physical therapists can participate in QI initiatives and integrate a quality-of-care approach in clinical practice are made.

Effect of non-surgical, non-pharmacological weight loss interventions in patients who are obese prior to hip and knee arthroplasty surgery: a rapid review.

BACKGROUND: Of the more than 104,000 Canadians who underwent elective total joint arthroplasty (TJA) surgery in 2012-2013 for hip and knee osteoarthritis (OA), 40 and 60 %, respectively, were obese. Obesity is associated with increased risks for receiving TJA, post-operative complications and delayed functional recovery. Current guidelines for patients with a body mass index (BMI) of ≥30 kg/m(2) are to participate in a weight management programme and to lose weight prior to TJA surgery. As part of a larger project, a rapid review was conducted to examine the effects of short-term non-pharmacological and non-surgical weight loss interventions in adults in the year prior to total hip arthroplasty (THA) and total knee arthroplasty (TKA) on surgical and patient outcomes, and adverse events. METHODS: We performed a rapid review and searched seven electronic databases for English language articles published between 1990 and February 2015. Observational studies evaluating the association between pre-operative weight loss and short- and long-term outcomes, and controlled trials of non-pharmacological and non-surgical weight loss interventions were considered for inclusion. Two reviewers independently screened and selected articles, assessed methodological quality and extracted data. RESULTS: Of 263 articles identified, a total of four studies met our inclusion criteria. In one of two high-quality retrospective cohort studies, weight loss ≥5 % of body weight in the year prior to TJA and maintained in the year after surgery was associated with a higher likelihood of deep surgical site infection in THA patients and 90-day readmission in TKA patients. No significant differences were reported in incidence of superficial surgical site infections in THA or TKA patients who lost weight pre-operatively compared to those who maintained their weight in either study. Two abstracts of randomized controlled trials were included; however, despite contacting the authors, full-length articles were not available. The limited information from the trials suggested that short-term dietician-supervised weight loss interventions were effective in weight loss prior to TJA. CONCLUSIONS: There is limited evidence to support the recommendation of weight loss in the year prior to TJA and to determine the effectiveness of short-term non-pharmacological, non-surgical weight management interventions on patient and surgical outcomes.

Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study.

OBJECTIVE: To synthesize professional and patient expertise with available evidence to recommend best practices for post-acute rehabilitation following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). METHODS: Two expert panels of clinicians, researchers, and patients from Canada and the US participated in a 3-round, online Delphi survey. RESULTS: Consensus was reached on 22 THA and 24 TKA best practice key statements. Recommendations common to both procedures included the need for supervised rehabilitation interventions provided by trained health professionals early after discharge from the acute care setting to optimize patient outcomes. Personal and environmental contextual factors were identified as influencing the process and outcomes of THA and TKA rehabilitation. Routine outcome assessment was recommended and several standardized outcome tools identified. Short-term followup care in the first 2 years postsurgery was recommended for both procedures. Specifics on timing, rehabilitation providers, need for long-term followup, and interventions differed for THA and TKA. Some recommendations received different levels of support based on the type of panelist (patient, physical therapist, surgeon), professional role (clinician, researcher), and/or country. CONCLUSION: A rigorous consensus method led to key recommendations for post-acute rehabilitation after primary THA and TKA for OA, which together with available evidence and acknowledgment of contextual factors will inform the development of clinical practice guidelines. This is an important step toward reducing practice variation, closing the evidence-practice gap, and improving the quality of rehabilitation services after THA and TKA.

Rehabilitation and total joint arthroplasty.

The long-term outcomes following primary TJA for OA are favorable. However, surgery alone fails to fully restore physical function and address longstanding impairments associated with chronic joint disease. Older adults undergoing TJA can gain similar benefits as those who are younger; however, the elderly are at increased risk for adverse events. Frailty, more so than age, is related to suboptimal outcomes. To what extent appropriate and sufficient rehabilitation can further improve health outcomes including activity and participation and positively impact prosthesis survival and need for revision is still unclear. There is evidence to suggest that evaluation and management of perioperative psychosocial and other patient factors are important in enhancing outcomes after TJA. Further, there is a growing body of research that points to the importance of progressive resistance training after TJA to address the muscle weakness associated with aging and end-stage hip and knee OA, and secondary to the surgery itself, and to optimize functional outcomes. With the projected increases in number of individuals undergoing TJA over the next two decades, it becomes even more critical to develop cost-effective rehabilitation strategies and identify individuals who would most benefit from such interventions.