Long-Term Career Earnings in Academia Might Offset the Opportunity Cost of Full-Time PhD and Postdoctoral Education for Physical Therapists Who Hold a Doctor of Physical Therapy Degree.

OBJECTIVE: Rigorously trained physical therapy researchers are essential for the generation of knowledge that guides the profession. However, there is a current and projected dearth of physical therapy researchers capable of sustaining research programs in part due to perceived financial barriers associated with pursuit of a doctor of philosophy (PhD) degree, with and without postdoctoral training, following doctor of physical therapy (DPT) degree completion. This study aimed to evaluate the financial impact of PhD and postdoctoral training, including opportunity cost, years to break even, and long-term earnings. METHODS: Clinical and academic salaries were obtained via the 2016 APTA Median Income of Physical Therapist Summary Report and 2019 CAPTE Annual Accreditation Report. Salaries were adjusted to total compensation to account for benefits and compared over a 30-year period starting after DPT education. Total compensations were also adjusted to the present value, placing greater weight on early career earnings due to inflation and potential investments. RESULTS: Relative to work as a clinical physical therapist, 4 years of PhD training result in an earnings deficit of $264,854 rising to $357,065 after 2 years of additional postdoctoral training. These deficits do not persist as evidenced by a clinical physical therapist career earning $449,372 less than a nonmajority scholarship academic career (DPT to PhD to academia pathway) and $698,704 less than a majority scholarship academic career (DPT to PhD to postdoctoral training to academia pathway) over a 30-year period. Greater long-term earnings for PhD careers persist when adjusting to present value. CONCLUSIONS: Although there is an initial opportunity cost of PhD and postdoctoral training represented by a relative earnings deficit, advanced research training results in greater long-term earnings. IMPACT: The findings of this study allow physical therapists interested in pursuing PhD and postdoctoral training to be better informed about the associated financial ramifications.

Integrating a physical activity coaching intervention into diabetes care: a mixed-methods evaluation of a pilot pragmatic trial.

Physical activity (PA) counseling is under-utilized in primary care for patients with type 2 diabetes mellitus (T2D), despite improving important health outcomes, including physical function. We adapted evidence-based PA counseling programs to primary care patients, staff, and leader's needs, resulting in "Be ACTIVE" comprised of shared PA tracker data (FitBit©), six theory-informed PA coaching calls, and three in-person clinician visits. In a pilot randomized pragmatic trial, we evaluated the feasibility, acceptability, and effectiveness of Be ACTIVE. Sedentary patients with T2D were randomized to Be ACTIVE versus an enhanced control condition. Mixed methods assessments of feasibility and acceptability included costs. Objective pilot effectiveness outcomes included PA (primary outcome, accelerometer steps/week), the Short Physical Performance Battery (SPPB) physical function measure, and behavioral PA predictors. Fifty patients were randomized to Be ACTIVE or control condition. Acceptability was >90% for patients and clinic staff. Coaching and PA tracking costs of ~$90/patient met Medicare reimbursement criteria. Pre-post PA increased by ~11% (Be ACTIVE) and ~6% in controls (group difference: 1574 ± 4391 steps/week, p = .72). As compared to controls, Be ACTIVE participants significantly improved SPPB (0.9 ± 0.3 vs. -0.1 ± 0.3, p = .01, changes >0.5 points prevent falls clinically), and PA predictors of self-efficacy (p = .02) and social-environmental support (p < .01). In this pilot trial, Be ACTIVE was feasible and highly acceptable to stakeholders and yielded significant improvements in objective physical function consistent with lower fall risk, whereas PA changes were less than anticipated. Be ACTIVE may need additional adaptation or a longer duration to improve PA outcomes.

We report results from a pragmatic and behavioral theory-based physical activity (PA) coaching program, termed "Be ACTIVE," for patients with type 2 diabetes that was designed to improve PA and function for patients and to be reimbursable and feasible for primary care teams. As compared to those who did not receive coaching, patients who received Be ACTIVE had physical function improvements that lowered their risk of falls. Be ACTIVE was delivered with fidelity and was highly acceptable to the key primary care stakeholders of patients, clinic staff coaches, and clinicians. Patients particularly liked the focus on setting goals to do enjoyable activities, the accountability of wearing a PA monitor, and the support of their coach. Clinical care professionals felt that their role of encouraging behavior change (coach) and safety monitoring (clinician) aligned well with their clinical expertise, and was professionally rewarding. Coaches felt the program helped them guide many patients to overcome preexisting negative perceptions of PA and develop intrinsic motivations to be active. The costs of clinic coach time and PA tracker rental needed to deliver the 12-week program could be reimbursed by the Medicare Chronic Disease Management programs, albeit with a patient co-payment required.

Poor Recovery of Activities-of-Daily-Living Function Is Associated With Higher Rates of Postsurgical Hospitalization After Total Joint Arthroplasty.

OBJECTIVE: Medicare beneficiaries are increasingly using home health (HH) as the first postacute care setting after hospital discharge following total joint arthroplasty (TJA). Yet, prior research has shown that changes in payment models for TJA may negatively influence functional outcomes for Medicare beneficiaries. The purpose of this study was to evaluate the impact of poor functional outcomes during an HH episode of care on hospitalization risk for older recipients of TJA. METHODS: For this study, 5822 Medicare beneficiaries who underwent elective TJA and subsequently participated in HH care following hospital discharge were identified using Medicare hospitalizations records and HH claims. Recovery of activities-of-daily-living (ADL) function was evaluated using patient assessment data completed at HH admission and discharge from the Medicare Outcomes and Assessment Information Set (OASIS). Hospitalization outcomes were captured from Medicare hospital claims. Cox proportional hazards regression was used to evaluate the hazard ratio for hospitalization after HH discharge. RESULTS: The 5822 Medicare beneficiaries who received a TJA and subsequently were discharged to HH were evaluated (n = 3989 [68.6%] following total knee replacement, n = 1883 [31.4%]) following total hip replacement). Nearly 9% (n = 534) of patients did not improve their ability to perform ADLs during the HH episode; this lack of improvement was associated with a more than 2-fold increase in hospital readmission rate following HH discharge (2.3% vs 4.9%). In adjusted models, there was a significant 77% increase (hazard ratio = 1.77; 95% CI = 1.14-2.74) in hospitalization risk during the 90-day postsurgical period. CONCLUSION: Poor recovery of ADL function in HH settings following TJA is strongly associated with elevated risk of future hospitalizations. IMPACT: Medicare beneficiaries who fail to make substantive improvements in basic ADL function during HH care episodes following TJA may need intensive monitoring from interdisciplinary team members across the continuum of care, especially during transitions from home care to outpatient care. LAY SUMMARY: An increasing number of patients receive home health care after joint replacement surgery, but outcomes after home health are unclear. These findings suggest that improvements in basic tasks such as walking or bathing are associated with a lower likelihood of hospitalization.

Reliability and precision of single frequency bioelectrical impedance assessment of lower extremity swelling following total knee arthroplasty.

Total knee arthroplasty (TKA) is the most common elective orthopedic surgery performed in the United States. Following surgery patients experience significant lower extremity swelling that is related to poor satisfaction with surgery and is hypothesized to contribute to functional decline. However, in practice, precise and reliable methods for measuring lower extremity swelling do not exist. The purpose of this study was to provide reliability and precision parameters of an innovative approach, single frequency bioelectrical impedance assessment (SF-BIA), for measuring post-TKA lower extremity swelling. Swelling in 56 patients (64.3 ± 9.3 years; 29 males) was measured before and after TKA using SF-BIA and circumferential measures (CM). Reliability of the measures was calculated using Intraclass Correlation Coefficients (ICC). Precision of the measures was provided using standard error of the measurement and minimal detectable change (MDC90). Change values between time points for SF-BIA and CM are provided. SF-BIA was found to have greater reliability following surgery compared to CM (ICC = 0.99 vs 0.68). SF-BIA was found to have an MDC90 = 2% following surgery, indicating improved ability to detect minute fluctuations in swelling compared to CM (MDC90 = 6%) following surgery. These results indicate that SF-BIA improves the precision and reliability of swelling measurement compared to CM.

Multiparticipant Rehabilitation in Skilled Nursing Facilities: An Observational Comparison Study.

OBJECTIVES: Post-acute care reform creates an impetus for skilled nursing facilities (SNFs) to reevaluate care delivery to promote value. One method to contain costs is to deliver rehabilitation with multiple individuals and 1 therapist. Our preliminary investigation proposed to identify clinical prescribing patterns for multiparticipant therapy and evaluate the impact on functional change. DESIGN: The study design was observational with prospective data collection. SETTING AND PARTICIPANTS: Data were collected on 458 individuals admitted to 1 SNF. MEASURES: Therapists administered the Short Physical Performance Battery (SPPB) and gait speed at admission and discharge. Unadjusted binomial logistic regression models analyzed the odds ratio for receiving multiparticipant therapy. Linear regression models analyzed the impact of multiparticipant therapy on functional outcomes. RESULTS: The odds of receiving multiparticipant therapy were greater with private pay or managed care compared with Medicare A [odds ratio (OR) 2.542; 95% confidence interval (CI) 1.631-3.960 and OR 2.182; 95% CI 1.812-2.629] or a Medicare priority diagnosis (OR 1.333; 95% CI 1.176-1.511). The odds of not receiving multiparticipant therapy were greater with pain that affects activity and sleep (OR 0.836; 95% CI 0.710-0.984; OR 0.809; 95% CI 0.662-0.989). The amount of multiparticipant therapy sessions did not affect adjusted functional change in the SPPB or gait speed (P > .195). Irrespective of care delivery mode, individuals demonstrated levels of function predictive of adverse events at discharge. CONCLUSIONS AND IMPLICATIONS: Payer source, diagnosis, and presence of significant pain may play a role in selection for multiparticipant therapy, with no differences in functional outcomes related to rehabilitation delivery. Importantly, individuals discharge from the SNF at alarmingly low levels of function, prompting the need to assess SNF rehabilitation and transition to the community, regardless of care delivery mode. Further research will inform an evidence-based decision guide regarding different modes and quality of SNF rehabilitation care delivery.

Home Health Rehabilitation Utilization Among Medicare Beneficiaries Following Critical Illness.

OBJECTIVES: Medicare beneficiaries recovering from a critical illness are increasingly being discharged home instead of to post-acute care facilities. Rehabilitation services are commonly recommended for intensive care unit (ICU) survivors; however, little is known about the frequency and dose of home-based rehabilitation in this population. DESIGN: Retrospective analysis of 2012 Medicare hospital and home health (HH) claims data, linked with assessment data from the Medicare Outcomes and Assessment Information Set. SETTING: Participant homes. PARTICIPANTS: Medicare beneficiaries recovering from an ICU stay longer than 24 hours, who were discharged directly home with HH services within 7 days of discharge and survived without readmission or hospice transfer for at least 30 days (n = 3,176). MEASUREMENTS: Count of rehabilitation visits received during HH care episode. RESULTS: A total of 19,564 rehabilitation visits were delivered to ICU survivors over 118,145 person-days in HH settings, a rate of 1.16 visits per week. One-third of ICU survivors received no rehabilitation visits during HH care. In adjusted models, those with the highest baseline disability received 30% more visits (rate ratio [RR] = 1.30; 95% confidence interval [CI] = 1.17-1.45) than those with the least disability. Conversely, an inverse relationship was found between multimorbidity (Elixhauser scores) and count of rehabilitation visits received; those with the highest tertile of Elixhauser scores received 11% fewer visits (RR = .89; 95% CI = .81-.99) than those in the lowest tertile. Participants living in a rural setting (vs urban) received 6% fewer visits (RR = .94; 95% CI = .91-.98); those who lived alone received 11% fewer visits (RR = .89; 95% CI = .82-.96) than those who lived with others. CONCLUSION: On average, Medicare beneficiaries discharged home after a critical illness receive few rehabilitation visits in the early post-hospitalization period. Those who had more comorbidities, who lived alone, or who lived in rural settings received even fewer visits, suggesting a need for their consideration during discharge planning. J Am Geriatr Soc 68:1512-1519, 2020.

The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia.

BACKGROUND: Dementia is a leading cause of disability for adults older than 65 years. Exercise intervention slows functional decline and improves balance; however, the efficacy of physical therapy (PT) services for persons with dementia is unknown. The purpose of this study is to assess the effect of home health PT services on physical function for Medicare beneficiaries with a primary diagnosis of dementia. DESIGN: Observational cohort study using a combined Medicare data set of home health beneficiaries; we performed augmented inverse probability weighted regression with demographic, comorbidity, and symptom-level characteristics analyzed as covariates. SETTING: Home healthcare, United States, 2012. PARTICIPANTS: Medicare beneficiaries who had a primary diagnosis of dementia and home health function evaluations at discharge (n = 1477). INTERVENTION: PT treatment, examined by (1) any PT and (2) PT visit number. MEASUREMENT: Improvement in composite activity of daily living (ADL) scores from home health admit to discharge. RESULTS: Any PT increased the probability of improvement in ADLs by 15.2% (P < .001). Compared to 1 to 5 PT visits, 6 to 13 visits increased the probability of ADL improvement by 11.6% (P < .001). CONCLUSION: PT intervention is beneficial for ADL function improvement in Medicare home health beneficiaries with a primary diagnosis of dementia. J Am Geriatr Soc 68:867-871, 2020.

Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty.

BACKGROUND: With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown. QUESTIONS/PURPOSES: (1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA? METHODS: This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence. RESULTS: Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008). CONCLUSIONS: Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoing TJA, which may include participation in preoperative rehabilitation (pre-habilitation) or more aggressive follow-up in the 30 days after surgery. Further research is needed to determine whether severe ADL dependence can be modified before surgery, and whether these changes in dependency can reduce readmission risk after TJA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Progressive Multicomponent Intervention for Older Adults in Home Health Settings Following Acute Hospitalization: Randomized Clinical Trial Protocol.

BACKGROUND: Hospitalization is a profound contributor to functional loss for older adults. Many modifiable risk factors (ie, weakness) may persist after hospitalization, representing portents of poor health, re-hospitalization, or death. Older adults frequently receive home health (HH) care after hospitalization to manage functional deficits that have worsened during hospital stays. However, how best to manage these deficits in HH settings has yet to be determined. OBJECTIVE: The objective is to determine if a higher intensity, progressive, multi-component (PMC) intervention, initiated upon admission to HH after an acute hospitalization, improves objectively measured and self-reported physical function more than usual care (UC) physical therapy. DESIGN: This will be a 2-arm randomized controlled clinical trial. SETTING: The setting will be participant homes. PARTICIPANTS: A total of 200 older adults with deconditioning following acute hospitalization and referred for HH physical therapy will participate. INTERVENTION: Participants will be randomized to either a PMC treatment group or a UC group and receive 12 therapy visits over a 60-day period. PMC participants will perform lower extremity resistance training at 80% of a 1-repetition maximum, task-specific activities of daily living training, along with advanced gait and balance training. PMC groups will also receive nutritional supplementation and nursing support during transition from hospital to home. The UC group will receive standard of care HH interventions. MEASUREMENTS: Physical performance, self-reported function, fatigue, and health care utilization outcomes will be measured at baseline, 30 days, 60 days, 90 days, and 180 days. All measures will be assessed by blinded study personnel. LIMITATIONS: The limitation is an inability to blind treating therapists to study allocation. CONCLUSIONS: The authors hope to determine whether higher intensity, multi-component exercise interventions improve outcomes more than UC physical therapy for older adults recovering from acute hospitalization in HH settings.

Impaired Physical Performance Predicts Hospitalization Risk for Participants in the Program of All-Inclusive Care for the Elderly.

Background: Medicaid spending on the Program of All-Inclusive Care for the Elderly (PACE) has grown rapidly over the last 5 years. Reducing hospitalization rates is a major goal for PACE. However, there is a paucity of research evaluating the relationship between impaired physical performance and hospitalizations in PACE. Objective: This study tested whether physical therapist-assessed physical performance, measured by the Short Physical Performance Battery (SPPB), can be used to identify participants in PACE at risk for all-cause hospitalizations or potentially avoidable hospitalizations (PAH). Design: This was a retrospective cohort study of 1093 participants in PACE facilities in the Denver, Colorado, area. Methods: Data were acquired from linked electronic medical record data and hospitalization claims. Unadjusted and adjusted Cox proportional hazards regression models were used to evaluate the relationship between SPPB scores and the probabilities of both all-cause hospitalizations and PAH. Results: The unadjusted likelihood of hospitalization increased with greater physical performance impairment (for SPPB scores ≥8/12: 12.2%; for SPPB scores of 4/12 to 7/12: 15.7%; for SPPB scores <4/12: 21.1%). Compared with participants with SPPB scores ≥8/12, participants with SPPB scores <4/12 had nearly double the unadjusted hazard for hospitalization (hazard ratio = 1.99; 95% CI = 1.34-2.96). In adjusted Cox regression models, participants with SPPB scores <4/12 remained significantly more likely to be hospitalized (hazard ratio = 1.87; 95% CI = 1.24-2.84). Similar relationships were observed for PAH. Limitations: The use of data from a single network of PACE facilities might limit generalizability to states with different Medicaid guidelines. Conclusions: The findings suggest that impaired physical performance is an independent risk factor for hospitalization among participants in PACE. These findings could help guide the development of PACE program modifications for measuring and intervening on impairments in physical function.

Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty.

BACKGROUND: Home-health-care utilization after total knee arthroplasty (TKA) is increasing. Recent publications have suggested that supervised rehabilitation is not needed to optimize functional recovery after TKA; however, few studies have evaluated patients in home-health-care settings. The objectives of this study were to (1) determine whether physical therapy (PT) utilization is associated with functional improvements for patients in home-health-care settings after TKA and (2) determine which factors are related to utilization of PT. METHODS: This study was an analysis of Medicare home-health-care claims data for patients treated with a TKA in 2012 who received home-health-care services for postoperative rehabilitation. Multivariable linear regression models were used to evaluate relationships between PT utilization and recovery in activities of daily living (ADLs). Negative binomial regression models were used to determine factors associated with PT utilization. RESULTS: Records from 5,967 Medicare beneficiaries were evaluated. Low home-health-care PT utilization (≤5 visits) was associated with less improvement in ADLs compared with 6 to 9 visits, 10 to 13 visits, or ≥14 visits. Compared with low home-health-care utilization, utilization of 6 to 9 visits was associated with a 25% greater improvement in ADLs over the home-health-care episode (p < 0.0001); 10 to 13 visits, with a 40% greater improvement (p < 0.0001); and ≥14 visits, with a 50% greater improvement (p < 0.0001). The findings remained robust following adjustments for medical complexity, baseline functional status, and home-health-care episode duration. After adjustment, lower PT utilization was observed for patients receiving home health care from rural agencies (10.7% fewer visits, 95% confidence interval [CI] = 7.9% to 13.7%), those with depressive symptoms (4.8% fewer visits, 95% CI = 1.3% to 8.3%), and those with any baseline dyspnea (5.3% fewer visits, 95% CI = 3.1% to 7.5%). CONCLUSIONS: Low home-health-care PT utilization was significantly associated with worse recovery in ADLs after TKA for Medicare beneficiaries, after controlling for medical complexity, baseline function, and home-health-care episode duration. Patients who are served by rural agencies or who have higher medical complexity receive fewer PT visits after TKA and may need closer monitoring to ensure optimal functional recovery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthrofibrosis Associated With Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS: In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS: Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION: Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.