Perceived Usability and Acceptability of Videoconferencing for Delivering Community-Based Rehabilitation to Individuals with Acquired Brain Injury: A Qualitative Investigation.

OBJECTIVES: There is limited research on the use of telerehabilitation platforms in service delivery for people with acquired brain injury (ABI), especially technologies that support delivery of services into the home. This qualitative study aimed to explore the perspectives of rehabilitation coordinators, individuals with ABI, and family caregivers on the usability and acceptability of videoconferencing (VC) in community-based rehabilitation. Participants' experiences and perceptions of telerehabilitation and their impressions of a particular VC system were investigated. METHODS: Guided by a theory on technology acceptance, semi-structured interviews were conducted with 30 participants from a community-based ABI service, including 13 multidisciplinary rehabilitation coordinators, 9 individuals with ABI, and 8 family caregivers. During the interview, they were shown a paper prototype of a telehealth portal for VC that was available for use. Interview transcripts were coded by two researchers and analysed thematically. RESULTS: The VC was used on average for 2% of client consultations. Four major themes depicted factors influencing the uptake of VC platforms; namely, the context or impetus for use, perceived benefits, potential problems and parameters around use, and balancing the service and user needs. Participants identified beneficial uses of VC in service delivery and strategies for promoting a positive user experience. CONCLUSIONS: Perceptions of the usability of VC to provide services in the home were largely positive; however, consideration of use on a case-by-case basis and a trial implementation was recommended to enhance successful uptake into service delivery.

Enabling More Accessible MS Rehabilitation Training Using Virtual Reality.

Multiple sclerosis (MS) is an autoimmune disorder caused by damage to the myelin that protects nerve fibres, resulting in demyelinated lesions and causing various symptoms, one of which is muscle weakness. Physical rehabilitation is an integral part of managing MS, as well as its symptoms, and over time, the forms of implementing rehabilitation have changed according to novel technologies. Virtual reality (VR) has already been successfully applied to many fields of life sciences. VR can recreate engaging virtual environments for the specific purpose of physical rehabilitation that one can experience from the home environment. As a proof of concept, three games were developed for multiple sclerosis (MS) through the ground-breaking game engine Unity: a Piano game, a Recycle game and a Tidy Up game. The Piano game had three levels, starting from learning simple keys and ending with small well-known songs, in order to gradually challenge the user as they progress through their rehabilitation. The Recycle game focused on entertainment; it was playful providing a simpler but engaging and fun experience that used items that are seen in everyday life. In addition, a scoring system was implemented in order to motivate the user. Finally, the Tidy Up game had three different levels giving the user goals to work towards; at each level, the time available to complete the game became shorter giving the user less time to tidy up the table. These games were presented to individuals with MS, who had never used VR. Feedback was collected in order to assess the usability and the perceived sense of presence generated by the proposed approach. The testing also aimed to better understand rehabilitation techniques including factors affecting motivation. The games for rehabilitation were warmly received, and feedback was positive regarding both the usability of the system and the perceived sense of presence within digital environments. Although the tested sample size limits were small, a limitation of the validity of the results, these initial findings suggest VR must be beneficial in MS physical rehabilitation of the upper limb although larger, more formal evaluation is required.

Home-based telerehabilitation software systems for remote supervising: a systematic review.

OBJECTIVES: In the past decade, with the ever-increasing growth of information and communication technologies, telerehabilitation, especially home-based rehabilitation (HBR), has been widely considered by researchers. Many software systems are developed to address HBR programs, which includes various functionalities. The aim of this study is to review the functional features of these systems designed for remote supervising of HBR programs. METHODS: Scopus, PubMed, EMBASE, ISI Web of Science, Cochrane Library, IEEE Xplore Digital Library, and ProQuest databases were searched for English-language articles published between January 2008 and February 2018 to retrieve studies reported an home-based telerehabilitation software system aiming to remotely supervise HBR program. RESULTS: A total of fifty studies that reported twenty-two unique systems met the inclusion criteria. Various functional features were identified including but not limited to exercise plan management, report/statistics generating, patient education, and task scheduling. Disorders or diseases addressed by these systems could mainly be grouped into five categories: musculoskeletal, neurological, respiratory, cardiovascular, and other health-related problems. Usability and acceptability, and clinical/patient outcomes were the most reported outcomes and data analysis was used by the majority of included studies to measure the outcomes. CONCLUSIONS: Systems developed for supervising of HBR program are diverse. However, preliminary results of this review revealed that these systems share more or less common functionalities. However, further research is needed to determine the requirements, structure, and effectiveness of these systems in real-life settings.

Raising the Digital Profile of Facial Palsy: National Surveys of Patients' and Clinicians' Experiences of Changing UK Treatment Pathways and Views on the Future Role of Digital Technology.

BACKGROUND: Facial nerve palsy leaves people unable to move muscles on the affected side of their face. Challenges exist in patients accessing facial neuromuscular retraining (NMR), a therapy used to strengthen muscle and improve nerve function. Access to therapy could potentially be improved through the use of digital technology. However, there is limited research available on patients' and clinicians' views about the potential benefits of such telerehabilitation based on their lived experiences of treatment pathways. OBJECTIVE: This study aims to gather information about facial palsy treatment pathways in the United Kingdom, barriers to accessing NMR, factors influencing patient adherence, measures used to monitor recovery, and the potential value of emerging wearable digital technology. METHODS: Separate surveys of patients with facial palsy and facial therapy specialists were conducted. Questionnaires explored treatment pathways and views on telerehabilitation, were co-designed with users, and followed a similar format to enable cross-referencing of responses. A follow-up survey of national specialists investigated methods used to monitor recovery in greater detail. Analysis of quantitative data was conducted allowing for data distribution. Open-text responses were analyzed using thematic content analysis. RESULTS: A total of 216 patients with facial palsy and 25 specialist therapists completed the national surveys. Significant variations were observed in individual treatment pathways. Patients reported an average of 3.27 (SD 1.60) different treatments provided by various specialists, but multidisciplinary team reviews were rare. For patients diagnosed most recently, there was evidence of more rapid initial prescribing of corticosteroids (prednisolone) and earlier referral for NMR therapy. Barriers to NMR referral included difficulties accessing funding, shortage of specialist therapists, and limited awareness of NMR among general practitioners. Patients traveled long distances to reach an NMR specialist center; 9% (8/93) of adults reported traveling ≥115 miles. The thematic content analysis demonstrates positive attitudes to the introduction of digital technology, with similar incentives and barriers identified by both patients and clinicians. The follow-up survey of 28 specialists uncovered variations in the measures currently used to monitor recovery and no agreed definitions of a clinically significant change for any of these. The main barriers to NMR adherence identified by patients and therapists could all be addressed by using suitable real-time digital technology. CONCLUSIONS: The study findings provide valuable information on facial palsy treatment pathways and views on the future introduction of digital technology. Possible ways in which emerging sensor-based digital technology can improve rehabilitation and provide more rigorous evidence on effectiveness are described. It is suggested that one legacy of the COVID-19 pandemic will be lower organizational barriers to this introduction of digital technology to assist NMR delivery, especially if cost-effectiveness can be demonstrated.

Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of treatment delivered via real-time telerehabilitation for the management of musculoskeletal conditions, and to determine if real-time telerehabilitation is comparable to conventional methods of delivery within this population. DATA SOURCES: Six databases (Medline, Embase, Cochrane CENTRAL, PEDro, psycINFO, CINAHL) were searched from inception to November 2015 for literature which reported on the outcomes of real-time telerehabilitation for musculoskeletal conditions. REVIEW METHODS: Two reviewers screened 5913 abstracts where 13 studies ( n = 1520) met the eligibility criteria. Methodological quality was assessed using the Downs & Black 'Checklist for Measuring Quality' tool. Results were pooled for meta-analysis based upon primary outcome measures and reported as standardised mean differences and 95% confidence intervals (CI). RESULTS: Aggregate results suggest that telerehabilitation is effective in the improvement of physical function (SMD 1.63, 95%CI 0.92-2.33, I2=93%), whilst being slightly more favourable (SMD 0.44, 95%CI 0.19-0.69, I2=58%) than the control cohort following intervention. Sub-group analyses reveals that telerehabilitation in addition to usual care is more favourable (SMD 0.64, 95%CI 0.43-0.85, I2=10%) than usual care alone, whilst treatment delivered solely via telerehabilitation is equivalent to face-to-face intervention (SMD MD 0.14, 95% CI -0.10-0.37, I2 = 0%) for the improvement of physical function. The improvement of pain was also seen to be comparable between cohorts (SMD 0.66, 95%CI -0.27-1.60, I2=96%) following intervention. CONCLUSIONS: Real-time telerehabilitation appears to be effective and comparable to conventional methods of healthcare delivery for the improvement of physical function and pain in a variety of musculoskeletal conditions.

Adherence and factors affecting satisfaction in long-term telerehabilitation for patients with chronic obstructive pulmonary disease: a mixed methods study.

BACKGROUND: Telemedicine may increase accessibility to pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), thus enhancing long-term exercise maintenance. We aimed to explore COPD patients' adherence and experiences in long-term telerehabilitation to understand factors affecting satisfaction and potential for service improvements. METHODS: A two-year pilot study with 10 patients with COPD was conducted. The intervention included treadmill exercise training at home and a webpage for telemonitoring and self-management combined with weekly videoconferencing sessions with a physiotherapist. We conducted four separate series of data collection. Adherence was measured in terms of frequency of registrations on the webpage. Factors affecting satisfaction and adherence, together with potential for service improvements, were explored through two semi-structured focus groups and an individual open-ended questionnaire. Qualitative data were analysed by systematic text condensation. User friendliness was measured by the means of a usability questionnaire. RESULTS: On average, participants registered 3.0 symptom reports/week in a web-based diary and 1.7 training sessions/week. Adherence rate decreased during the second year. Four major themes regarding factors affecting satisfaction, adherence and potential improvements of the intervention emerged: (i) experienced health benefits; (ii) increased self-efficacy and independence; and (iii) emotional safety due to regular meetings and access to special competence; (iv) maintenance of motivation. Participants were generally highly satisfied with the technical components of the telerehabilitation intervention. CONCLUSIONS: Long-term adherence to telerehabilitation in COPD was maintained for a two-year period. Satisfaction was supported by experienced health benefits, self-efficacy, and emotional safety. Maintenance of motivation was a challenge and might have affected long-term adherence. Four key factors of potential improvements in long-term telerehabilitation were identified: (i) adherence to different components of the telerehabilitation intervention is dependent on the level of focus provided by the health personnel involved; (ii) the potential for regularity that lies within the technology should be exploited to avoid relapses after vacation; (iii) motivation might be increased by tailoring individual consultations to support experiences of good health and meet individual goals and motivational strategies; (iv) interactive functionalities or gaming tools might provide peer-support, peer-modelling and enhance motivation.

Conditions of Use, Reliability, and Quality of Audio/Video-Mediated Communications During In-Home Rehabilitation Teletreatment for Postknee Arthroplasty.

BACKGROUND: Audio/video-mediated communication between patients and clinicians using videoconferencing over telecommunication networks is a key component of providing teletreatments in rehabilitation. OBJECTIVE: The objectives of this study were to (1) document the conditions of use, performance, and reliability of videoconferencing-based communication in the context of in-home teletreatment (TELE) following total knee arthroplasty (TKA) and (2) assess from the perspective of the providers, the quality attributes of the technology used and its impact on clinical objectives. MATERIALS AND METHODS: Descriptive embedded study in a randomized controlled trial using a sample of 97 post-TKA patients, who received a total of 1,431 TELE sessions. Technical support use, service delivery reliability, performance, and use of network connection were assessed using self-report data from a costing grid and automated logs captured from videoconferencing systems. Physical therapists assessed the quality and impact of video-mediated communications after each TELE session on seven attributes. RESULTS: Installation of a new Internet connection was required in 75% of the participants and average technician's time to install test and uninstall technology (including travel time) was 308.4 min. The reliability of service delivery was 96.5% of planned sessions with 21% of TELE session requiring a reconnection during the session. Remote technical support was solicited in 43% of the sessions (interventions were less than 3-min duration). Perceived technological impacts on video-mediated communications were minimal with quality of the overall technical environment evaluated as good or acceptable in 96% of the sessions and clinical objectives reached almost completely or completely in 99% of the sessions. CONCLUSIONS: In-home rehabilitation teletreatments can be delivered reliably but requires access to technical support for the initial setup and maintenance. Optimization of the processes of reliably connecting patients to the Internet, getting the telerehabilitation platform in the patient's home, installing, configuring, and testing will be needed to generalize this approach of service delivery.

An Autotuning Cable-Driven Device for Home Rehabilitation.

Out of all the changes to our daily life brought by the COVID-19 pandemic, one of the most significant ones has been the limited access to health services that we used to take for granted. Thus, in order to prevent temporary injuries from having lingering or permanent effects, the need for home rehabilitation device is urgent. For this reason, this paper proposes a cable-driven device for limb rehabilitation, CUBE2, with a novel end-effector (EE) design and autotuning capabilities to enable autonomous use. The proposed design is presented as an evolution of the previous CUBE design. In this paper, the proposed device is modelled and analyzed with finite element analysis. Then, a novel vision-based control strategy is described. Furthermore, a prototype has been manufactured and validated experimentally. Preliminary test to estimate home position repeatability has been carried out.

Pulmonary Rehabilitation in a Post-COVID-19 World: Telerehabilitation as a New Standard in Patients with COPD.

Pulmonary rehabilitation (PR) is effective in reducing symptoms and improving health status, and exercise tolerance of patients with chronic obstructive pulmonary disease (COPD). The coronavirus disease 19 (COVID-19) pandemic has greatly impacted PR programs and their delivery to patients. Owing to fears of viral transmission and resultant outbreaks of COVID-19, institution-based PR programs have been forced to significantly reduce enrolment or in some cases completely shut down during the pandemic. As a majority of COPD patients are elderly and have multiple co-morbidities including cardiovascular disease and diabetes, they are notably susceptible to severe complications of COVID-19. As such, patients have been advised to stay at home and avoid social contact to the maximum extent possible. This has increased patients' vulnerability to physical deconditioning, depression, and social isolation. To address this major gap in care, some traditional hospital or clinic-centered PR programs have converted some or all of their learning contents to home-based telerehabilitation during the pandemic. There are, however, some significant barriers to this approach that have impeded its implementation in the community. These include variable access and use of technology (by patients), a lack of standardization of methods and tools for evaluation of the program, and inadequate training and resources for health professionals in optimally delivering telerehabilitation to patients. There is a pressing need for high-quality studies on these modalities of PR to enable the successful implementation of PR at home and via teleconferencing technologies. Here, we highlight the importance of telerehabilitation of patients with COPD in the post-COVID world and discuss various strategies for clinical implementation.

The musculoskeletal problems and psychosocial status of teachers giving online education during the COVID-19 pandemic and preventive telerehabilitation for musculoskeletal problems.

BACKGROUND: Musculoskeletal and psychosocial problems have tended to increase during the COVID-19 pandemic. OBJECTIVE: To evaluate the changes in musculoskeletal problems and psychosocial status of teachers during the COVID-19 pandemic due to online education and to investigate the effects of preventive telerehabilitation applications for musculoskeletal problems. METHODS: Forty teachers who conducted online education during the pandemic volunteered to participate in the study. All assessments were performed via online methods. The Cornell Musculoskeletal Discomfort Questionnaire (CMDQ), ProFitMap-Neck questionnaire, Oswestry Disability Index (ODI), and Upper Extremity Functional Index (UEFI) were used to evaluate musculoskeletal problems; the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory (BDI) were used to evaluate anxiety and depression, respectively; and the Work-Life Balance Scale (WLBS) was used to evaluate how well individuals achieve this balance. Information about before online education, during online education, and after training was obtained with the assessments. After the first assessment, telerehabilitation, which involved presentations and brochures, was applied to 18 participants willing to participate in the training. RESULTS: The ProFitMap, UEFI, and WLBS scores during the online education decreased significantly, while the scores of the CMDQ, ODI, BDI, and BAI during the online education increased significantly compared to the pre-online education scores (p < 0.05). In addition, the total CMDQ, ProFitMap, and ODI scores improved significantly after the training (p < 0.05). CONCLUSION: Musculoskeletal and psychosocial problems increased in teachers during online education. Preventive telerehabilitation methods will be beneficial for individuals who do not have access to face-to-face physiotherapy.

A standardized review of smartphone applications to promote balance for older adults.

BACKGROUND: Balance is one of the risk factors for falls in older adults. The use of smartphone applications (apps) related to health (mHealth) is increasing and, while there is potential for apps to be used as a self-managed balance intervention, many healthcare providers are concerned about the content and credibility of mHealth apps overall. PURPOSE: This study evaluates the quality of balance promoting apps and identifies strengths and areas of concern to assist healthcare providers in recommending these resources. MATERIALS AND METHODS: Balance apps for the general public, offered on the iPhone Operating System (iOS) and Android platforms, were evaluated using the Mobile Application Rating Scale (MARS). RESULTS: Five iOS apps met the inclusion criteria. The mean scores for each of the domains in MARS were: Engagement (3.32), Information (3.7), Functionality (3.8), and Esthetics (3.8). Overall, one app (UStabilize) received a rating of 4.43 in MARS five-point scale, which was considered "good". Other apps in the review demonstrated acceptable quality. CONCLUSIONS: The reviewed balance apps targeted to improve or maintain physical balance were of acceptable quality. Apps address many current issues older adults have to accessing rehabilitation services and, as such, may be particularly useful for this group. Future research should focus on assessing and comparing app efficacy. Development of balance apps for the Android platform is also necessary. Implications for Rehabilitation Given the availability and accessibility of various mHealth apps and the increasing mobile device usage among older adults, mobile apps are a promising avenue for delivering rehabilitation interventions, such as balance training, to older adults. Smartphone apps exist for balance training but overall confidence in health apps within the healthcare community is low and rigorous evaluation is required. A range of apps exist that demonstrate acceptable to good quality and stakeholders should work towards having these apps listed in credible mHealth clearinghouses.

Telerehabilitation in individuals with severe acquired brain injury: Rationale, study design, and methodology.

BACKGROUND: Severe acquired brain injury (SABI) rehabilitation should be as intensive and long as to allow the patients get the best independence and quality of life (QoL), but facing with the rehabilitation socioeconomic burden. Telerehabilitation (TR) could supply frail subjects requiring long-term rehabilitation. METHODS: A multicenter, prospective, parallel design, single-blind trial will be conducted at the IRCCS Neurolesi Bonino Pulejo (Messina, Italy) and IRCCS Hospital San Camillo (Venice, Italy) involving patients suffering from SABI and requiring home motor and cognitive rehabilitation. We will investigate the use of TR, based on advanced Information and Communication Technology (ICT) solutions, taking into account that the supervision of rehabilitation at home will be enriched with the counseling and vital parameters monitoring. The enrolled patients will be balanced for pathology, and randomized in 2 groups, performing TR (G1) or standard rehabilitation training (G2), respectively, according to a pc-generated random assignment. TR will be delivered by means of an advanced video-conferencing system, whereas the patient will be provided with low-cost monitoring devices, able to collect data about his/her health status and QoL. In both the groups each treatment (either cognitive or motor, or both as per patient functional status) will last about 1 hour a day, 5 days/week, for 12 weeks. Two structured telephone interviews will be administered to the patients (when possible) and/or their caregivers, and to all the healthcare professionals involved in the patient management, 1 week after the beginning and at the end of the TR. All the patients will undergo a complete neurological and cognitive examination performed by skilled physicians and psychologists, blindly. Clinical evaluations will be administered blindly, before and after the treatments. RESULTS: the data of this study should demonstrate that TR is at least non-inferior in comparison with the same amount of usual territorial rehabilitative physical treatments, taking into account patients' functional recovery, psychological well-being, caregiver burden, and healthcare costs. CONCLUSION: data coming from this study could demonstrate the usefulness of TR in facing the rehabilitation socioeconomic burden of managing patients with SABI, so to allow the patients get the best independence and quality of life (QoL).

Cognitive function in multiple sclerosis improves with telerehabilitation: Results from a randomized controlled trial.

Cognitive impairment affects more than half of all individuals living with multiple sclerosis (MS). We hypothesized that training at home with an adaptive online cognitive training program would have greater cognitive benefit than ordinary computer games in cognitively-impaired adults with MS. This was a double-blind, randomized, active-placebo-controlled trial. Participants with MS were recruited through Stony Brook Medicine and randomly assigned to either the adaptive cognitive remediation (ACR) program or active control of ordinary computer games for 60 hours over 12 weeks. Training was remotely-supervised and delivered through a study-provided laptop computer. A computer generated, blocked stratification table prepared by statistician provided the randomization schedule and condition was assigned by a study technician. The primary outcome, administered by study psychometrician, was measured by change in a neuropsychological composite measure from baseline to study end. An intent-to-treat analysis was employed and missing primary outcome values were imputed via Markov Chain Monte Carlo method. Participants in the ACR (n = 74) vs. active control (n = 61) training program had significantly greater improvement in the primary outcome of cognitive functioning (mean change in composite z score±SD: 0·25±0·45 vs. 0·09±0·37, p = 0·03, estimated difference = 0·16 with 95% CI: 0·02-0·30), despite greater training time in the active control condition (mean±SD:56·9 ± 34·6 vs. 37·7 ±23 ·8 hours played, p = 0·006). This study provides Class I evidence that adaptive, computer-based cognitive remediation accessed from home can improve cognitive functioning in MS. This telerehabilitation approach allowed for rapid recruitment and high compliance, and can be readily applied to other neurological conditions associated with cognitive dysfunction. TRIAL REGISTRATION: Clinicaltrials.gov NCT02141386.

Compensating for telecommunication delays during robotic telerehabilitation.

Rehabilitation robotic systems may afford better care and telerehabilitation may extend the use and benefits of robotic therapy to the home. Data transmissions over distance are bound by intrinsic communication delays which can be significant enough to deem the activity unfeasible. Here we describe an approach that combines unilateral robotic telerehabilitation and serious games. This approach has a modular and distributed design that permits different types of robots to interact without substantial code changes. We demonstrate the approach through an online multiplayer game. Two users can remotely interact with each other with no force exchanges, while a smoothing and prediction algorithm compensates motions for the delay in the Internet connection. We demonstrate that this approach can successfully compensate for data transmission delays, even when testing between the United States and Brazil. This paper presents the initial experimental results, which highlight the performance degradation with increasing delays as well as improvements provided by the proposed algorithm, and discusses planned future developments.

Cardiac telerehabilitation: A novel cost-efficient care delivery strategy that can induce long-term health benefits.

Background Finding innovative and cost-efficient care strategies that induce long-term health benefits in cardiac patients constitutes a big challenge today. The aim of this Telerehab III follow-up study was to assess whether a 6-month additional cardiac telerehabilitation programme could induce long-term health benefits and remain cost-efficient after the tele-intervention ended. Methods and results A total of 126 cardiac patients first completed the multicentre, randomised controlled telerehabilitation trial (Telerehab III, time points t0 to t1). They consequently entered the follow-up study (t1) with evaluations 2 years later (t2). A quantitative analysis of peak aerobic capacity (VO2 peak, primary endpoint), international physical activity questionnaire self-reported physical activity and HeartQoL quality of life (secondary endpoints) was performed. The incremental cost-effectiveness ratio was calculated. Even though a decline in VO2 peak (24 ± 8 ml/[min*kg] at t1 and 22 ± 6 ml/[min*kg] at t2; P ≤ 0.001) was observed within the tele-intervention group patients; overall they did better than the no tele-intervention group ( P = 0.032). Dividing the incremental cost (-€878/patient) by the differential incremental quality-adjusted life years (QALYs) (0.22 QALYs) yielded an incremental cost-effectiveness ratio of -€3993/QALY. Conclusions A combined telerehabilitation and centre-based programme, followed by transitional telerehabilitation induced persistent health benefits and remained cost-efficient up to 2 years after the end of the intervention. A partial decline of the benefits originally achieved did occur once the tele-intervention ended. Healthcare professionals should reflect on how innovative cost-efficient care models could be implemented in standard care. Future research should focus on key behaviour change techniques in technology-based interventions that enable full persistence of long-term behaviour change and health benefits. This study is registered in the ISRCTN registry (ISRCTN29243064).

Telerehabilitation after total knee replacement in Italy: cost-effectiveness and cost-utility analysis of a mixed telerehabilitation-standard rehabilitation programme compared with usual care.

OBJECTIVES: To assess cost-effectiveness and cost utility of telerehabilitation (TR) versus standard rehabilitation (SR) after total knee replacement (TKR). DESIGN: Markov decision modelling of cost-effectiveness and cost-utility analysis based on patient-level and secondary data sources employing Italian National Health Service (NHS; Ita-NHS) and Society perspectives. SETTING: Primary care units (PCUs) in Italy. PARTICIPANTS: Patients discharged after TKR. INTERVENTIONS: Mixed SR-TR service (10 face-to-face sessions and 10 telesessions) versus SR (20 face-to-face sessions) PRIMARY AND SECONDARY OUTCOME MEASURES: The incremental cost per additional knee flexion range of motion (ROM) and per QALY gained by SR-TR compared with SR. Second, we considered the probability of being cost-effective and the probability of being more effective and less expensive. RESULTS: TR appears to be the cost-effective in the base case and in all of the considered scenarios, but is no longer more effective and less expensive if transportation costs are excluded. Comparing SR-TR with SR, the incremental cost-effectiveness ratio (ICER) adopting the Ita-NHS perspective for the base case was -€117/ROM gained. The cost-effectiveness probability for SR-TR was 0.98 (ceiling ratio: €50/ROM), while the joint probability of being more effective and less expensive was 0.87. Assuming that TR would increase health-related quality of life (HRQOL) utilities by 2.5%, the ICER adopting Ita-NHS perspective is -€960/QALY (cost-effectiveness probability: 1; ceiling ratio: €30 000/QALY). All the performed sensitivity analyses did not change the conclusions, but if transportation costs were excluded, the probability for SR-TR of being more clinically effective and less expensive reduced to 0.56. CONCLUSIONS: The analysis suggested SR-TR to be cost-effective, even less expensive and more effective if the PCUs provide ambulance transportations. However, the uncertainty related to TR costs, HRQOL and long-term clinical outcomes raises important topics for future research, which should be addressed to confirm our estimates. TRIAL REGISTRATION NUMBER: ISRCTN45837371.

When the Need is Greater Than Feasible / Cuando la necesidad es mayor de lo factible

No disponible