Increased utilization of musculoskeletal care is driving the search for more sustainable models to incentivize high-value care. With many total joint replacement surgeries already in bundled payments, health systems must find new ways to reduce costs while maintaining clinical outcomes.
Many health systems are investigating the effects of remote patient monitoring and digital patient engagement on preoperative patient optimization and postoperative recovery. For total knee arthroplasty (TKA) surgery, virtual physical therapy proven to produce similar results Outpatient physical therapy for traditional TKA.
Currently, 2.8% to 5% of TKAs in the United States are performed on an outpatient basis, usually in relatively young patients with few comorbidities.However, the prevalence of same-day TKA surgery is exponential growthdriven by cost containment pressures and the recent removal of TKA and total hip replacement (THA) procedures from Medicare inpatient lists.
Some forecasts predict Over 50% TKA It will be offered as an outpatient procedure for the next five years. Although orthopaedic practices have become more comfortable with the benefits of telephysical therapy, there are still concerns about its use for outpatient surgery.
A study evaluating outpatient versus virtual physical therapy
Our institution designed a study to determine the need for formal physical therapy after outpatient TKA surgery. Patients who received same-day discharge TKA between August 2019 and March 2021 were randomly assigned to an outpatient physical therapy (OPT) or internet-based virtual physical therapy (VPT) program.
Of the 194 patients who met the inclusion criteria, 99 were randomized to OPT and 95 to VPT. After withdrawal and crossover due to clinical indication or patient preference, the study included 89 OPT and 72 VPT patients with no significant differences in baseline variables (sex, age, BMI, and surgical laterality) between groups.
Throughout the care process, all patients participated in a remote care management and patient engagement platform. The platform provides a personalized care pathway based on a patient’s demographics and clinical status, adjusted for the patient’s current activity level, pain, and range of motion.
All patients receive preoperative education through a virtual joint course with teach-back questions that provides program-specific content to help patients prepare for recovery in themselves and at home. In a previous study examining virtual versus face-to-face preoperative education for total joint arthroplasty, there were no statistically significant differences in patient satisfaction or functional outcomes.
Within 90 days after surgery, OPT patients completed a standard course of physical therapy, while VPT patients underwent remote physical therapy through a care management platform. Patients watched videos and completed a series of prescribed exercises, such as support squats, as they progressed through the stages of the care plan.
The care management platform enables remote monitoring of all patients’ adherence to evidence-based care plans. Providers are notified if their patients experience increased pain or reduced range of motion, allowing the care team to deliver targeted interventions in the form of follow-up calls or in-person appointments.
Additionally, all patients have access to the platform’s direct doctor/patient messaging feature.
Patients concerned about pain, medication, or swelling can contact their provider for a response.Research shows that direct doctor-patient messaging can facilitate rapid on-site treatment of wound complications, while at the same time Prevent unwanted access For wounds that exhibit a normal healing process.
Patient Assessment Methods and Research Results
All patients completed Veterans RAND 12 Health Survey (VR-12), which assesses physical and mental health before and six weeks, twelve weeks and one year after surgery.patients also completed Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) Survey, which measures overall knee health after TKA at six, twelve and one year postoperatively. During these same time intervals, patients ranked pain intensity on a Numerical Rating Scale (NRS) and answered patient satisfaction questions.
Functional assessments of all patients were performed in the clinic preoperatively and six weeks postoperatively by the physical therapy team. These assessments assessed patients’ knee flexion, knee extension, four-meter (4M) gait, and timed start (TUG). TUG assesses the time it takes a patient to stand up from a chair, walk 3 meters, turn around, and return to a sitting position, and compares it with short-term and long term function After joint replacement.
The findings were presented in March at the annual meeting of the American College of Orthopaedic Surgeons. We found no significant differences between the OPT and VPT groups in:
- VR-12 psychosomatic component scores at 6 weeks, 12 weeks, and 1 year after surgery
- KOOS Jr, NRS pain or patient satisfaction scores at 6 weeks, 12 weeks and 1 year after surgery
- On-site functional assessment six weeks after surgery
- 6-week TUG score (OPT 9.49 vs VPT 9.85; p=0.49)
- 4-meter gait (OPT 1.13, VPT 1.12; p=0.92)
- Knee flexion (OPT 117.77 vs VPT 117.79; p=0.99)
- Expansion (0.51 in the OPT group, 0.86 in the VPT group; p=0.29)
Additionally, patients reported higher satisfaction with the overall care experience for the VPT cohort. This may be due to the substantial cost and time savings of completing physical therapy at home. On average, patients in the OPT cohort attended 11.6 physical therapy sessions, had an average patient copay of $15.05, and required an average of 11.5 minutes of travel time per visit.
Offers greater convenience, lower cost, and similar results
Finding that a well-supported, evidence-based virtual physical therapy program yielded the same functional and patient-reported outcomes as outpatient physical therapy—even for outpatient TKA procedures—was a game changer.
As health systems begin to incorporate virtual treatment plans into their orthopaedic care regimens, it’s important to remember that one size doesn’t fit all. Each individual’s plan of care should be tailored to their circumstances, clinical situation, and preferences. A successful orthopaedic practice needs to offer multiple rehabilitation options.
In our study, we had a small clinical crossover from VPT to OPT cohorts. Further research is needed to determine whether there are any predictors of which patients may be better served by outpatient PT. For example, functional considerations might include history of falls, need for mobility aids, or objective gait assessment performance. Other considerations may include computer literacy and the presence of a solid home support system.
Throughout the study, we found that the direct messaging component of our care management platform provided an important communication channel, especially for patients in the VPT group who did not see a physical therapist in person. When patients know they will receive a prompt response, they are less likely to seek support through the emergency room or urgent care.Care Management Platforms That Offer Direct Messaging, Study Shows Reduce readmission rates through musculoskeletal procedures.
In our health system, this study shows that virtual physical therapy is the way of the future for most patients. Shifting the rehabilitation paradigm to embrace telerehabilitation demonstrated multiple advantages without compromising clinical outcomes.
Photo: Liubomir Worona, Getty Images
