The rise in musculoskeletal care utilization is driving the exploration of more sustainable models to incentivize high-value care. As many total joint replacement procedures are already under bundled payments, health systems must find new ways to reduce cost while maintaining clinical outcomes.
Many health systems are studying the efficacy of remote patient monitoring and digital patient engagement on preoperative patient optimization and postoperative recovery. For total knee arthroplasty (TKA) procedures, virtual physical therapy has been proven to produce similar outcomes to outpatient physical therapy for traditional TKAs.
Currently, between 2.8% and 5% of TKAs in the U.S. are performed on an outpatient basis, typically on relatively young patients with few co-morbidities. However, the prevalence of same-day TKA procedures is increasing exponentially, fueled by cost containment pressures and the recent removal of TKA and total hip arthroplasty (THA) procedures from the Medicare Inpatient-Only list.
Some projections anticipate that more than 50% of TKAs will be offered as ambulatory procedures within the next five years. While orthopedic practices have become much more comfortable with the benefits of remote physical therapy, there is still apprehension regarding its adoption for outpatient procedures.
A study to evaluate outpatient vs. virtual physical therapy
Our institution devised a study to determine if formal physical therapy is necessary following outpatient TKA procedures. Patients undergoing same-day discharge TKAs between August 2019 and March 2021 were randomized to either outpatient physical therapy (OPT) or an 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 withdrawals and crossovers due to clinical indications or patient preference, the study included 89 OPT and 72 VPT patients, with no significant difference in baseline variables (gender, age, BMI, and procedure laterality) between groups.
All patients were enrolled in a remote care management and patient engagement platform throughout their episode of care. The platform provides individualized care pathways based on the patient’s demographic profile and clinical status, adjusted to reflect the patient’s current activity level, pain, and range of motion.
All patients received preoperative education via a virtual joint class with teach-back questions, which delivers procedure-specific content to helps patients prepare themselves and their homes for recovery. In a previous study examining virtual vs. in-person preoperative education for total joint replacements, there was no statistically significant difference in either patient satisfaction or functional outcomes.
During the 90 days following surgery, the OPT patients completed a standard course of physical therapy, while VPT patients were enrolled in remote physical therapy via the care management platform. Patients watched videos and completed a series of prescribed exercises, such as supported squats, as they progressed through their care plan phases.
The care management platform enabled remote monitoring of all patients’ adherence to their evidence-based care plan. Providers were notified if their patients experienced increased pain or a decreased range of motion, which allowed care teams to deliver targeted intervention in the form of follow-up phone calls or in-person appointments.
In addition, all patients had access to the platform’s direct physician/patient messaging feature.
Patients who were concerned about their pain, medications, or swelling could reach out to their providers for a response. Research shows that direct physician-patient messaging can facilitate rapid in-person treatment of wound complications while preventing unnecessary visits for wounds exhibiting the normal healing process.
Patient evaluation methods and study results
All patients completed the Veterans RAND 12-Item Health Survey (VR-12), which assesses physical and mental health, preoperatively and at six weeks, twelve weeks, and one year postoperative. Patients also completed the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) survey, which measures overall knee health following a TKA, at six weeks, twelve weeks, and one year postoperative. At these same time intervals, patients ranked the intensity of their pain via a Numerical Rating Scale (NRS) and answered patient satisfaction questions.
Functional assessments of all patients were performed in the clinic by the physical therapy team both preoperatively and at six weeks postoperative. These assessments evaluated the patient’s knee flexion, knee extension, four-meter (4M) gait, and timed up and go (TUG). The TUG assesses the time it takes a patient to rise from a chair, walk three meters, turn around, and return to sitting, and is correlated with short-term and long-term function following arthroplasty.
The results of the study were presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons in March. We found no significant differences between the OPT and VPT groups in:
- VR-12 physical and mental component scores at 6 weeks, 12 weeks, and 1 year postoperative
- KOOS Jr, NRS Pain, or patient satisfaction scores at 6 weeks, 12 weeks, and 1 year postoperative
- In-person functional assessments at six weeks postoperative
- 6-week TUG scores (9.49 for OPT group vs. 9.85 for VPT group; p=0.49)
- 4-meter gait (1.13 for OPT group vs. 1.12 for VPT group; p=0.92)
- Knee flexion (117.77 for OPT group vs. 117.79 for VPT group; p=0.99)
- Extension (0.51 for OPT group vs. 0.86 for VPT group; p=0.29)
In addition, patient-reported satisfaction rates regarding the overall care experience were higher for the VPT cohort. This may be due to the significant cost and time savings of completing physical therapy at home. On average, patients in the OPT cohort attended 11.6 physical therapy sessions, which cost an average $15.05 in patient copays and required an average 11.5 minutes of travel time per visit.
Offering greater convenience, lower costs, and similar outcomes
Discovering that a well-supported, evidence-based virtual physical therapy program produces the same functional and patient-reported outcomes as outpatient physical therapy—even for ambulatory TKA procedures—is a game-changer.
As health systems begin to incorporate virtual therapy programs into their orthopedic care protocols, it’s important to remember that one size does not fit all. Each individual’s care plan should be tailored to suit their circumstance, clinical status, and preferences. Successful orthopedic practices will need to offer a variety of rehabilitation options.
In our study, we had a small minority of clinical crossovers from the VPT to the OPT cohort. Further research is needed to determine if any predictive indicators can identify patients who would be better served by outpatient PT. For example, functional considerations might include fall history, the need for mobility aids, or objective gait assessment performance. Other considerations might include computer literacy and the presence of a sturdy home support system.
Throughout the study, we found that the direct messaging component of our care management platform provided an essential avenue of communication, especially for patients in the VPT group who were not seeing a physical therapist in person. When patients know they will receive a timely reply, they are less likely to seek support via the ER or urgent care. Research shows that providing a care management platform with direct messaging decreases readmission rates across musculoskeletal procedures.
Within our health system, this study has demonstrated that virtual physical therapy is the way of the future for the majority of patients. Shifting the recovery paradigm to embrace remote rehabilitation demonstrates multiple advantages without compromising clinical outcomes.
Photo: Liubomyr Vorona, Getty Images
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