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Episode Transcript:

ALEXANDER GARBIN: Hello and welcome to the Restart Podcast. Podcast brought to you by the research team at the University of Colorado Anschutz Medical Campus, where we discuss research related to optimizing older adult health and function and how it can impact clinical care and everyday older adult life. Today I am joined by Dr. Jeremy Graber. He is a current research fellow at the Eastern Colorado VA, received his DPT from Indiana University and is a recent graduate from the University of Colorado. Thanks for joining me.

JEREMY GRABER: Thanks for having me, Alex.

ALEXANDER GARBIN: So today we were going to talk about a recently published manuscript in JOSPT called Expert Consensus for the Use of Outpatient Rehabilitation Visits after a total knee arthroplasty Delphi study. Before really delving into the methods and results, I was hoping you might be able to give us a brief overview of why you did this study and really the current state of physical therapy for people with total knee arthroplasty.

JEREMY GRABER: Yeah. So really our motivation for doing this study is there's quite a bit of variability in how a rehabilitation is delivered, especially in the outpatient setting. There's been some work done to show in terms of the types of interventions that are delivered, but we really wanted to focus on how many visits patients receive and after. Looking through the literature, we basically found there's very little out there to guide how visitors are delivered. And there's quite a bit of variability and a few studies that have been done and how many patient visits patients tend to receive. So we were interested in understanding sort of, you know, what is a reasonable framework to put together that could help guide how often a patient comes in for care.

ALEXANDER GARBIN: Is your idea right now that people are getting more visits than needed or fewer visits than needed?

JEREMY GRABER: I think it could go either way. So you know what we say in the in the manuscript, really? And the argument that we make is when there's really no baseline level, that sort of is like what you tailor from. The amount of care patients get tends to be more reflective of the capacity of the local system that they're in. So for a clinic that maybe has lots of slots available, lots of appointments available, those patients may be more likely to get more care than they need, whereas a clinic who's super busy and maybe doesn't have the resources to get patients in as often as would be ideal, those patients might receive less. And of course, you know, there's lots of variability even within the setting, but unlike a system level that that's kind of the that's our hypothesis for what's going on.

ALEXANDER GARBIN: Yeah, I can see the logic behind that. What is the consequence of having these non optimal number of visits?

JEREMY GRABER: The consequence is that rehabilitation becomes less efficient. So for a patient who maybe could benefit from more intensive rehab, more frequent touches, maybe their recovery is slower, or maybe they don't recover to the level that they really desire after surgery. Or for the patient who's doing quite well, maybe needs less active care or is capable of, you know, managing their own treatment, then they're receiving more care than they need. So basically, like, we're not delivering the right amount of care to the right person. And that's going to become more and more important as there's this push and especially in joint replacement recovery for like bundled payments where the amount of reimbursement that a system gets is sort of predetermined from the outset. So there's a push to reduce

the amount of rehabilitation that's delivered because that's more money then for the system. So there's a push to reduce rehabilitation overall or to streamline it. And so if you don't have a way to the right amount of care, to the right person, then there's also the risk of if you're indiscriminately reducing rehab for everyone. Now, some people are going to get cut out of the rehab that they need.

ALEXANDER GARBIN: Yeah, it makes a lot of sense. So in the title you mentioned this is a Delphi study for those that might not be aware of this. Could you describe what a Delphi study is?

JEREMY GRABER: Yeah. So a Delphi study is it's it's more like a framework than like this really rigid study design. And it's a framework to gather the opinion of experts in a specific field or topic of interest, to gather their opinion and then to iteratively build consensus among those experts. So usually it consists of several structured rounds where within each round you kind of provide feedback to the experts so they know how other experts responded to the topic of interest. And the idea is that round by round, the experts kind of come to a middle ground or consensus on key topics.

ALEXANDER GARBIN: And in the background, you mentioned a prior Delphi effort that was, I think, in 2014 published. And in this article, your article, you mention a few different things that differ from this 2014 article. Is there anything really in the concept of it's been ten years that made you think we could have a successful Delphi study that comes the consensus where this prior research article did not.

JEREMY GRABER: Yes. So when we looked at that study. The thing that stuck out was it was a very it was a much more broad overall in what their goals were for that research. So really was to develop best practice recommendations overall for rehabilitation after total hip arthroplasty. And so we thought, you know, we're really asking a much more specific question. And I think within their study design, you know, it was it was a much smaller topic of interest. And so we thought if we really focused specifically on how many visits would be optimal for patients after knee replacement, we might be more likely to gain consensus because we could be much more focused on that topic overall.

ALEXANDER GARBIN: Mm hmm. And you mentioned they did both total knee and total arthroplasty. Is there a reason that your team focused solely on total knee?

JEREMY GRABER: So we focused on total knee arthroplasty, mainly because in the THA space there's already been a really large push to cut rehabilitation overall. And lots of patients actually don't receive rehabilitation at all. And the TKA space is sort of. Maybe heading that same direction. And so we're kind of trying to be proactively a little bit more upstream, you know, to make sure the right amount of care is delivered to the right patient, where it may be harder to make that kind of a push in to where that change has already sort of been put in place.

ALEXANDER GARBIN: So looking at the results now, it stated that and the visit frequency consensus, eight out of the nine recommendations were met with consensus. And I should say there's a lot of great results in this manuscript. Too many to really discuss each one over voice, but we'll have the manuscript linked in the show notes that can go through. Each of these recommendations are met by Delphi. But back to my question, what's the surprising that you had consensus met after round one in so many areas given you did have a lot of variance and perfections in your Delphi panel?

JEREMY GRABER: Yeah, it actually was really surprising in given that, yeah, we had two surgeons, we had researchers, we had physical therapy clinicians. And, you know, given that the state of the field was that there's quite a bit of variability in how care is delivered. It actually was surprising to see there was so

much agreement among experts about what dental care should look like. But that actually kind of gave us a lot of confidence in our results overall and that we're not we felt like we weren't forcing this agreement on our Delphi participants, that it really already existed. And we use the Delphi just to bring it to light.

ALEXANDER GARBIN: Yeah. There is one category that never did reach consensus, that ninth category. Are able to speak a little bit about that and why you think consensus was an issue.

JEREMY GRABER: Yeah. So I'll start just by explaining what the nine visit frequency recommendation categories are. So basically the way that we designed this was we envision that the amount of care that should be recommended for patients probably depends on how their recovery is progressing. So we said let's create separate categories of frequency recommendations for patients who are recovering fast, like faster than expected patients who are recovering slow, and then patients who are recovering about like, as you would expect. And then within each of those three categories, the amount of care that patients receive or the amount of care that patients need probably also depends on how far they are from surgery, like tissue healing, pain recovery, things like that. So we have a different recommendation for each of those categories within month one, month two and three. So those are three by three. That's the nine visit frequency recommendations. And the only one that we didn't reach consensus on were patients recovering faster than expected in month three. And we sort of had a split where some of our Delphi panelists felt like those patients should probably just be discharged, you know, by month three. A lot of recovery has already happened and they're already ahead of ahead of where they think they should be. So they can probably manage independently, whereas the other half of the group really said, you know, yeah, maybe they're ahead of where I thought they should be and it's month three, they're doing much better, but maybe they have really ambitious goals. And so we shouldn't just off, you know, out of hand say that they don't need more rehabilitation. It really should be more of a discussion with the patient to figure out if more rehab is indicated.

ALEXANDER GARBIN: And one of those groups was more comprised of surgeons or the other group as more comprised of PTs. Is that correct?

JEREMY GRABER: Yes, we did find the group that felt like most patients who have a recovering faster in month three should be discharged was primarily surgeons, although there were pre-teens in that mix and there were a few surgeons that were also in the other group as well. But we did kind of notice that was the general trend. Interesting.

ALEXANDER GARBIN: Okay. So with these recommendations and really the value of this study is now you have this consensus that hopefully can be used to optimize those visit patterns. How do you see this being used? Are you on to deliver it to surgeons to tell us this is how many visits I'd like my patient to receive? Does it go directly to PTs or is it something that you can deliver to patients?

JEREMY GRABER: So ideally be great if we can deliver it on all those levels. I think you know where it would be most effective. So a lot of times the way that care is delivered is sort of dictated at the whether it be the hospital level. If they have like a protocol in place or at the surgeon level where they often have their post-operative protocol they'd like to see followed. So it'd be great if a surgeon and the rehab team would come together and say, this is a framework that we're going to use. And then when the patient and a physical therapists are going through their rehab, then they could review that framework together. And we really see it as more of a jumping off point for, you know, how to structure, visit frequency, not

as a hard and fast rule by any means. So as we've discussed in the paper, is really more of. The P.T. can tell a patient, Hey, you're its month to your recovery faster than we expected. This is what experts recommend for how frequent you should come in. Let's talk about it. Let's talk about your goals and where you want to be in your priorities. And then, you know, maybe those recommendations don't work for that patient, but at least you have a common starting ground that you can have this discussion with and kind of empower the patient a little more to know. Like what's typical? Where are they at?

ALEXANDER GARBIN: I will say for the listeners - in the article which I’ll have a link in the show notes, that box 2 has some really nice examples of how this conversation might go between, I believe, a patient and physical therapist dyad, for if they're on track with their treatment, if they're behind or if they are ahead. So the really nice example and maybe how you might be able to use this clinically. So one aspect that you touched on a little bit earlier, just on the side of payment and an entity that has some decision making over a number of visits as insurance companies or the payers. Did you consider these at all when you were designing the study or the design of your Delphi process? And how do you consider these payers in the context of the study results?

JEREMY GRABER: Yeah. It's definitely true that insurance reimbursement can be a big driver of how care is delivered. And so the way that we the way that we talk about that in the paper is really, you know. That's something that has to be part of the conversation between the patient and the clinician if you are using this framework. I think the way that we'd like to see this go in the longer term is, you know, maybe. Groups, organizations, clinics, if they sort of adopt this model and can show that we can deliver more efficient rehabilitation, you know, hopefully in the long term, that can kind of shape the way that reimbursement looks for outpatient rehabilitation.

ALEXANDER GARBIN: Mm hmm. Yeah, I'd say that's certainly the hope. So you mentioned earlier the goal would be to deliver those to multiple levels, the patients, surgeons, maybe even insurance companies. How do you see this being disseminated so that you can have that clinical impact on number of visits after total knee arthroplasty.

JEREMY GRABER: Yeah, that's a good question. You know, I think it's something that has to be done at the level of the unit that we're talking about. So like at the hospital, it's something that has to be championed by, you know, the clinical team. And then you have to get the administrative team on board, too. And that can be challenging until you've really shown that this is something that works or is effective. And so I think that's really the next step. You know, before we can really push this out and say people should use this, we'd like to test out like let's use it and see if really, you know, does it make care more efficient? And that's kind of where some of our next directions are going.

ALEXANDER GARBIN: I’m excited to see the results of that. So the way we like to end this podcast is really having a takeaway from the manuscript for researchers, clinicians, as well as older adult patients or potential patients. It's something you'd be able to do.

JEREMY GRABER: Yeah. So I'd say for, for researchers. You know, one thing with total knee arthroplasty rehabilitation studies is there's tons of variability in the outcomes that are used in the way that care is delivered. As far as how frequently patients are seen, this is potentially now a framework that can be used. So if researchers were to adopt this, there could be a common structure for how care is actually delivered. For clinicians, this is something that you could adopt right away. You know, if you want to, instead of purely relying on your clinical intuition or your normal clinical practice patterns, you could

adopt this. You know, it is a step up in evidence, even though it's just expert opinion hasn't been tested rigorously yet. It's at least something that clinicians could use so that. From question to commission, you have this kind of starting the same starting point and there's a little bit less variation. And then for older adults, you know, if you're having a knee replacement, we really sort of envision this as we're giving you more information about what, you know what's been recommended to other patients in your similar condition. And you can take that information now and make a more informed decision and be more active in decision making about your care after knee replacement, as opposed to just sort of completely relying on the information provided like from your clinician or your surgeon topic.

ALEXANDER GARBIN: I think those are all good takeaways for all categories. Thank you again for joining us today on this podcast, Jeremy. And for everyone listening, thank you for listening.

JEREMY GRABER: Thank you.