key: cord-0706768-qpnxo3wt authors: Werneke, Mark W; Deutscher, Daniel; Grigsby, David; Tucker, Carole A; Mioduski, Jerome E; Hayes, Deanna title: Telerehabilitation During the Covid-19 Pandemic in Outpatient Rehabilitation Settings: A Descriptive Study date: 2021-04-13 journal: Phys Ther DOI: 10.1093/ptj/pzab110 sha: b7e8b2a8e0c77d212a4e455b99f90d5830d349e9 doc_id: 706768 cord_uid: qpnxo3wt OBJECTIVE: COVID-19 has widely affected delivery of health care. In response, telerehabilitation (TR) has emerged as alternative care model. Aims were: (1) describe baseline patient characteristics and available unadjusted outcomes for episodes of care administered during COVID-19 using TR vs. traditional in-person care, (2) describe TR frequency levels by condition and telecommunication modes. METHODS: A descriptive retrospective observational design was used to report patient variables and outcomes including physical function, number of visits, and patient satisfaction, by TR frequency (few, most, or all visits) and telecommunication modes. Standardized differences were used to compare baseline characteristics between episodes with and without TR. RESULTS: Sample consisted of 222,680 patients [59% female; mean age (SD) = 55(18)]. Overall TR rate was 6% decreasing from 10% to 5% between 2(nd) and 3(rd) quarters of 2020. Outcome measures were available for 90% to 100% of episodes. Thirty-seven percent of clinicians administered care via TR. Patients treated using TR compared to in-person care were more likely to be younger, and live in large metropolitan areas. From those with TR, 55%, 20%, and 25% had TR during few, most, or all visits, respectively. TR care was administered equally across orthopedic body parts, with lower use for non-orthopedic conditions such as stroke, edema, and vestibular dysfunction. TR was primarily administered using synchronous (video or audio) modes. The rate of patients reported being very satisfied with their treatment results was 3% higher for no TR compared to TR. CONCLUSIONS: These results provide new knowledge about to whom and how TR is being administered during the pandemic in outpatient rehabilitation practices throughout the USA. The database assessed was found to be suitable for conducting studies on associations between TR and diverse outcome measures, controlling for a comprehensive set of patient characteristics, to advance best TR care models, and promote high quality care. IMPACT: This study provided detailed and robust descriptive information using an existing national patient database containing patient health and demographic characteristics, outcome measures, and TR administration data. Findings support the feasibility to conduct future studies on associations between TR care and patient outcomes, adjusting for a wide range of patient characteristics and clinical setting factors that may be associated with the probability of receiving TR. Finding of limited and decreasing use of TR over the study period calls for studies aimed to better understand facilitators and inhibitors of TR use by rehabilitation therapists during everyday practice to promote its use when clinically appropriate. orthopedic body parts, with lower use for non-orthopedic conditions such as stroke, edema, and vestibular dysfunction. TR was primarily administered using synchronous (video or audio) modes. The rate of patients reported being very satisfied with their treatment results was 3% higher for no TR compared to TR. These results provide new knowledge about to whom and how TR is being administered during the pandemic in outpatient rehabilitation practices throughout the USA. The database assessed was found to be suitable for conducting studies on associations between TR and diverse outcome measures, controlling for a comprehensive set of patient characteristics, to advance best TR care models, and promote high quality care. Impact. This study provided detailed and robust descriptive information using an existing national patient database containing patient health and demographic characteristics, outcome measures, and TR administration data. Findings support the feasibility to conduct future studies on associations between TR care and patient outcomes, adjusting for a wide range of patient characteristics and clinical setting factors that may be associated with the probability of receiving TR. Finding of limited and decreasing use of TR over the study period calls for studies aimed to better understand facilitators and inhibitors of TR use by rehabilitation therapists during everyday practice to promote its use when clinically appropriate. The coronavirus pandemic (COVID-19) has widely affected all aspects of society and impacted delivery of physical therapy and other health care services internationally as well as in the United States. [1] [2] [3] [4] In response, telerehabilitation (TR) has emerged as a promising alternative model to traditional in-person clinical visits. TR refers to clinical services administered at a distance using telecommunication. 5 TR can be delivered using a variety of telecommunication media technologies with either real time (synchronous) 2-way interactive mediums such as video and/or audio calls, or asynchronous E-visits not in real time, eg, virtual check-ins, remote evaluations of recorded videos or applications/links to exercises and educational materials. 4, 6 Evidence exists on benefits and patient acceptance of TR care for patients with a wide variety of conditions including orthopedic (eg, low back, total joint arthroplasty), [5] [6] [7] [8] neurological (eg, stroke, multiple sclerosis), [9] [10] [11] and wide spread chronic pain syndromes (eg, fibromyalgia, rheumatoid arthritis). 12- 14 Preliminary findings indicate that care delivered via TR in addition to or as replacement of in-person clinic visits was generally either equivalent to or yielded slightly better outcomes compared to usual in-person physical therapy care alone. 5, 15 However, many authors recommend caution to avoid generalization and overestimation of these findings given methodological weaknesses in available studies, heterogeneous nature of patient characteristics, variability in clinical conditions, and small sample sizes. 6, 12, 16, 17 Evidence supporting the benefits and effectiveness of TR was mainly published prior to COVID-19. Since the onset of COVID-19, many state and federal regulatory and reimbursement policies were implemented to enhance the administration of TR care by rehabilitation therapy specialists. 18, 19 [H2] Telerehabilitation TR data were collected using the following survey question ("How many of your current therapy visits have taken place over the internet or by phone (telehealth) instead of in the clinic."). if the episode of care included both synchronous and asynchronous telecommunication modes. [H2] Outcomes The outcomes described were physical function (PF) change, number of treatment visits during the episode of care from intake to discharge, and patient satisfaction with treatment results at discharge. PF was assessed at intake and discharge using a set of patient-reported outcome measures (PROMs) developed using item response theory (IRT). [22] [23] [24] [25] Measure administration mode was through computerized adaptive tests (CATs) described previously in detail. [26] [27] [28] [29] [30] [31] The IRT model calibrated the PF scores into a linear metric from 0 (low) to 100 (high) functioning. Number of visits were used as a proxy to describe direct costs and health care usage incurred by TR use as recommended in a recent systematic review by van der Meij. 32 Patient satisfaction with treatment results data were collected using a question that was administered on every follow-up patient survey ("How satisfied were you with overall results of your treatment at this facility?"). Patient response categories were: very satisfied, somewhat satisfied, neither satisfied or dissatisfied, somewhat dissatisfied, or very dissatisfied. To address the first aim, standardized difference analytical methods were used to determine differences in baseline characteristics between those episodes with TR and those without TR. Standardized differences were calculated to compare means of continuous variables and prevalence of dichotomous variables as recommended by Austin. 33 Briefly for continuous variables the standardized difference was defined as: Where ̅ 1 denote the mean of the covariate in each group, and denote the full sample standard deviation. For dichotomous variables the standardized difference was defined as: where ̂ denote the prevalence or mean of the dichotomous variable in each group. Unlike p-values, standardized difference analyses are not influenced by sample size, and can be interpreted as an effect size, with values of 0.2, 0.5, and 0.8 proposed previously to represent thresholds of small, medium, and large effect sizes, respectively. 34 Standardized difference values <0.1 were suggested to represent clinically negligible differences. 33 For our second aim, we calculated the standardized difference between 2 orthopedic body parts that had the highest and lowest rates of TR use, allowing us to infer if TR was equally administered between all orthopedic body parts. Additionally, we calculated percentages for telerehabilitation frequency levels ie, few, most or all, by telecommunication technology modes ie, synchronous, asynchronous, and both (mixed) modes. [H1] Results [H2] Patients with and without TR Baseline patient characteristics were compared between episodes with and without TR ( Table 1 ). was 7% lower (standardized difference = 0.14), high blood pressure was 7% lower (standardized difference = 0.14), and obesity was 6% lower (standardized difference = 0.12). Unadjusted patient outcomes at discharge for the full sample and the samples using or not using TR for PF change, number of visits, and patient satisfaction are presented in Table 2 Percentages of TR use by frequency levels and body part or care type are presented in Table 3 . [ The study's major findings were: 1) only 6% of episodes of care in our sample incorporated some level of TR provided by 37% of clinicians; 2) TR was more likely to be administered during the 2 nd quarter, 2020 (10%) compared to the 3 rd quarter 2020 (5%); 3) meaningful differences in some patient health and demographic characteristics were observed between TR and no TR subgroups; 4) TR frequency levels varied from 55%, 20%, and 25% for few, most, or all visits, respectively; 5) any TR use was equally administered across orthopedic body parts, with lower use for conditions of stroke, upper or lower quadrant edema, and vestibular dysfunction; and 6) percentages per TR technology modes were 60%, 21%, and 19% for synchronous, asynchronous, and both or mixed modes respectively. [H2] Implication for practice The low TR administration rate by service providers in our study contrasts with recent studies consistently recommending a rapid adoption and implementation of TR in replacement of or in addition to in-person rehabilitation clinic visits since the start of the COVID-19 pandemic. 2, 4, 20, 37, 38 The recommendations supporting TR's outcome effectiveness, reduction in patient in-direct the circumstances under which video medium is superior to telephone as a telehealth modality. 48 In another recent study, the authors reported that 75% of patients aged 65+ operated TR telecommunication mediums independently and concluded TR was feasible in adults of all ages. 38 We recommend selecting TR communication technologies which are most user-friendly and capable of expanding access of rehabilitation services to all of our patients. We recommend future studies examining the optimal interactions between TR delivery modes and frequency levels to achieve best patient outcomes. We did not anticipate the low adoption and implementation of TR by providers and the sharp reduction in TR administration between the 2 nd and 3 rd quarters 2020 given recent reports that telehealth is rapidly being implemented in light of the COVID-19 pandemic. 44 We speculate that the reduction in TR use observed may be primarily explained by 1) the easing of stay-at-home and mandatory restrictions during the 3 rd quarter, 2020 and 2) subsequently, lightening of pandemic restrictions decreased some of the motivation of both patients and providers to continue using alternative TR care services, favoring the familiarity of an in-person approach. One possible explanation for the decrease in TR administration may be patient dissatisfaction with TR compared to in-person care. The unadjusted results indicate that it is plausible that patients were less likely to be very satisfied with TR and that patients with specific conditions may have had less improvement than those treated in-person. However, due to the nature of this descriptive study and no adjustment as to the probability of being treated using TR, further research is needed to study associations between TR use and patient satisfaction or other patient outcomes while controlling for potential confounders of the outcomes assessed. Implementation of TR faces many challenges which may also explain the overall low TR adoption by clinicians research is required to 1) study associations between TR use and patient satisfaction and improvement in physical function outcomes while controlling for potential confounders of the outcomes assessed and 2) determine the value of TR care in physical therapy. Second, our descriptive data may not be generalizable to the overall outpatient rehabilitation population in the US. Although this was not the purpose of this study, testing for the generalizability of the national database analyzed merits attention. Third, TR frequency level was based on patient's recall at discharge. Validating patient-reported TR frequency levels using billing data, which were not available to us, are recommended for future research. Fourth, we analyzed data only from clinicians using FOTO to collect treatment outcomes, with no comparison to clinicians who either did not document treatment outcomes or did not use FOTO for outcome documentation. Therefore, we cannot rule out a potential selection bias. Our results provide new knowledge regarding to whom and how TR is being administered during COVID-19 in outpatient rehabilitation practices included in our study. The database assessed was found to be suitable for future studies on associations between TR use during the episode of care, and diverse outcome measures documented during routine rehabilitation outpatient practice, while controlling for a comprehensive set of patient characteristics. Studies on the generalizability of these findings into the "real-world" settings where telerehabilitation is yet to be adopted are needed to advance best TR care models and promote patient outcomes during and after the COVID-19 pandemic. This study was performed at Net Health Systems, Inc., Pittsburgh, PA. There are no funders to report for this submission. 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