Associations Between Telerehabilitation and Outcomes for Patients with Low Back Pain During the COVID-19 Pandemic

Research Objectives To examine associations between frequency of telerehabilitation i.e., any few, most or all, and outcomes of functional status, number of visits, and patient satisfaction during COVID-19 and to compare functional status outcomes by telerehabilitation delivery mode i.e., synchronous, asynchronous, mixed, for patients with low back pain. Design Retrospective observational cohort. Setting Outpatient rehabilitation. Participants Sample consisted of 91,117 episodes of care (58% women;mean age = 55 [SD = 18]). Interventions Not applicable. Main Outcome Measures Lumbar Computer Adaptive Test (LCAT) patient-reported outcome measure was administered to assess functional status. LCAT has been shown to be reliable, valid, and responsive. Number of visits during the episode of care were documented at discharge. Data on patient satisfaction with treatment results were collected: “How satisfied were you with overall results of your treatment at this facility?” Results Telerehabilitation was administered in 5013 care episodes (5.5%). Propensity score matching was used to match episodes of care with or without telerehabilitation exposure by the probability of receiving telerehabilitation. Standardized differences were used to compare samples before and after matching. All standardized differences between matched samples were < 0.1. There was no significant difference in functional status points (range = 0–100, with higher representing better functional status) between matched samples, except for episodes that had few (−1.7) and all (+2.0) telerehabilitation frequencies or that involved the asynchronous (−2.6) telerehabilitation mode. These point differences suggest limited clinical importance. Episodes with any telerehabilitation frequency involved significantly fewer visits (0.7 to 1.3) than episodes with no telerehabilitation, except that those with the most telerehabilitation frequencies had nonsignificantly fewer visits (0.6). A smaller proportion of patients with telerehabilitation than of patients with no telerehabilitation (−4.0% to −5.0%, respectively) reported being very satisfied with treatment results, except for those with the ‘all’ telerehabilitation frequency. Conclusions A positive association between telerehabilitation and outcomes was observed, with a trend for better functional status outcomes and fewer visits when all care was delivered through telerehabilitation. Satisfaction tended to be lower with telerehabilitation use. Author(s) Disclosures No conflicts to declare.

Is Telerehabilitation a Viable Option for People With Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic.

OBJECTIVE: The aims of this study were to examine associations between frequency of telerehabilitation (TR) and outcomes of functional status (FS), number of visits, and patient satisfaction during COVID-19 and to compare FS outcomes by TR delivery mode for individuals with low back pain. METHODS: Propensity score matching was used to match episodes of care with or without TR exposure by the probability of receiving TR. FS, visits, and satisfaction were compared for individuals without TR and those who received care by TR for "any," "few," "most," or "all" frequencies (4 matched samples), and FS was compared for individuals receiving synchronous, asynchronous, and mixed TR modes (3 matched samples). Standardized differences were used to compare samples before and after matching. Outcomes between matched samples were compared using z tests with 95% CI. RESULTS: The sample consisted of 91,117 episodes of care from 1398 clinics located in 46 states (58% women; mean age = 55 [SD = 18]). Of those, only 5013 episodes (5.5%) involved any amount of TR. All standardized differences between matched samples were <0.1. There was no significant difference in FS points (range = 0-100, with higher representing better FS) between matched samples, except for episodes that had ``few'' (-1.7) and ``all'' (+2.0) TR frequencies or that involved the asynchronous (-2.6) TR mode. These point differences suggest limited clinical importance. Episodes with any TR frequency involved significantly fewer visits (0.7-1.3) than episodes with no TR, except that those with the "most" TR frequency had non-significantly fewer visits (0.6). A smaller proportion of individuals with TR (-4.0% to -5.0%) than of individuals with no telerehabilitation reported being very satisfied with treatment results, except for those with the "all" TR frequency. CONCLUSIONS: A positive association between TR and rehabilitation outcomes was observed, with a trend for better FS outcomes and fewer visits when all care was delivered through TR. Satisfaction tended to be lower with TR use. Overall, this observational study showed that for people with low back pain, physical therapy delivered through TR was equally effective as and more efficient than in-person care, with a trend of higher effectiveness when used for all visits during the episode of care. No differences in FS outcomes were observed between care delivered with synchronous and mixed TR delivery modes and care delivered with no TR. However, the asynchronous mode of TR was associated with worse functional outcomes than no TR. Although the majority of people were very satisfied with their treatment results with and without TR, very high satisfaction rates were reported by a slightly smaller proportion of individuals with TR versus those without TR. Our results suggest that TR is a viable option for rehabilitation care for individuals with low back pain and should also be considered in the post-COVID-19 era.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities.

Importance: In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective: To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design Setting and Participants: This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures: Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures: Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results: The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years; 143 830 women [71.5%]; 185 854 White patients [92.4%]); 147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: -15.9 minutes per day; 95% CI, -16.9 to -14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day; 95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, -13.3 to -11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase; 95% CI, -1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days; 95% CI, -4.83 to -0.54), or functional score at discharge (0.04 point increase in activities of daily living score; 95% CI, -0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19-related restrictions on communal activities in SNFs. Conclusions and Relevance: In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities

This cross-sectional study assesses whether implementation of the Patient Driven Payment Model is associated with changes in therapy utilization or health outcomes. Key Points Question Was the Patient Driven Payment Model (PDPM), implemented in October 2019, associated with rehabilitation therapy utilization and health outcomes of patients admitted to skilled nursing facilities (SNFs)? Findings In this cross-sectional study of 201 084 patients admitted to an SNF after hip fracture between January 2018 and March 2020, those admitted post-PDPM received about 13% fewer therapy minutes than those admitted pre-PDPM, but the likelihood of rehospitalization and functional scores at discharge remained unchanged. Meaning Implementation of PDPM was associated with a reduction in the volume of therapy use without changes in subsequent hospitalization risk or discharge functional scores. Importance In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design, Setting, and Participants This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years;143 830 women [71.5%];185 854 White patients [92.4%]);147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: −15.9 minutes per day;95% CI, −16.9 to −14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day;95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, −13.3 to −11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase;95% CI, −1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days;95% CI, −4.83 to −0.54), or functional score at discharge (0.04 point increase in activities of daily living score;95% CI, −0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19–related restrictions on communal activities in SNFs. Conclusions and Relevance In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.

Rapid Changes in the Provision of Rehabilitation Care in Post-Acute and Long-Term Care Settings During the COVID-19 Pandemic.

OBJECTIVES: Little is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs. DESIGN: Qualitative analysis of open-ended survey results. SETTING AND PARTICIPANTS: 30 clinical and administrative staff working in post-acute and long-term care. METHODS: From June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data. RESULTS: We identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients' motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients' isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency. CONCLUSIONS AND IMPLICATIONS: Survey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.