Impact of a Remote Patient Monitoring Platform on Outcomes Following a Total Hip or Knee Arthroplasty.

Background: The coronavirus pandemic highlighted the need for remote patient monitoring to deliver and provide access to patient care and education. A mobile-based app providing interactive tools for patient education and monitoring was piloted at Thunder Bay Regional Health Sciences Centre (TBRHSC) in November 2020. We aimed to examine the platform's impact on postoperative length of stay, hospital readmissions, and emergency department (ED) visits 60 days postsurgery in total hip and knee arthroplasty patients in Northwestern Ontario. Methods: Data were assessed from patients undergoing primary total hip or knee arthroplasties at TBRHSC from March 1, 2020, to February 28, 2022. Patients were divided into 2 cohorts based on enrollment with the mobile-based app (SeamlessMD). Statistical differences in outcomes were determined using Mann-Whitney or χ2 tests. An odds ratio was calculated for ED visits. Results: Patients enrolled in the mobile-based app had statistically lower length of stay (U = 7779.0, P < .001) and fewer ED visits (χ2 (1,212) = 5.570, P = .018) than patients not enrolled in the program. Patients not enrolled had 2.31 times greater odds of visiting the ED postsurgery (odds ratio = 0.432, 95% confidence interval = 0.213-0.877, P = .022). There were no statistical differences found in readmission rates. Conclusions: The implementation of the mobile-based app at TBRHSC showed its potential value as a tool to reduce costs in the healthcare system and improve patient outcomes. Consequentially, more formal studies are required to elucidate the magnitude of this effect.

Comparison of a validated decision-support tool to a standard of care triage system for knee osteoarthritis assessment: a proof-of-concept study.

BACKGROUND: Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches. METHODS: We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen κ statistic) were performed, between the APP assessment decision (surgical or non-surgical) and the decision-support tool recommendation, and between the surgeon's decision (surgical or non-surgical) and the decision-support tool recommendation. RESULTS: We found a near-perfect agreement (κ = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement (κ = 0.618, n = 72) between the decision-support tool recommendation and the surgeon's decision. CONCLUSION: The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting.

The Need for Multidimensional Stratification of Chronic Low Back Pain (LBP).

MINI: The authors wanted to determine which existing primary-care low back pain stratification schema is associated with distinct subpopulations. Initial stratification by DMPP identified potentially distinct epidemiological groups. DMPP stratification resulted in discrimination beyond that provided by disability or chronicity risk stratification alone. STUDY DESIGN: A cross-sectional study of Canadian patients suffering from low back pain (LBP) seeking primary care. OBJECTIVE: The aim of this study was to determine which existing primary care LBP stratification schema is associated with distinct subpopulations as characterized by easily identifiable primary epidemiological factors. SUMMARY OF BACKGROUND DATA: LBP is among the most frequent reasons for visits to primary care physicians and a leading cause of years lived with disability. In an effort to improve treatment response/outcomes in LBP primary care, different classification systems have been proposed in an effort to provide more tailored treatment with the intent of improving outcomes. Group-specific risk factors and underlying etiology might suggest a need for, or inform, changes to treatment approaches to optimize LBP outcomes. METHODS: Stratification by dominant mechanical pain patterns; chronicity risk; disability severity. Multinomial logistic regression was used to identify the system showing greatest variability in associations with age, sex, obesity, and comorbidity. Once identified, the remaining schemas were incorporated into the model. RESULTS: N = 970; mean age: 50 years (range: 18-93); 56% female. Stratification by pain pattern revealed greater variability. Adjusted analysis: Increasing age was associated with greater odds of intermittent, extension-based back- or leg-dominant pain [odds ratio (OR): 1.02 and 1.06; P < 0.01]; being male with leg-dominant pain (ORs > 2; P < 0.01). Overweight/obesity was associated with extension-based leg-dominant pain (OR = 2.6; P < 0.02) and increasing comorbidity with extension-based back-dominant pain (OR = 1.3; P < 0.01). Severe disability was associated only with constant leg pain (OR = 3.9; P < 0.01), and high chronicity risk with extension-based leg-dominant pain (OR = 0.4; P = 0.03). CONCLUSION: Dominant mechanical symptom stratification resulted in further discrimination of an epidemiologically distinct and a large subgroup of LBP patients not identified by disability or chronicity risk stratification alone. Findings suggest a need for primary care initiated multidimensional stratification in chronic LBP. LEVEL OF EVIDENCE: 3.

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings.

BACKGROUND: The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings. METHODS: We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded. RESULTS: Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals. CONCLUSION: Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.

CONTEXTE: Les cliniques interprofessionnelles d'évaluation de la colonne vertébrale et d'éducation (Inter-professional Spine Assessment and Education Clinics [ISAEC]) ont été mises sur pied pour améliorer les soins primaires d'évaluation, d'éducation et de prise en charge des patients atteints de symptômes persistants ou récurrents de lombalgie. Cette étude a pour but d'évaluer l'effet des ISAEC sur l'accès à une évaluation chirurgicale et sur la pertinence et l'efficacité de la référence des patients en milieux ruraux, urbains et métropolitains répondant a priori aux critères de référence. MÉTHODES: Nous avons mené une étude rétrospective de données prospectives issues de cliniques du réseau des ISAEC situées à Thunder Bay, à Hamilton et à Toronto, en Ontario. Nous avons retenu pour l'étude les patients répondant aux critères de référence en chirurgie; pour chacun de ces patients, nous avons consigné le temps d'attente pour obtenir une évaluation chirurgicale, les images obtenues par résonance magnétique (IRM) aux fins de référence et la pertinence de la référence. RÉSULTATS: Au total, 422 patients, soit 10 % des patients des ISAEC au cours de la période étudiée, ont été dirigés en évaluation chirurgicale. Les temps d'attente moyens pour obtenir une évaluation chirurgicale étaient de 5,4 semaines, de 4,3 semaines et de 2,2 semaines dans les centres métropolitains, urbains et ruraux, respectivement. Le recours à l'IRM aux fins de référence a diminué de 31 % par rapport à la situation initiale. Parmi les patients référés en évaluation chirurgicale formelle, 80 % présentaient une douleur principalement localisée dans les jambes. La référence de 96 % des patients a été jugée adéquate. CONCLUSION: Même si les ressources en soins de santé sont concentrées en milieu métropolitain, c'est le milieu rural qui a connu la plus grande baisse du temps d'attente. La mise sur pied d'un modèle de soins partagés en réseau pour les patients aux prises avec des symptômes de lombalgie a amélioré l'accès aux évaluations chirurgicales de façon significative, malgré la variété géographique des milieux de pratique et les divers obstacles rencontrés. Les baisses les plus importantes ont été observées en milieu rural. De plus, des améliorations significatives de la pertinence et de l'efficacité des références ont été observées lors de la comparaison avec les rapports antérieurs, pour tous les sites de l'étude.