myHip&Knee: Improving Patient Engagement and Self-Management Through Mobile Technology.

Given the increasing volume of hip and knee replacement surgery with reduced hospital stays and resources, we explored technology to address gaps in patient care and enhance self-management. The team at the Holland Orthopaedic and Arthritic Centre of Sunnybrook Health Sciences Centre, which performs a high volume of joint replacement surgery, partnered with patients and a health technology company to create a mobile app: myHip&Knee. The results to date demonstrate that the app improves patient experience and reduces follow-up calls to surgeons' offices, ultimately reducing demand on healthcare resources. Early engagement of privacy and legal services, close patient and family collaboration and a well-developed evaluation strategy represent critical steps to successful development.

Evaluation of an advanced-practice physical therapist in a specialty shoulder clinic: diagnostic agreement and effect on wait times.

PURPOSE: To examine the role of an advanced-practice physiotherapist (APP) with respect to (1) agreement with an orthopaedic surgeon on diagnosis and management of patients with shoulder problems; (2) wait times; and (3) satisfaction with care. METHODS: This prospective study involved patients with shoulder complaints who were referred to a shoulder specialist in a tertiary care centre. Agreement was examined on seven major diagnostic categories, need for further examination and surgery, and type of surgical procedure. Wait times were compared between the APP- and surgeon-led clinics from referral date to date of initial consultation, date of final diagnostic test, and date of confirmed diagnosis and planned treatment. A modified and validated version of the Visit-Specific Satisfaction Instrument assessed satisfaction in seven domains. Kappa (κ) coefficients and bias- and prevalence-adjusted kappa (PABAK) values were calculated, and strength of agreement was categorized. Wait time and satisfaction data were examined using non-parametric statistics. RESULTS: Agreement on major diagnostic categories varied from 0.68 (good) to 0.96 (excellent). Agreement with respect to indication for surgery was κ=0.75, p<0.001; 95% CI, 0.62-0.88 (good). Wait time for APP assessment was significantly shorter than wait time for surgeon consultation at all time points (p<0.001); the surgeon's wait time was significantly reduced over 3 years. High satisfaction was reported in all components of care received from both health care providers. CONCLUSIONS: Using experienced physiotherapists in an extended role reduces wait times without compromising patient clinical management and overall satisfaction.

Objectif : Examiner le rôle du physiothérapeute en pratique avancée en ce qui a trait (1) aux accords avec un chirurgien orthopédique sur le diagnostic et la gestion de patients aux prises avec des problèmes à l'épaule; (2) au temps d'attente; (3) à la satisfaction par rapport aux soins. Méthode : Cette étude prospective a fait appel à des patients avec des douleurs à l'épaule qui ont été dirigés vers des spécialistes de l'épaule dans un centre de soins tertiaires. Les accords ont été examinés pour sept catégories de diagnostics, en fonction de la nécessité d'examens plus poussés ou de chirurgie et du type d'intervention chirurgicale projeté. On a comparé les temps d'attente pour le physiothérapeute en pratique avancée et les cliniques dirigées par un chirurgien à partir de la date où le patient a été redirigé à la consultation initiale, jusqu'à la date de diagnostic définitif, jusqu'à la date de diagnostic confirmé et jusqu'au traitement planifié. Une version modifiée et validée de l'instrument d'évaluation de la satisfaction à la suite d'une consultation (Visit-Specific Satisfaction Instrument) a permis de mesurer la satisfaction dans sept domaines. Les coefficients kappa (κ) et les valeurs kappa ajustées pour la prévalence et le biais (PABAK) ont été calculés et les accords ont été catégorisés selon leur force. Les données sur les temps d'attente et la satisfaction ont été examinées à l'aide de statistiques non paramétriques. Résultats : Le degré d'accord sur les diagnostics importants variait de 0,68 (bon) à 0,96 (excellent). Les accords en ce qui concerne le recours à la chirurgie étaient de κ=0,75, p<0,001, I.C. 95%, 0,62­0,88 (bon). Les temps d'attente pour une évaluation par un physiothérapeute en pratique avancée étaient considérablement plus courts que ceux pour une consultation auprès d'un chirurgien à toutes les étapes (p<0,001); les temps d'attente pour un chirurgien étaient considérablement réduits sur 3 ans. Un degré élevé de satisfaction a été observé dans toutes les composantes des soins prodigués par des fournisseurs de soins. Conclusions : Le recours à un physiothérapeute expérimenté dont la pratique s'étend hors des rôles traditionnels réduit les temps d'attente sans nuire à la gestion clinique du patient ni influer sur sa satisfaction globale.

Toward a joint health and disease management program. Toronto hospitals partner to provide system leadership.

The Joint Health and Disease Management Program in the Toronto Central Local Health Integration Network (TC LHIN) is envisioned as a comprehensive model of care for patients with hip and knee arthritis. It includes access to assessment services, education, self-management programs and other treatment programs, including specialist care as needed. As the first phase of this program, the hospitals in TC LHIN implemented a Hip and Knee Replacement Program to focus on improving access and quality of care, coordinating services and measuring wait times for patients waiting for hip or knee replacement surgery. The program involves healthcare providers, consumers and constituent hospitals within TC LHIN. The approach used for this program involved a definition of governance structure, broad stakeholder engagement to design program elements and plans for implementation and communication to ensure sustainability. The program and approach were designed to provide a model that is transferrable in its elements or its entirety to other patient populations and programs. Success has been achieved in creating a single wait list, developing technology to support referral management and wait time reporting, contributing to significant reductions in waits for timely assessment and treatment, building human resource capacity and improving patient and referring physician satisfaction with coordination of care.

A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients.

A new model of care has been implemented at the Sunnybrook Holland Orthopaedic and Arthritic Centre that expands the role of physiotherapists to improve access and quality of care for patients requiring hip and knee replacement surgery. An advanced practice physiotherapist (APP) role was created to support both referral management and post-operative care to reduce surgeon workload and better streamline services. This article describes our nine-step framework for implementing an APP role and can be used as a template for other organizations evolving similar roles. The framework was adapted from the participatory, evidence-based, patient-focused process for the development of an advanced practice nurse role. Key steps include (1) obtaining stakeholder consensus, (2) identifying barriers and facilitators and (3) developing the necessary administrative and training supports as well as clinical protocols and an evaluation framework. Approaching change in a series of small steps (plan-do-study-act [PDSA] methodology) alongside existing processes has facilitated buy-in and role acceptance. The early and continued involvement of decision-makers within the organization has been paramount to successful implementation. In addition, patient input has been central to the evolution of the role, with patient satisfaction a key indicator. The new role and model of care reconfigures traditional roles and introduces a team approach that results in timely access to care for patients. Benefits include an improved assessment process, enhanced education across the care continuum and improved coordination and delivery of services.

Achieving team consensus on best practice rehabilitation guidelines following primary total hip replacement (THR) surgery.

The demand for hip replacements is on the rise; however, despite commonly employed post-operative positional and activity restrictions, limited evidence exists to substantiate such practices. Guidelines provide a means of assisting the healthcare team in decision-making; however, when a clinical decision has to be made in the absence of scientific evidence, guideline developers rely on consensus processes. A formal consensus process based on a nominal group technique was used to incorporate the scientific evidence and practitioner experience for the development of primary total hip replacement guidelines at a specialized orthopaedic tertiary care facility. Agreement was reached regarding a number of practice issues, which historically had varied among the surgeons. Given the lack of available guidance on how to synthesize research findings in conjunction with expert opinion, the process we employed has been described so that others may use, modify and refine it. Further scientific inquiry into safe activity resumption post-total hip replacement is warranted.