Implementing the Effective Coach2Move Approach for Community-Dwelling Older Adults with Mobility Limitations in Physical Therapist Practice: A Multi-Methods Process Evaluation.

OBJECTIVE: The aims of this study were to evaluate the adoption of and fidelity to the Coach2Move approach; identify differences between physical therapists with a specialization in geriatrics and physical therapists without a specialization; explore if level of adoption and specialization explain variances in effectiveness; and explore group differences in attitudes and experiences with implementation. METHODS: A multi-methods process evaluation of Coach2Move implementation through 2 education days, 3 peer-assessment meetings, and an adapted electronic health record was performed alongside a cluster randomized stepped-wedge trial comparing regular care physical therapy with Coach2Move. Participants were 36 physical therapists with a specialization (n = 17) and without a specialization (n = 19) who treated 292 community-dwelling older adults. Level of adoption and fidelity were analyzed by comparing pre-implementation scores with scores 1 year later. Coach2Move adoption was measured by e-assessment scores and fidelity through health record indicators. The impact of specialization and adoption on health outcomes was examined using a mixed-model ANOVA. Therapists' attitudes and experiences were collected through a survey based on semi-structured interviews. RESULTS: Mean total indicator scores on the e-assessment (adoption of a Coach2Move mindset) increased from baseline 17% (SD = 5%) to 47% (SD = 9%) at follow-up. Physical therapists with a specialization in geriatrics scored higher than physical therapists without (54% [SD = 6%] vs 41% [SD = 6%]). Mean indicator scores on health records (fidelity) increased from 35% (SD = 12%) at baseline to 47% (SD = 15%) at follow-up. Mean scores of physical therapists with a specialization in geriatrics were higher. Level of adoption and specialization (yes/no) did not explain the variance in effectiveness. Physical therapists identified important facilitators, including tailored education and peer-assessment meetings, while adequate reimbursement for the extra time investment was considered a necessity. Different workflows in practices were perceived as a barrier. CONCLUSION: Implementation led to increased adoption and fidelity of the Coach2Move intervention by physical therapists but shows room for improvement. Attitudes towards the approach and its implementation were positive. Future implementation efforts on adoption could be improved by focusing on a fair compensation structure by third party payers and insurance companies and optimizing organizational and financial context within practices. IMPACT: This study evaluated the implementation of Coach2Move, a clinical reasoning approach designed to increase physical activity and improve self-efficacy in older adults. Overall, the study demonstrates the potential of Coach2Move to be effectively adopted by physical therapists. However, addressing therapist compensation and adapting to practice workflows are important considerations for successful large-scale implementation.

External Validation of Prediction Models for Surgical Complications in People Considering Total Hip or Knee Arthroplasty Was Successful for Delirium but Not for Surgical Site Infection, Postoperative Bleeding, and Nerve Damage: A Retrospective Cohort Study.

Although several models for the prediction of surgical complications after primary total hip or total knee replacement (THA and TKA, respectively) are available, only a few models have been externally validated. The aim of this study was to externally validate four previously developed models for the prediction of surgical complications in people considering primary THA or TKA. We included 2614 patients who underwent primary THA or TKA in secondary care between 2017 and 2020. Individual predicted probabilities of the risk for surgical complication per outcome (i.e., surgical site infection, postoperative bleeding, delirium, and nerve damage) were calculated for each model. The discriminative performance of patients with and without the outcome was assessed with the area under the receiver operating characteristic curve (AUC), and predictive performance was assessed with calibration plots. The predicted risk for all models varied between <0.01 and 33.5%. Good discriminative performance was found for the model for delirium with an AUC of 84% (95% CI of 0.82-0.87). For all other outcomes, poor discriminative performance was found; 55% (95% CI of 0.52-0.58) for the model for surgical site infection, 61% (95% CI of 0.59-0.64) for the model for postoperative bleeding, and 57% (95% CI of 0.53-0.61) for the model for nerve damage. Calibration of the model for delirium was moderate, resulting in an underestimation of the actual probability between 2 and 6%, and exceeding 8%. Calibration of all other models was poor. Our external validation of four internally validated prediction models for surgical complications after THA and TKA demonstrated a lack of predictive accuracy when applied in another Dutch hospital population, with the exception of the model for delirium. This model included age, the presence of a heart disease, and the presence of a disease of the central nervous system as predictor variables. We recommend that clinicians use this simple and straightforward delirium model during preoperative counselling, shared decision-making, and early delirium precautionary interventions.

Implementing a Personalized Physical Therapy Approach (Coach2Move) Is Effective in Increasing Physical Activity and Improving Functional Mobility in Older Adults: A Cluster-Randomized, Stepped Wedge Trial.

OBJECTIVE: The purpose of this study was to assess whether the superior cost-effectiveness of a personalized physical therapy approach (Coach2Move)-which was demonstrated in a previous trial compared with usual care physical therapy (UCP)-can be replicated in daily clinical practice. METHODS: A multicenter, cluster-randomized, stepped wedge trial with 4 clusters consisting of 4 physical therapist practices in the Netherlands was used to compare a personalized physical therapy approach to elicit physical activity (Coach2Move) versus care as usual. Multilevel analyses for effectiveness were conducted for the amount of physical activity (Longitudinal Aging Study Amsterdam Physical Activity Questionnaire) and functional mobility (Timed "Up & Go" Test) at 3, 6 (primary outcome), and 12 months' follow-up. Secondary outcomes were level of frailty (Evaluative Frailty Index for Physical Activity), perceived effect (Global Perceived Effect and Patient-Specific Complaints Questionnaires), quality of life (Euro Quality of Life-5 Dimensions-5 Levels [EQ-5D-5L]), and health care expenditures. RESULTS: The 292 community-dwelling older adults with mobility problems visiting physical therapists were included in either the Coach2Move (n = 112; mean [SD] age = 82 [5] years; 60% female) or UCP (n = 180; mean [SD] age = 81 (6) years; 62% female) section of the trial. At baseline, Coach2Move participants were less physically active compared with UCP participants (mean difference = -198; 95% CI = -90 to -306 active minutes). At 6 months, between-group mean differences [95% CI] favored Coach2Move participants on physical activity levels (297 [83 to 512] active minutes), functional mobility (-14.2 [-21 to -8]) seconds), and frailty levels (-5 [-8 to -1] points). At 12 months, the physical activity levels of Coach2Move participants further increased, and frailty levels and secondary outcomes remained stable, whereas outcomes of UCP participants decreased. After the Coach2Move implementation strategy, physical therapists utilized significantly fewer treatment sessions compared with before the implementation (15 vs 22). Anticipated cost savings were not observed. CONCLUSION: This study replicated the results of an earlier trial and shows that Coach2Move leads to better mid- and long-term outcomes (physical activity, functional mobility, level of frailty) in fewer therapy sessions compared with UCP. Based on these and earlier findings, the implementation of Coach2Move in physical therapist practice is recommended. IMPACT: This article describes the implementation of the Coach2Move approach, a treatment strategy that has proven to be cost-effective in a previously conducted randomized controlled trial. Implementation of Coach2Move in a real-life setting allowed an evaluation of the effects in a clinically relevant population. Coach2Move has been shown to increase physical activity, improve functional mobility, and reduce frailty more effectively compared with UCP therapy and therefore has application for physical therapists working with older adults in daily clinical practice. LAY SUMMARY: Coach2Move is a new physical therapy approach for older adults. Implementation of Coach2Move in daily clinical practice can help people better outcomes over a longer period of time against similar costs compared with regular physical therapy.

Development of prediction models for complications after primary total hip and knee arthroplasty: a single-centre retrospective cohort study in the Netherlands.

OBJECTIVE: The aim of this study was to develop prediction models for patients with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to predict the risk for surgical complications based on personal factors, comorbidities and medication use. DESIGN: Retrospective cohort study. SETTING: Tertiary care in outpatient clinic of university medical centre. PARTICIPANTS: 3776 patients with a primary THA or TKA between 2004 and 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: Multivariable logistic regression models were developed for primary outcome surgical site infection (SSI), and secondary outcomes venous thromboembolism (VTE), postoperative bleeding (POB), luxation, delirium and nerve damage (NER). RESULTS: For SSI, age, smoking status, body mass index, presence of immunological disorder, diabetes mellitus, liver disease and use of non-steroidal anti-inflammatory drugs were included. An area under the receiver operating characteristic curve (AUC) of 71.9% (95% CI=69.4% to 74.4%) was found. For this model, liver disease showed to be the strongest predictor with an OR of 10.7 (95% CI=2.4 to 46.6). The models for POB and NER showed AUCs of 73.0% (95% CI=70.7% to 75.4%) and 76.6% (95% CI=73.2% to 80.0%), respectively. For delirium an AUC of 85.9% (95% CI=83.8% to 87.9%) was found, and for the predictive algorithms for luxation and VTE we found least favourable results (AUC=58.4% (95% CI=55.0% to 61.8%) and AUC=66.3% (95% CI=62.7% to 69.9%)). CONCLUSIONS: Discriminative ability was reasonable for SSI and predicted probabilities ranged from 0.01% to 51.0%. We expect this to enhance shared decision-making in considering THA or TKA since current counselling is predicated on population-based probability of risk, rather than using personalised prediction. We consider our models for SSI, delirium and NER appropriate for clinical use when taking underestimation and overestimation of predicted risk into account. For VTE and POB, caution concerning overestimation exceeding a predicted probability of 0.08 for VTE and 0.05 for POB should be taken into account. Furthermore, future studies should evaluate clinical impact and whether the models are feasible in an external population.

Implementation of a Cost-Effective Physical Therapy Approach (Coach2Move) to Improve Physical Activity in Community-Dwelling Older Adults With Mobility Problems: Protocol for a Cluster-Randomized, Stepped Wedge Trial.

BACKGROUND: Coach2Move is a personalized treatment strategy by physical therapists to elicit physical activity in community-dwelling older adults with mobility problems. OBJECTIVE: The primary objective of this study is to assess the effectiveness and cost-effectiveness of the implementation of Coach2Move compared with regular care physical therapy in daily clinical practice. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION: A multicenter cluster-randomized stepped wedge trial is being implemented in 16 physical therapist practices (4 clusters of 4 practices in 4 steps) in the Netherlands. The study aims to include 400 older adults (≥70 years) living independently with mobility problems and/or physically inactive lifestyles. The intervention group receives physical therapy conforming to the Coach2Move strategy; the usual care group receives typical physical therapist care. MEASUREMENTS: Measurements are taken at baseline and 3, 6, and 12 months after the start of treatment. The primary outcomes for effectiveness are the amount of physical activity (LASA Physical Activity Questionnaire) and functional mobility (Timed Up and Go test). Trial success can be declared if at least 1 parameter improves while another does not deteriorate. Secondary outcomes are level of frailty (Evaluative Frailty Index for Physical Activity), perceived effect (Global Perceived Effect and Patient Specific Complaints questionnaire), quality of life (EQ-5D-5 L), and health care expenditures. Multilevel linear regression analyses are used to compare the outcomes between treatment groups according to an intention-to-treat approach. Alongside the trial, a mixed-methods process evaluation is performed to understand the outcomes, evaluate therapist fidelity to the strategy, and detect barriers and facilitators in implementation. LIMITATIONS: An important limitation of the study design is the inability to blind treating therapists to study allocation. DISCUSSION: The trial provides insight into the effectiveness and cost-effectiveness of the Coach2Move strategy compared with usual care. The process evaluation provides insight into influencing factors related to outcomes and implementation.

Effectiveness of Supervised Home-Based Exercise Therapy Compared to a Control Intervention on Functions, Activities, and Participation in Older Patients After Hip Fracture: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this review was to investigate whether supervised home-based exercise therapy after hospitalization is more effective on improving functions, activities, and participation in older patients after hip fracture than a control intervention (including usual care). Furthermore, we aimed to account the body of evidence for therapeutic validity. DATA SOURCES: Systematic searches of Medline, Embase, and CINAHL databases up to June 30, 2016. STUDY SELECTION: Randomized controlled trials studying supervised home-based exercise therapy after hospitalization in older patients (≥65y) after hip fracture. DATA EXTRACTION: Two reviewers assessed methodological quality (Physiotherapy Evidence Database) and therapeutic validity (Consensus on Therapeutic Exercise Training). Data were primary analyzed using a best evidence synthesis on methodological quality and meta-analyses. DATA SYNTHESIS: A total of 9 articles were included (6 trials; 602 patients). Methodological quality was high in 4 of 6 studies. One study had high therapeutic validity. We found limited evidence in favor of home-based exercise therapy for short- (≤4mo) and long-term (>4mo) performance-based activities of daily living (ADL) and effects at long-term for gait (fast) and endurance. Evidence of no effectiveness was found for short- and long-term effects on gait and self-reported (instrumental) ADL and short-term effects on balance, endurance, and mobility. Conflicting evidence was found for strength, long-term balance, short-term gait (comfortable), long-term self-reported ADL, and long-term mobility. CONCLUSIONS: Research findings show no evidence in favor of home-based exercise therapy after hip fracture for most outcomes of functions, activities, and participation. However, trials in this field have low therapeutic validity (absence of rationale for content and intensity and reporting of adherence), which results in interventions that do not fit patients' limitations and goals.