Breaking Down Quality Indicators in Post-Op Rehab and PT


Identifying quality indicators will be important under MACRA. Some say quality indicators are true measurements that reflect the standard of care.

For patients with hip and knee osteoarthritis, total arthroplasty is a relatively common procedure. To date, however, no official best practice recommendations exist for post-operative rehabilitation and physical therapy services. To clear up any confusion, Marie Westby, PT, Ph.D., from the University of British Columbia, surveyed two expert panels, including U.S. and Canadian clinicians, researchers and patients, in a three-round online Delphi survey. They offered their input on how best to proceed with maximizing and optimizing a patient’s condition post-surgery. The result was 22 best practices for total hip arthroplasty and 24 for total knee arthroplasty. Overall, survey participants pointed to the need for supervised rehabilitation interventions provided by trained health professionals within the first two post-surgical years. However, no consensus emerged on the specifics of how these services can best be provided. Ultimately, though, Dr. Westby said, the survey outcome is a strong step toward reducing practice variation, closing the evidence-practice gap, and improving rehabilitation service quality. Rheumatology Network spoke with Westby about the implications of her study and the impact it could have on reimbursement in the MACRA environment. Rheumatology Network:  Why did you decide to look into best practices for total hip and knee arthroplasty? Dr. Westby:  As a physical therapist, I provide rehabilitation services after hip and knee replacement surgery. I noticed the amount of variation in care and the different outcomes patients experienced. It started with a survey I conducted across our province in British Columbia more than 15 years ago. I was shocked by the variety of care. That’s when I decided to go back to school to formalize my research training in order to standardize or identify what the best practices are for hip and knee replacement rehabilitation. What I saw ranged from patients having joint replacement and being discharged from the hospital with some rehabilitation or physical therapy services or they didn’t know they were supposed to receive anything or they have a really nice well-coordinated program in the community where they know what to expect. In those cases, patients start a formal rehabilitation program within a week from surgery, they’re followed for 8-to-12 weeks, and it’s a comprehensive program with excellent communication. It varies in British Columbia because we don’t have the high volume of patients that exist in the United States, so we don’t do a lot of procedures. There are fewer well-established programs. But, some places, like Vancouver does hundreds of joint replacements a year, so they have those well-established programs in place.  [[{"type":"media","view_mode":"media_crop","fid":"51072","attributes":{"alt":"Marie Westby, Ph.D.","class":"media-image media-image-right","id":"media_crop_7052405459789","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6281","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Marie Westby, Ph.D.","typeof":"foaf:Image"}}]] I was concerned that even the most basic rehabilitation wasn’t being offered to patients even in the forms of tele-rehab or single-visit follow-up care. Rheumatology Network:   Why does identifying best practices matter? Dr. Westby:  From the patient perspective, so much is invested in the surgery itself in terms of the cost regardless of which healthcare system they’re in. So much is put into it, and rehabilitation is a fraction of the overall cost. Patients tell us, and I’ve seen this over 25 years of practice that rehabilitation does make a difference in the overall recovery because they’ve lived with osteoarthritis or another arthritis form in their knee or hip for a decade or more. The surgery itself, while it relieves pain, restores motion, and makes improvements in basic function, still leaves a lot of problems with walking, muscle weakness and balance. Only with appropriate rehabilitation are people able to return to sports or exercise. Patients invest a lot and undertake risk to do it. I think they and the healthcare system need to invest similar amounts into their ultimate recovery. We need to optimize the outcomes. With the surgery itself, you get between 75 percent and 80 percent of the outcome of the process. The extra 20 percent to 25 percent is achieved with appropriate rehabilitation. It would be a shame to under-reach and the patient never reach their full potential. From the provider perspective, all licensed healthcare personnel are ideally providing services and interventions that are evidence based. Best practices haven’t been identified before. People aren’t actually sure of the appropriate timing or location or type of treatment and intervention and assessment that should be done. We all want to provide the best care possible that is evidence based so that we can be effective. In many cases, that will allow us to be more efficient and save dollars. That connection between best practices and cost savings has been established in other areas. The literature, though, that we have to work with in hip and knee replacements is weak. It would be nice to know that we’re providing effective care at a reduced cost.  Marie Westby, Ph.D. Rheumatology Network:  What are the most important parts of your results? What are their impacts? Dr. Westby:  The most important thing is the strong support for the need for structured and supervised rehabilitation by all of the experts in the survey panel. The panel, as a whole, agreed it’s necessary, but there was no agreement on timing or location for where the services should be rendered. It helps patients prepare for the experienced if they know what’s in place after surgery. They’ll know what to look for. The work I’ve gone on to do deals with the minimum standards of care based on quality indicators. Patients are better able to monitor their own care and can prepared to be more engaged. They can look for providers who offer similar levels of care so they don’t have to be as concerned about the specific provider from whom they receive care. Supervision can be through the telephone or video, or it can be a follow-up visit one time to the clinic. There are different ways to do it. It doesn’t always have to be once or twice a week in the office. Patients just need to know that there’s someone there to answer their questions in a timely manner if they have any because there’s very little contact with the surgeons after the procedure is complete. Maybe there’s a 3-to-6 week visit and a 6-to-12 month visit. Really, it’s the physical therapy and rehabilitation provides to offer the interim educational support and answers to questions in the immediate post-operative period. Rheumatology Network:   Was there anything unexpected in your findings? Anything that could present a challenge? Dr. Westby:  Something that really came out – that I’m glad to see – is that the literature is addressing the contextual issues that impact rehabilitation care and outcomes. Some of those issues have to do with the patients themselves and their own general health, anxiety, depression and the kind of medical coverage they have. I found it interesting that regardless of what role the survey panelist played – research, clinical, surgeon or physical therapist – they really recognized how important it is to consider the personal and external factors when looking into what kind of rehabilitation services or outcomes you can expect. And, the larger registries are starting to collect this information, as well. Based on an analysis of survey panelists responses compared to patient response. It was evident that there’s variability between the experts about what they thought was important about the right timing and appropriate provider for rehabilitation services, as well as what the appropriate setting would be. Even though they came to a consensus about the need for supervised services, their views differed in other aspets of joint replacements. I was surprised about the timing. They really couldn’t come to an agreement about whether rehabilitation for knee and hip replacement should start right away after the hospital discharge or to wait several weeks. There was a lack of consensus around the setting. They couldn’t come to an agreement, and that’s actually a good thing. It shows that rehabilitation services can be provided in a variety of settings and one isn’t necessarily better than the other.  One of the things I’m working on with colleagues is trying to define the minimal dosage in terms of rehabilitation. The panel didn’t come to an agreement on how many days a week or for how many hours a session rehab should go one. Nor did they decide the intensity. And, that’s how payments are determined. They’re often made based on the number of visits. Many extend out to 90 days post-discharge, but it’s never been established that 90 days is the ultimate rehabilitation dosage for hip and knee replacement. It’s ranged anywhere from less than 3-to-4 weeks to up to 20-to-24 weeks. It’s surprising and frustrating because those numbers and dosages are what payments for services are based on. Rheumatology Network:   How does this research fit in with MACRA and changing reimbursement policies? Dr. Westby:  I think it’s going to be the follow-up on the most recent work with quality indicators that’s going to make the difference. Expert opinion is considered low-level evidence. Now, we can take that and move forward to identify quality indicators that are true measurements that will reflect the standard of care. They will be used to provide care within the bundled payment approach in terms of letting providers know what they should monitor and report on. Rheumatology Network:   How can your work be used to promote better and improved outcomes? Dr. Westby:  The project I’m working on now is to develop two separate tool kits. The first is for patients and family members to help them understand the quality indicators so they now have a minimum standard of care that they know they should receive. It helps them understand how to use the indicators to engage in their own care and discuss it with providers. And, in some circumstances, it might help them identify a provider to go to. If they have the choice within the community to see one private practice or another, patients can look at measurement indicators and see what the practice is reporting on. What do they make available on their website? How can the patient use that information to make an informed decision? The other tool kit is for the healthcare professional, and it develops tools that are ideal for therapy and rehabilitation purposes. It can be used at the point of care for real-time decision making. Right now, most quality indicators come from data collected from electronic medical records or registries or questionnaires conducted after the fact. Data from questionnaires doesn’t help because it’s not collected in real time. It’s responsive, and the patient can’t benefit from it. In Canada, we don’t have pay-for-performance, but it might be coming. Regardless, private practices can monitor their data to help them fill in the gaps when they aren’t doing well in certain areas. They can take those measurements and do a quality improvement programs, address the problems, and find some areas where they can create better outcomes. Many multi-site clinics can find the ones that aren’t performing as well as the others. Maybe they aren’t seeing as many patients, and they could identify ways to increase patient volume or reduce costs. It can be used for marketing purposes. If they’re willing to look at where they have gaps and possibly aren’t performing well, they can make improvements.  Rheumatology Network:   What do you see as the next steps? Dr. Westby:  I’m really focusing on physical therapy and encouraging providers to get involved in the whole process in both the United States and Canada. If they don’t have a say in which measures are included or acceptable for the quality reporting used to support bundled care, then the ones that are selected as measures, they might find aren’t applicable to them or they’re just not feasible Or, perhaps they don’t really guide practice. And, the ultimate downside is that this affects their remuneration. Providers really need to have a say in what’s chosen. They need to participate in forums and meetings where people are selecting which measures to use.  


Westby MD, Brittain A, Backman CL. “Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study.” Arthritis Care Res (Hoboken). 2014 Mar;66(3):411-23. doi: 10.1002/acr.22164.

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