Standardized Care Helps Knee Rehabilitation, Intermountain Study Finds

When physical therapists follow best-practice care guidelines for total knee rehabilitation, patients achieve better outcomes in their recovery –– and when those guidelines are implemented as part of a systemwide quality effort the high-quality care patients receive is standardized and consistent, regardless of the setting, according to new research of nearly 13,000 patients from Intermountain Health in Salt Lake City.

In the two new studies published in the Journal of Orthopaedic & Sports Therapy, researchers at Intermountain found that when clinicians follow standardized care guidelines, outcomes are maximized for patients in rehabilitation from total knee replacement surgery.

But those guidelines don’t mean much if they’re not used, say researchers, which can lead to worse outcomes in those patients, lower quality of life, and result in higher healthcare costs, regardless of whether therapy is provided in an urban hospital or rural community clinic.

As the population in the United States ages and more knee replacement surgeries are performed, quality of care is paramount. By 2030, 1.26 million total know replacements are expected to be performed nationally. Making sure patients get the best overall care, including after surgery, is critical.

“We were able to show, in a real-world setting in our health system, that these guidelines do make a difference in helping patients return to their regular lives after what’s become a common, but still major surgery,” said study author Kate Minick, director of research for rehabilitation services at Intermountain Health.

“We also showed that our efforts over the last decade to improve adherence to these guidelines has worked. We want our patients to return to their regular lives as soon as possible, without lingering pain. These guidelines, and our adherence to them, work and these studies demonstrate that,” she added.

Outpatient physical therapy is an important part of the recovery process. Rehabilitation / physical therapy sessions restore range of motion, build strength in muscles around the joint, and improve balance, endurance, and function.

In the first study, Intermountain researchers conducted a retrospective study to compare two groups of Intermountain Health patients who had a total knee arthroplasty and at least three outpatient physical therapy visits. Of those patients, 9,797 received physical therapy care according to care guidelines, and 2,558 received non-standard care.

Their progress was measured by the Knee Outcome Survey — Activities of Daily Living questionnaire, which measures knee symptoms and functional limitations during activities of daily life, like walking and getting up from a chair and climbing stairs. Intermountain researchers found that patients who received care according to standardized guidelines had better Knee Outcome Survey scores than those who did not.

In the second study, researchers examined the success of Intermountain’s efforts to improve guideline adherence, an effort the health system initially started in 2013.

This included implementing Continuous Quality Improvement strategies applied to those care guidelines, providing necessary equipment to all physical therapy centers, changes to the electronic health record to align with guidance, systematic chart audits, individualized peer feedback, and incentivization for meeting annual performance goals.

At the beginning of the study, Intermountain clinicians received training by a multi-day course, followed by continuing education. This effort also had its own dedicated implementation team, which included an operations manager, director of quality and outcomes, data analyst, statistician, and quality improvement leaders.

To measure the success of these efforts, Intermountain researchers studied outcomes for 12,355 knee replacement patients who received at least three physical therapy visits between 2008 and 2019.

They found that, six years after implementing the care guidelines, the number of patients who did not have meaningful progress declined significantly without an increase in the number of physical therapy visits.

“When we implemented this standard in our healthcare system, more patients got better,” said Minick. “Each one of those patients is living a life out there that’s better for them and their families, which is why these results are so important.”

“The benefit of these studies is that this improvement has been made and is being maintained,” added Minick. “Thanks to this long-term quality improvement initiative, the care guidelines have been implemented and are in use, and we are continuing to see the positive benefit in our patients.”

– Intermountain Healthcare