This project was reviewed by the DVAHCS Institutional Review Board and determined to be a non-research operations activity as described in Veterans Health Administration Handbook 1058.05 (November 11, 2016). The authors followed the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) checklist in the development of this manuscript.
Group PT for knee OA program
Veterans at the DVAHCS with a diagnosis of knee OA are eligible for this program. Veterans are referred to Group PT via an electronic referral from a treating health care provider, including any primary care or specialty medical provider or physical therapists on staff (i.e., if evaluation in response to a PT consult indicates Group PT may be appropriate). The referral specifies inclusion criteria of 1) Knee OA diagnosed by imaging, 2) Cognitively intact, 3) No history of falls, 4) No neurological deficits (i.e. post-stroke, Parkinson’s, multiple sclerosis), and 5) Patient >50 years of age. The referral also notes, “This consult is NOT for patients complaining of knee pain without imaging changes”. Once the referral is issued, it is then triaged by the physical therapist to determine if the Veteran meets inclusion criteria. Veterans are then contacted via telephone by a scheduler within Physical Medicine and Rehab Service (PM&RS) and can agree to be scheduled for an initial session in the Group PT program, request individual PT instead, or decline PT all together; reasons for declining are documented within the electronic health record (EHR). At the initial Group PT session, the physical therapist performs an assessment, collects baseline measures (described below), and determines whether the patient is appropriate for continuing to participate in the Group PT program. In some cases the physical therapist may decide, based on clinical judgement, that individual PT is more appropriate for a given patient due to comorbid physical health conditions (e.g., severe medical conditions that limit activity or require closer supervision) or psychological health conditions that are exacerbated by group situations. This determination can be made on the basis of medical record review when the patient is referred or following initial in-person evaluation in the Group PT program. Additionally, Veterans referred to PT for knee pain via standard consult process may subsequently be referred to the class if deemed appropriate by the evaluating PT.
For each participant, the Group PT program includes 6 one-hour sessions. Although participants are encouraged to attend sessions on consecutive weeks, sessions can be rescheduled when there are conflicts. One physical therapist leads each Group PT session with a maximum of 10 Veterans per class. Veteran program admission occurs on a rolling basis, as space allows. Group sessions are modeled after those developed and tested in the previous clinical trial , where the physical therapist engages attendees in group discussion or instruction (approximately 10 min) regarding exercise successes and barriers (3 sessions), overview of exercise and knee OA (1 session), joint protection (1 session) and activity pacing (1 session). The remainder of the session involves group stretching exercises (including seated hamstring stretch, standing quadriceps stretch, and standing calf stretch) and strengthening exercises (including standing calf raises, single leg balance, squats or min-squats, step-ups, partial stands from a chair and seated hip abduction with a therapy band). Participants leave each session with handout instructions for home exercise and a therapy band for at-home resistance exercises. Participants are encouraged to stretch daily and perform strengthening exercise three times per week, beginning with a standard set of exercises and encouraged to add repetitions, sets or resistance as they experience improvement.
Participants’ age, sex and residential distance from the DVAHCS (in miles) were obtained from the EHR. At the first Group PT session, participants reported the number of years they had knee pain.
Implementation metrics were assessed using EHR data stored in the VA Corporate Data Warehouse (CDW). For our evaluation, we examined a cohort of patients who were referred to the Group Physical Therapy for Knee OA sessions between August 1, 2016 and July 31, 2017. We also collected information about the service location and staff position ordering the referral from EHR data.
To assess program penetration (e.g. the extent to which the service reaches the target population) we identified the total number of referrals issued during the one-year cohort entry period, as well as by clinical service that issued the referral. We also observed the number of patients who scheduled an initial Group PT session and the number who initiated the program (defined as completing at least one appointment), from among those with referrals. Reasons for not initiating Group PT were extracted from the EHR.
Implementation Fidelity-Attendance at Group PT Sessions
We examined several measures of program fidelity. First, we calculated the number of Group PT sessions attended by each participant who initiated Group PT. Attendance at sessions was verified via chart review of the EHR appointment data between October 1, 2016 through September 30, 2017, to allow all patients in the cohort time to complete the 6-session program. We calculated the mean and standard deviation (SD) of sessions attended per person. Second, we computed the mean number of attendees per Group PT session. Third, we computed the number and proportion of patients who completed all 6 sessions. Reasons participants did not attend all six sessions were extracted from the EHR when available or were surveyed by phone to inquire about reasons for discontinuation (attendance of < 5 sessions).
Patient-level measures (impact)
We assessed physical function through patient self-reported and PT evaluation of physical function at the beginning of their first session and at the end of the last (sixth) session. Satisfaction was measured after their last session only.
Western Ontario and McMaster universities osteoarthritis index (WOMAC)
The WOMAC is a measure of lower extremity pain (5 items), stiffness (2 items), and function (17 items) [9, 10]. All items were rated on a Likert scale of 0 (no symptoms) to 4 (extreme symptoms), with a total range of 0–96 and higher scores indicating worse symptoms. Pain and function subscales were also examined separately, with ranges of 0–20 and 0–68, respectively.
Participants reported their average daily level of pain on a numeric scale of 0 (no pain) to 10 (worst pain).
30 –second chair rise
Participants began in a seated position and were instructed to stand up completely and return to the seated position, without using their arms or hands for support, as many times as they could during a 30-s period . Participants were given a score of 0 if they could not complete at least one chair rise.
Single leg stand
Participants were instructed to stand on one leg, with eyes open and without holding onto anything for support, for as long as they could [12, 13]. This was repeated for both legs, with a maximum time of 60 s each. Participants were given a score of 0 if they could not complete the test.
Patient feedback on the group PT program
Participants indicated their overall satisfaction with the Group PT program as: not satisfied, somewhat unsatisfied, neutral, somewhat satisfied, and completely satisfied. Participants were asked how they would rate their ability to deal with daily problems with knee function and pain after completing the program, compared with before the program, with response options of: much worse, a little worse, about the same, a little better and much better. Finally, participants were asked whether they would recommend the Group PT program to other Veterans if they needed VA physical therapy for a condition such as theirs, with response options of: definitely no, probably no, probably yes and definitely yes.