Improving the model of care for knee osteoarthritis: a mixed-method study investigating physical therapy utilization
Date
2020
Authors
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Publisher
University of Delaware
Abstract
Although physical therapy (PT) is recommended as an approach to reduce pain and improve function, adults with knee osteoarthritis (OA) infrequently use it. It is unclear why PT is underutilized for knee OA. As a first step to understand the broader problem of PT underutilization, the objective of this dissertation was to identify factors associated with PT utilization within a focused sample of adults with knee OA. The long-term goal of this research is to improve the model of care for knee OA by optimizing high-value healthcare in clinical practice. To achieve the overall objective, the following three studies were conducted. ☐ First, a qualitative descriptive study using semi-structured interviews was conducted to identify patient-reported barriers and facilitators to PT utilization for knee OA (Aim 1). Themes identified as either barriers or facilitators among the twenty-two participants were: 1) previous experience with PT, 2) physician referral, 3) beliefs about treatment efficacy before and after knee replacement surgery, 4) insurance coverage, and 5) preference to avoid surgery. Findings from Aim 1 indicate a previous positive encounter with PT, and a physician referral were reasons participants utilized PT for knee OA. However, knowledge about and access to PT services were not identified as factors related to utilization. ☐ Second, a qualitative descriptive study using focus group discussions was conducted to determine adults with knee OA understanding of the disease and perceptions of PT as a treatment option (Aim 2). Of the thirty participants, knee OA was identified as “bone on bone,” and they reported having limited knowledge about the disease. Participants also described the cause of knee OA as overuse, aging, obesity, and heredity. The consequences of knee OA were seen as severe disability related to knee pain, and most believed surgery was inevitable. Two focus groups had positive perceptions of PT, which typically was associated with personally having medical training. Four focus groups reported negative or mixed perceptions and thought PT did not work before surgery. Findings from Aim 2 indicate that adults with knee OA had limited knowledge and misconceptions about the disease that appeared to influence their perceptions of PT as a treatment option. ☐ Third, a retrospective cross-sectional cohort study was conducted using administrative data from the Oregon All-Payer All-Claims (APAC) database (N=12,590) patient-level claims. In the cohort, 6.5% (821/12,590) utilized PT for knee OA. Adults with Medicaid were 38% (1.38 [1.15, 1.66]) more likely to use PT for knee OA compared to those with commercial insurance. Males were 21% (0.79 [0.68, 0.91]) less likely to use PT than females. Adults who had a knee injection, another medical visit, and knee replacement they were 41% (1.41 [1.22, 1.64]), 192% (2.92 [2.51, 3.39]), and 109% (2.09 [1.72, 2.53]) more likely to use PT compared those who did not utilize these services. ☐ The combined results of the three studies generated hypotheses and created a model as to why PT is underutilized for knee OA. Further work is needed to validate the proposed model by determining if the patient-reported barriers or facilitators and understanding of knee OA and perceptions of PT as a treatment option are similar patient-reported themes among different knee OA populations. Also, if an association between the insurance type, gender, and use of other knee-OA healthcare services with PT utilization exists in other statewide All-Payer All-Claims datasets.
Description
Keywords
Health services research, Knee osteoarthritis, Non-surgical treatments, Physical therapy utilization