Therapist Visits Research Articles

Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study.

The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession. This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed. Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%). Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes. Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

Factor XI Deficiency Hemarthrosis Post–Lateral Meniscectomy: A Case Report

BACKGROUND: A 28-year-old recreationally active female sustained a lateral meniscus injury that was managed by undergoing a lateral meniscectomy and debridement. CASE PRESENTATION: Postoperative recovery was complicated by a hemarthrosis (joint bleed) related to a rare bleeding disorder called Factor XI deficiency or hemophilia C. OUTCOME: This case report outlined the timeline of events including presurgical planning, initial outpatient physical therapist visit, hemophilia treatment center hemarthrosis management, return to outpatient physical therapist, and progression to running. DISCUSSION: Rehabilitation of younger, active patients looking to return to impact sports, such as running, is not well published in patients with a history of joint bleeds. An outline of the general progression utilized for this patient is discussed. JOSPT Cases 2023;3(3):194-198. Epub: 10 July 2023. doi:10.2519/josptcases.2023.11777

Healthcare utilization, costs, and epidemiology of Huntington’s disease in Israel

IntroductionData on Huntington’s disease (HD) epidemiology, treatment patterns, and economic burden in Israel are scarce. MethodsAnnual prevalence and incidence of HD (ICD-9-CM 333.4) were assessed in the Israel-based Maccabi Healthcare Services (MHS) database 2016–2018. Adherence (medication possession rate [MPR], proportion of disease covered) were assessed for adult people with HD (PwHD) 2013–2018. Healthcare resources utilization (HCRU) and costs related to inpatient and outpatient visits and all medications in 2018 were assessed for PwHD, who were randomly matched to MHS members without HD (1:3) by birth-year and sex. ResultsOverall, 164 patients had at least one HD diagnosis. Annual prevalence and incidence were 4.45 and 0.24/100,000, respectively. A total of 67.0% of adult patients (n = 106) were taking tetrabenazine (median MPR and proportion of disease covered, 74.3% and 30.2%, respectively), 65.1% benzodiazepines (75.8% and 32.3%), and 11.3% amantadine (79.2% and 6.0%). Over a 1-year follow-up, PwHD (n = 81) had significantly more neurologist, psychiatrist, physiotherapist, and speech therapist visits (P < 0.05 for each) and more hospitalization days (P < 0.0001) compared with matched controls (n = 243). Total healthcare and medication costs per patient (US dollars) were significantly higher for PwHD than controls ($7,343 vs. $3,625; P < 0.001). Discussion/ConclusionPwHD have greater annual HCRU and medical costs than MHS members without HD in Israel. Among those who have taken medications, adherence was lower than 80% (both MPR and proportion of disease covered), which may translate into suboptimal symptom relief and quality of life.

Promoting Wellness or Waste? Evidence from Antidepressant Advertising

It is taken as given by many policy makers that Direct-to-Consumer Advertising of prescription drugs drives inappropriate patients to treatment. Alternatively, advertising may provide useful information that causes appropriate patients to seek treatment. I study this dynamic in the context of antidepressants. Leveraging variation driven by the borders of television markets, I find that a 10 percent increase in anti-depressant advertising leads to a 0.3 percent ($32 million) increase in new prescriptions followed by reductions in workplace absenteeism worth about $770 million. I find no effect of advertising on prices, generic penetration, drug switches, adverse effects, non-adherence rates, or therapist visits. (JEL D83, I12, J22, L65, M31, M37)

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial

BackgroundEach year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as “peer coaches” to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.MethodsThis was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.ResultsAchieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.ConclusionsThe trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.Trial registrationClinicalTrials.gov, NCT04840407. Retrospectively registered on 9 April 2021

Prehabilitation-Driven Changes in Frailty Metrics Predict Mortality in Patients With Advanced Liver Disease.

Frailty is a predictor of morbidity and mortality in cirrhosis. Although evidence for prehabilitation is promising, the data for liver transplant (LT) candidates are limited. The primary aim of this study was to evaluate the effect of a novel prehabilitation strategy on changes in frailty metrics and survival in LT candidates. The secondary aim was to determine liver-related and extrahepatic conditions associated with frailty. In this ambispective cohort study, all patients underwent frailty assessment using the liver frailty index (LFI), 6-minute walk test, and gait speed test performed by a dedicated physical therapist. Home-based exercise prescription was individualized to each patient's baseline physical fitness. We included 517 patients (59% men, median age 61 years, and a model for end-stage liver disease score of 12) evaluated during 936 PT visits. Frailty metrics were affected by age, sex, and liver-related parameters, but not by model for end-stage liver disease. Patients with nonalcoholic fatty liver disease and alcohol-related cirrhosis had worse frailty metrics by all tools. We demonstrated the feasibility of prehabilitation in improving both LFI and 6-minute walk test, particularly in adherent patients. A median LFI improvement of 0.3 in frail patients was associated with improved survival in univariate analysis. Compliance with physical therapist visits (hazards ratio = 0.35 [0.18-0.67] for 2 visits and hazards ratio = 0.54 [0.31-0.94] for ≥3 visits) was independently associated with increased survival. Prehabilitation improves frailty metrics in LT candidates and is associated with a survival advantage. Our findings provide a framework for the standardized prehabilitation program in LT candidates while prioritizing compliance, adherence, and on-training LFI goal accomplishment.

The Role of Virtual Physical Therapy in a Post-Pandemic World: Pearls, Pitfalls, Challenges, and Adaptations.

To keep patients healthy and safe during the pandemic, payers and the federal government temporarily relaxed restrictions, expanded the eligible provider list for providing telehealth services, and developed a reimbursement structure. Physical therapists were uniquely challenged during the pandemic, requiring a reassessment of techniques and strategies in order to best support patients. The purpose of this case report is to describe a musculoskeletal institution's experience with implementing telehealth physical therapy. Previous telehealth experience enabled the infrastructure of a wide-scale adoption across institutions to respond to the COVID-19 pandemic. However, to fill in training gaps for Hospital for Special Surgery (HSS) outpatient physical therapists, HSS Rehabilitation developed a robust education and implementation program. This training was influenced by clinician and patient surveys as well as the development of a published HSS Rehabilitation telehealth guide. Prior to performing telehealth physical therapist visits, clinicians were required to complete all training material to ensure comfortability and confidence. The adoption of telehealth among clinicians was born out of necessaity; however, the speed with which HSS Rehabilitation pivoted was critical to avoid lapses in care. In a 4-week period after the New York City shelter in-place orders, 173 therapists were trained and performing virtual visits. HSS Rehabilitation determined telehealth physical therapy had quicker access to care, similar patient satisifaction, and increased geographical outreach compared with in-person care. The transition to telehealth physical therapy included a multi-step process that provided clinician training, established protocols and guidelines, and obtained a better understanding of the patient experience. Telehealth physical therapy has shown early benefits such as improving patient access to care and better continuity of care for traveling patients. Even after the current public health emergency, there is a place for high-value telehealth physical therapy in caring for patients with musculoskeletal conditions.

Association Between Use of Rehabilitation in the Acute Care Hospital and Hospital Readmission or Mortality in Patients With Stroke

ObjectiveTo examine the association between the number of physical and occupational therapist visits received in the acute care hospital and the risk of hospital readmission or death. DesignRetrospective cohort study of electronic health records and administrative claims data collected for 2.25 years (January 1, 2016-March 30, 2018). SettingTwelve acute care hospitals in a large health care system in western Pennsylvania. ParticipantsAdults (N=8279) discharged with a primary stroke diagnosis. InterventionsThe exposure was number of physical and occupational therapist visits during the acute care stay. Main Outcome MeasuresGeneralized linear mixed models were estimated to examine the relationship between therapy use and 30- and 7-day hospital readmission or death (outcome), controlling for patient demographic and clinical characteristics. ResultsThe 30- and 7-day readmission or death rates were 16.0% and 5.7%, respectively. The number of therapist visits was inversely related to the risk of 30-day readmission or death. Relative to no therapist visits, the odds of readmission or death were 0.70 (95% confidence interval [CI], 0.54-0.90) for individuals who received 1-2 visits, 0.59 (95% CI, 0.43-0.81) for 3-5 visits, and 0.57 (95% CI, 0.39-0.81) for >5 visits. A similar pattern was seen for the 7-day outcome, with slightly larger effect sizes. Effects were also greater in individuals with more mobility limitations on admission and for those discharged to a postacute care facility vs home. ConclusionsThere was an inverse relationship between the number of therapist visits and risk for readmission or death for patients with stroke discharged from an acute care hospital. Effects differed by time to the event (30d vs 7d), discharge location, and mobility limitations on admission.

Predictive Factors for Patients' Failure to Show for Initial Outpatient Physical Therapist Evaluation.

The objective of this study was to examine primary factors that may predict patients' failure to show at initial physical therapist evaluation in an orthopedic and sports outpatient setting. A retrospective analysis of patients' demographic data for physical therapist evaluations between January 2013 and April 2015 was performed. A binary logistic regression model was used to evaluate the odds of a no-show at evaluation. Demographic variables of age, employment status, days waited for the appointment, payer source, and distance traveled to the clinic were analyzed. Independent variables were considered significant if the 95% CIs of the odds ratios (ORs) did not include 1.0. A total of 6971 patients were included in the final analysis, with 10% (n=698) of the scheduled patients having a no-show event for their initial evaluation. The following factors increased the odds of patients having a no-show event: days to appointment (OR=1.058; 95%CI=1.042-1.074), unemployment status (OR=1.96; 95% CI=1.41-2.73), unknown employment status (OR=3.22; 95% CI=1.12-8.69), Medicaid insurance (OR=4.87; 95%CI=3.43-6.93), Medicare insurance (OR=2.22; 95% CI=1.10-4.49), unknown payer source (OR=262.84; 95% CI=188.72-366.08), and distance traveled 8 or more kilometers (OR=1.31; 95% CI=1.01-1.70). Female sex (OR=0.73; 95% CI=0.57-0.95) and age 40years or older (OR=0.44; 95% CI=0.33-0.60) decreased the odds of a no-show event. Results from this study indicate there may be some demographic factors that are predictive of patients failing to attend their first physical therapist visit. Understanding the predictive factors and identifying potential opportunities for improvements in scheduling processes might help decrease the number of patients failing to show for their initial physical therapy appointment, with the ultimate goal of positively influencing patient outcomes.

Medication management patterns among Medicare beneficiaries with chronic obstructive pulmonary disease who initiate nebulized arformoterol treatment.

Purpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta2 agonist (LABA), and identified the predictors of initiation.Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490–492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed.Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhaled (37%) short-acting bronchodilator or a systemic corticosteroid (46%), and many received antibiotics (37%). Compared to controls, beneficiaries who initiated arformoterol were significantly more likely to have had an exacerbation, a COPD-related hospitalization, and a pulmonologist or respiratory therapist visit prior to initiation (all p<0.05). Beneficiaries with moderate/severe psychiatric comorbidity or dual-eligible status were significantly less likely to initiate arformoterol, as compared to controls (all p<0.05).Conclusion: Medicare beneficiaries who initiated nebulized arformoterol therapy had more exacerbations and hospitalizations than controls 90 days prior to initiation. Findings revealed inadequate use of maintenance medications, suggesting a lack of compliance with evidence-based treatment guidelines.

Factors Associated With Nonadherence to Pelvic Floor Physical Therapy Referral for the Treatment of Pelvic Pain in Women.

Patients with pelvic pain due to pelvic floor myofascial pain syndrome are often referred for pelvic floor physical therapy, the primary treatment option. However, many patients do not adhere to the treatment. The purpose of this study was to examine the adherence rate and outcomes of patients referred for physical therapy for pelvic floor myofascial pain syndrome and identify risk factors associated with nonadherence. This was a retrospective cohort study. ICD-9 codes were used to identify a cohort of patients with pelvic floor myofascial pain syndrome during a 2-year time period within a single provider's clinical practice. Medical records were abstracted to obtain information on referral to physical therapy, associated comorbidities and demographics, and clinical outcomes. "Primary outcomes" was defined as attendance of at least 1 visit. Secondary outcomes included attendance of at least 6 physical therapist visits and overall improvement in pain. Statistical analysis was performed using chi-square, Fisher exact, and independent t tests. Nonparametric comparisons were performed using Wilcoxon signed rank test. Multivariate analysis was completed to adjust for confounders. Of the 205 patients, 140 (68%) attended at least 1 session with physical therapy. At least 6 visits were attended by 68 (33%) patients. Factors associated with poor adherence included parity and a preexisting psychiatric diagnosis. The odds of attending at least 1 visit were 0.75 (95% confidence interval=0.62-0.90) and 0.44 (95% confidence interval=0.21-0.90), respectively. Patients who attended ≥ 6 visits were more likely to have private insurance (78%) and travel shorter distances to a therapist (mean=16 miles vs 22). Patients with an improvement in pain (compared with those who were unchanged) attended an average of 3 extra physical therapist visits (mean=6.9 vs 3.1). Limitations include reliance on medical records for data integrity; a patient population derived from a single clinic, reducing the generalizability of the results; the age of the data (2010-2012); and the likely interrelatedness of many of the variables. It is possible that maternal parity and psychiatric diagnoses are partial surrogates for social, logistic, or economic constraints and patient confidence. Initial adherence to pelvic floor physical therapy was less likely for multiparous women and women with a history of psychiatric diagnosis. Persistent adherence was more likely with private insurance or if the physical therapist location was closer. Pain improvement correlated with increased number of physical therapist sessions.

Promoting Wellness or Waste? Evidence from Antidepressant Advertising

It is taken as given by many policy makers that Direct-to-Consumer Advertising of prescription drugs drives inappropriate patients to treatment. Alternatively, advertising may provide useful information that causes appropriate patients to seek treatment. I study this dynamic in the context of antidepressants. Leveraging variation driven by the borders of television markets, I find that a 10% increase in antidepressant advertising leads to a 0.3% ($32 million) increase in new prescriptions followed by reductions in workplace absenteeism worth about $770 million. I find no effect of advertising on prices, generic penetration, drug switches, adverse effects, non-adherence rates or therapist visits.

Minimally Clinically Important Change in the Activity Measure for Post-Acute Care (AM-PAC), a Generic Patient-Reported Outcome Tool, in People With Low Back Pain.

The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined. The study objective was to determine the MCID for AM-PAC in people with low back pain. This was a retrospective cohort study. Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older. A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5. The estimated MCID was designed for people with low back pain only. The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain.

Functional Goals and Predictors of Their Attainment in Low-Income Community-Dwelling Older Adults

ObjectiveTo describe functional goals and factors associated with goal attainment among low-income older adults with disabilities living in the community. DesignSecondary analysis. SettingParticipants' homes. ParticipantsOlder adults (N=226) with disability who participated in the Community Aging in Place, Advancing Better Living for Elders trial. InterventionsA 5-month, home-based, person-directed, structured program delivered by an interprofessional team: occupational therapist, registered nurse, and handyman. Main Outcome MeasuresProcess of occupational therapist goal setting and attainment at the final occupational therapist visit. ResultsParticipants identified 728 functional goals (mean of 3.2 goals per participant), most commonly related to transferring (22.0%; n=160 goals), changing or maintaining body position (21.4%; n=156 goals), and stair climbing (13.0%; n=95 goals). Participants attained 73.5% (n=535) of goals. Goal attainment was highest for stair climbing (86.3%), transferring (85.6%), and self-care (84.6%); walking goals were less likely attained (54.0%). Goal attainment was not associated with age, sex, education, depressive symptoms, function, or health-related quality of life but was less likely among participants who had severe pain compared with those without pain (adjusted odds ratio, 0.38; 95% confidence interval, 0.17–0.86). When participant readiness to change score increases by 1 point on the 4-point scale, goal attainment was 62% more likely (adjusted odds ratio, 1.62; 95% confidence interval, 1.14–2.29). ConclusionsHome-based collaborative goal setting between older adults and occupational therapists is feasible and particularly effective when individuals are ready or willing to adopt new strategies to achieve identified goals.

Home-based Reach-to-Grasp training for people after stroke is feasible: a pilot randomised controlled trial

Objective: To determine feasibility of a randomised controlled trial (RCT) of home-based Reach-to-Grasp training after stroke. Design: single-blind parallel group RCT. Participants: Residual arm deficit less than 12 months post-stroke. Interventions: Reach-to-Grasp training in 14 one-hour therapist’s visits over 6 weeks, plus one hour self-practice per day (total 56 hours). Control: Usual care. Main Measures: Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), pre-randomisation, 7, 12, 24 weeks post-randomisation. Results: Forty-seven participants (Reach-to-Grasp=24, usual care=23) were randomised over 17 months. Reach-to-Grasp participants received a median (IQR) 14 (13,14) visits, and performed 157 (96,211) repetitions per visit; plus 30 minutes (22,45) self-practice per day. Usual care participants received 10.5 (5,14) therapist visits, comprising 38.6 (30,45) minutes of arm therapy with 16 (6,24) repetitions of functional tasks per visit. Median ARAT scores in the reach-to-grasp group were 8.5 (3.0,24.0) at baseline and 14.5 (3.5,26.0) at 24 weeks compared to median of 4 at both time points (IQR: baseline (3.0,14.0), 24 weeks (3.0,30.0)) in the usual-care group. Median WMFT tasks completed at baseline and 24 weeks were 6 (3.0,11.5) and 8.5 (4.5,13.5) respectively in the reach-to-grasp group and 4 (3.0,10.0), 6 (3.0,14.0) in the usual care group. Incidence of arm pain was similar between groups. The study was stopped before 11 patients reached the 24 weeks assessment. Conclusions: An RCT of home-based Reach-to-Grasp training after stroke is feasible and safe. With ARAT being our preferred measure it is estimated that 240 participants will be needed for a future two armed trial.

Can the Otago falls prevention program be delivered by video? A feasibility study

ObjectivesWe assessed the feasibility of delivering the Otago Exercise Programme (OEP) via an interactive DVD (ie, OEP-DVD) in combination with monthly physical therapist phone calls to older adults.DesignThis pre-post (baseline...

Medical Resource Utilization and Cost of HIV-Related Care in the Highly Active Antiretroviral Therapy Era at a University Clinic in Sweden

Little is known regarding healthcare costs for HIV/AIDS patients in the era of highly active antiretroviral therapy (HAART) and subgroups of patients according to the severity and progression of HIV infection in Sweden. The objective of this study is therefore to describe the direct medical resource use and cost of healthcare for HIV patients at a university clinic in Sweden. A patient registry database for HIV treatment at the Department of Infectious Diseases, Sahlgrenska University Hospital, between 2000 and 2005 provided information on patient characteristics, antiretroviral drugs and dosages, tests and diagnostic procedures, outpatient visits and inpatient stays. The review used publicly available unit costs with a county council perspective, expressed in 2006 Euros. Two hundred and eighty-five patients with a mean age of 38 years in 2000 (64% men) were followed for 1368 patient-years. They had a mean (median) of 6.3 (0) inpatient days, 4.1 (3.7) physician visits, 4.2 (3.8) nurse visits, 2.6 (0.7) counsellor visits and 11.5 (7.7) tests and diagnostic procedures per patient-year. Only 12 deaths were recorded during the study period, and the proportion of treated patients with successful treatment (HIV-RNA < 50 copies/mL) increased from 74% to 92% during the period. The mean cost per patient-month amounted to €1069. The main cost driver was HIV drugs (51%), followed by inpatient stays (including hospitalizations for opportunistic infections; 22%), outpatient physician, nurse or therapist visits (19%) and diagnostics and tests (7%). All non-drug costs increased with a decreasing CD4 cell count. Overall, approximately half of the direct costs of HIV treatment were not related to antiretroviral treatment. The non-antiretroviral costs were inversely correlated with HIV-induced immune deficiency.

The impact of BMI on direct costs in Children and Adolescents: empirical findings for the German Healthcare System based on the KiGGS-study

Childhood obesity is a growing public health burden. Among German children and adolescents, 15% are overweight (including obese) and 6.3% are obese according to a national reference. This is the first German study to assess aspects of the economic burden associated with overweight and obesity in children and adolescents based on a representative cross-sectional survey. Based on the German Interview and Examination Survey for Children and Adolescents (KiGGS), direct costs induced by utilisation of healthcare services (physician and therapist visits, hospital stays) were assessed using a bottom-up approach. To investigate the impact of body mass index (BMI) on costs, univariate analyses were performed and multivariate generalised mixed models were estimated. Average annual total costs were estimated to be €442 (95% CI [402-486]). Bivariate analysis showed considerable differences between BMI groups in physician costs, but not for hospital or therapist costs. High socioeconomic status, residence in west Germany and underweight had a significant negative impact on total costs in multivariate analysis. The effect of overweight on total costs is positive but not significant; neither is the effect of obesity. However, overweight and obese children exhibit significantly higher physician costs and a higher probability of being high utilisers of healthcare services. The economic implications of overweight and obesity are, to some extent, already visible in childhood. The results suggest that obese children should be classified as priority group for prevention. Despite limitations, this study provides important information concerning the relevance of childhood obesity as a health problem.

The internet‐based arthritis self‐management program: A one‐year randomized trial for patients with arthritis or fibromyalgia

To determine the efficacy of an Internet-based Arthritis Self-Management Program (ASMP) as a resource for arthritis patients unable or unwilling to attend small-group ASMPs, which have proven effective in changing health-related behaviors and improving health status measures. Randomized intervention participants were compared with usual care controls at 6 months and 1 year using repeated-measures analyses of variance. Patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia and Internet and e-mail access (n = 855) were randomized to an intervention (n = 433) or usual care control (n = 422) group. Measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy. At 1 year, the intervention group significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found. The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.

The Ibis XP tilt-in-space powered wheelchair: A review

Trying to find the most appropriate wheelchair to meet the individual needs of a large and often diverse client group can be a challenge for therapists. This is particularly so in the case of wheelchair users whose functional ability and sitting stability deteriorates over a period of time. Continuing to meet a changing need can be time consuming and expensive. As a result, the client may have to wait some time before his or her needs are met, particularly if funding is limited or if therapists are scarce on the ground. Consequently, a ‘catch up’ becomes the order of the day: the client's condition changes, the therapist visits, modifications are agreed, but by the time they are implemented they are no longer appropriate for the client, whose needs have further deteriorated. Fundamentally, many clients therefore never have their needs met adequately. A number of factors need to be considered when prescribing suitable wheelchairs, such as the diagnosis or disability of the user, his/her projected long-term needs, functional ability, size and sitting ability. The Ibis XP from Movingpeople.net is a compact powered tilt-in-space wheelchair that is multi-adjustable – an endless range of combinations, all from one frame size. In addition to the single frame design, a range of accessories can be purchased either at the time of the prescription or subsequently, in order to customize the chair to the needs of the user as and when these change.