The ultimate goal and primary responsibility of professional physical therapist (PT) education is to produce graduates who can function as competent practitioners. Clinical practice is the arena in which PT students translate theoretical knowledge and skills into actual patient care.1 Clinical education currently comprises nearly one-third of the time in a typical 36-month professional level Doctor of Physical Therapy (DPT) program (mean 35.9 weeks, range 24–60 weeks).2,3 The Physical Therapist Clinical Performance Instrument (PT CPI) is the most common tool used to measure student clinical performance1,3,4 in a progression toward professional level performance. However, PT CPI scores have not been found to be related to scores on the National Physical Therapy Examination (NPTE), raising concerns that neither measure may fully assess or predict readiness for practice.5,6 In addition, it is not known whether a student's PT CPI rating coincides with their actual clinical effectiveness.7,8
Physical therapist educational research must not only determine if, when, what, and how students are learning, but also whether they are actually providing quality patient care in a consistent, safe, effective, and efficient manner.6 Though they have historically been infrequently used as a measure of learning, evaluating patient outcomes is arguably one of best ways to objectively measure the success of PT education because it targets the true purpose of learning—caring for patients.8,9 It is critical for evidence-based PT education for quantifiable patient-level outcomes to be used to measure clinical competency so that areas of strength and/or deficiency in PT student practice can be identified.1
In medical education, patient outcomes are being examined via retrospective cohort studies in order to optimize safe and effective patient care. Comparing the outcomes of patients treated by medical students and residents to those of staff physicians has helped identify areas of practice where medical trainee competency was similar to that of medical staff,10–14 as well as areas where trainees lacked competency and caused harm to patients.15,16 Patient outcomes were found to be important independent measures of medical student clinical competency because high academic performance did not predict positive patient outcomes.15,16
To our knowledge, only 2 studies have examined the clinical effectiveness of PT students. O'Sullivan and Hickey17 compared the outcomes of student-treated and staff-treated outpatients and found that both groups demonstrated significantly improved pre-post intervention scores on standardized assessment tools.17 Likewise, Rone-Adams et al18 retrospectively evaluated the records of student-treated and staff-treated outpatients and found no significant differences in functional outcomes, treatment visits, or treatment durations of subjects. The authors reported a trend toward less effective and less efficient student-provided care but analyses were too underpowered to be conclusive. Because the authors included both PT and occupational therapist (OT) students and clinicians, direct application to physical therapy practice is limited.
Based on the aforementioned reasons, we felt it was timely to examine the clinical effectiveness and efficiency of patient care delivered by PT students in acute care. In acute care, PTs must consider multiple factors to provide efficient, effective patient care, including the disease process, medications, current medical status, use of support equipment, limits/risks with mobility, and discharge needs.19 Continual dynamic assessment and intervention dosage are important components of clinical reasoning as mobilization occurs.20 In addition to providing direct care to the patient, they must be proficient in navigating the medical system, as well as collaborating and advocating for the patient in communications with a diverse and highly specialized medical team.20,21
Patients undergoing primary total knee arthroplasty were chosen as an initial study population for student/staff outcome comparison due to the use of standardized clinical pathways, which help decrease variability in care. As the demand for primary knee arthroplasties is projected to rise by 673% to 3.48 million procedures by 2030,22 it is imperative that all physical therapy providers demonstrate competency with this patient population.23
The purpose of this study was: (1) to compare the functional outcomes achieved by staff-treated and student-treated inpatients who underwent primary total knee arthroplasty, and (2) to examine the efficiency of each group of therapy providers. Based on the prior studies of student-treated patient outcomes, we hypothesized that there would be no differences in the functional outcomes or the therapy efficiency between the subject groups.
A retrospective cohort study design was used to identify recipients of a primary unilateral total knee arthroplasty who were treated exclusively by PT students and compare their outcomes to those treated exclusively by physical therapy staff, including licensed PTs and PTAs.
The setting for this study was a teaching hospital in the Midwest region of the United States. Table 1 highlights standardized strategies that are used at this hospital to optimize outcomes after total knee arthroplasty. Physical therapy staff and PT students, under the direction of their clinical instructors (CIs), followed the clinical pathway shown in Table 2. Patients progressed through the pathway at the provider's discretion until goals were met or they were discharged from the hospital. Typical goals for discharge included the ability to transfer, ambulate household distances with an appropriate gait aid, negotiate stairs (if necessary for household mobility), and perform a home exercise program with minimal assistance from a caregiver. Because care was standardized, it was assumed that differences in patient outcomes at discharge would be more likely related to differences in providers.
To determine sample size, we performed a pilot chart review using 3 months of patient data (April, May, June 2010) which showed a mean improvement of 5.1 (+/- 3.4) points on the Functional Outcome Measure (FOM) from the initial score recorded at PT evaluation to the final score recorded at the final dismissal session. We chose to use a > 30% difference (1.53 points) between the staff-treated and student-treated groups as the indicator of meaningful functional significance. Based on clinical experience, we believed that such difference would be influential in determining the discharge location for the patient. A difference of > 1.5 points would signify that the level of assistance that the patient required for at least 1 mobility category would be significantly different between groups and would likely impact discharge location (ie, patient requiring moderate assistance rather than minimal assistance). Based on the pilot chart review, we found that a sample of 80 patients per group would provide 80% power to detect a 30% difference between groups (2 sample t test with alpha level of .05).
We used a database query to identify all potential study patients from this institution's Joint Registry Database. Inclusion criteria were as follows: > 18 years of age, recipient of a unilateral bi-compartmental or tri-compartmental primary total knee arthroplasty (ICD-9 code: 81.54), hospitalization between August 2008 and August 2010, signed consent from the patient to use his/her medical record for research purposes, and physical therapy treatment provided exclusively by either PT students or by the physical therapy staff. Patients enrolled in the Minnesota Medicaid program were excluded from the study, as it prohibits student-provided physical therapy services. According to recent nationally representative data, Medicaid recipients represent approximately 3.04% of total knee arthroplasty surgeries.24 Once all potential study participants were identified, further queries of the electronic medical record were used to make the final selection of 160 patients (see Figure 1). The end result revealed 2 study groups represented by patients who received student-provided (n = 80) or staff-provided (n = 80) physical therapy between March 2009 and August 2010.
Staff, Student, and Clinical Education Characteristics
Patients in the staff-treated study group were treated by 25 licensed PTs and PTAs with 8 to 25 years of experience. Patients in the student-treated study group had 26 student providers from 9 different PT education programs. PT students in this setting act under the supervision of a licensed PT serving as their CI using a collaborative clinical education model. This model has been used historically at this institution since the 1930s and is known as the Mayo Collaborative Model of Clinical Education.25 The CI works full-time in the role throughout the year to educate, mentor, and supervise 2 or 3 PT students, overseeing the provision of patient care provided throughout the internship without managing a separate caseload. The education of the students is their primary job responsibility. Supervision was provided based on the state's stipulations in the Physical Therapy Practice Act as follows:
“On-site supervision” means the physical therapist is easily available for instruction to the student physical therapist. The physical therapist shall have direct contact with the patient during at least every second treatment session by the student physical therapist. Telecommunications, except within the facility, do not meet the requirement of on-site supervision.26
We used the Mayo Clinic electronic medical record in conjunction with the Mayo Total Joint Registry database to retrospectively gather data from the records of eligible patients. Electronic documentation by all members of the health care team helped ensure protection and accessibility of all data. We presumed that all documentation within the medical record was accurate and valid.
We collected patient and surgical demographic data to ensure similarity and valid comparisons between groups. The following variables have been found to be influential on total knee arthroplasty outcomes and were examined: age,24,27 race,28 sex,28 height/weight, living alone, pre-op functional status,29 pre-op residence, pre-op education,30 surgeon experience,31–33 anesthesia/analgesia,30,34–38 and comorbidities.24,27
We used the Functional Comorbidity Index (FCI) to quantify and compare the coexisting medical conditions for each group. The FCI is the only known index designed with physical function in mind and has been found to correlate with other physical function scores.39 The FCI contains a list of 18 comorbid conditions that may impact physical function. Each condition present accounts for 1 point, and the number of conditions are recorded as a summative score (0–18). We used the FOM to quantify mobility outcomes. The FOM is an outcome tool designed by the therapists at this institution to quantify acute care therapy-related outcomes. To complete the FOM, therapists assign a numeric value between 0 and 7 to the assistance level that a patient requires for 3 functional mobility tasks (transfers, gait, stair negotiation) (Table 3). These physical assistance levels are widely understood and consistently used in documentation in the physical therapy profession. High PT interrater reliability has been reported when using these assistance levels to grade transfers and ambulation for acute care patients who undergo total knee arthroplasty (kappa values between 0.75 and 0.99).40 In addition, this system of grading has been found to be valid and reliable with other outcome measures.41,42
We consulted statisticians from the Center for Translation Science Activities and the Division of Biostatistics at the Mayo Clinic to discuss quality research study design and to determine appropriate statistical tests and measures for proposed outcomes. The primary outcomes of interest that we examined were functional improvement (total change in the FOM score) and provider efficiency (change in FOM score per therapy session). Secondary outcomes that were examined included number of therapy sessions/minutes, gait distance at discharge, knee range of motion at discharge, and discharge location.
We performed the data analysis using Statistical Package for the Social Sciences43 at a .05 level of significance. Independent 2-sample t tests were used to analyze continuous demographic data and outcome measurements between groups. Fisher exact tests were used to compare nominal demographic information. Linear regression was used to determine the effect estimate and standard deviation between groups after adjusting for the covariates that differed significantly between groups (history of back pain and weight bearing status).
Most baseline characteristics of the patients were similar to national demographic data from 1990–2004 for this population,27 with a male to female ratio of approximately 2:3, a mean age of 66.22 years (versus 68.21 nationally), and 60% of patients having Medicare as a payer (versus 55% nationally). However, 95% of the patients in our study categorized themselves in the “white” race group compared to only 69% nationally.27
All baseline demographics and surgical variables were comparable between the 2 groups (Tables 5 and 6), except that the student-treated group had a greater number of patients with a history of low back pain (P = .003). There was incomplete preoperative joint range of motion data in the medical record for 30% of the staff-treated group and 35% of the student-treated group. However, analysis of the patients who had complete data showed no significant differences between the groups.
The comorbidities of the groups in this study (see Table 4) were similar to nationally representative study data for patients undergoing primary total knee arthroplasty. Data from 1990–2004 reported the most common comorbidities in this patient population to be hypertension (45.78%), diabetes mellitus (13.13%), coronary artery disease (10.3%), pulmonary disease (8.72%), and obesity (6.35%).27 In addition, the burden of comorbid conditions for each group was similar, and there was no significant difference between the FCI scores for the staff-treated subject group (3.35 + 1.54) and the student-treated subject group (3.58 + 1.57). While national data indicates that only 6.35% of patients undergoing total knee arthroplasty were obese, 68% of the subjects in this study were categorized as such. While some research has reported poorer outcomes for patients with obesity,29 a review of literature by Downsey and Choong44 found no conclusive evidence to support a difference in early outcomes and complications between obese and non-obese patients following joint arthroplasty.
The minimal change in FOM score of 1.53 was deemed to be clinically important as a marker of difference in group outcomes. As shown in Table 7, there were no significant differences between groups in FOM improvement (P = .955). When each FOM subscale was examined individually, there remained no significant differences between groups (Figure 2).
In addition, we found no differences in efficiency between groups with 1.20 + .67 FOM points gained per session in the staff-treated subject group and 1.14 + .75 FOM points gained per session in the student-treated subject group.
As shown in Table 7, there were no statistically significant differences between groups in the number of therapy sessions, total therapy minutes, knee flexion, knee extension, hospital length of stay, or discharge location. A greater average ambulation distance was achieved in the student-treated group (P = .011). There were no significant outliers in the data to account for this difference. We considered that the difference might be because the staff-treated group contained more patients who were partial weight bearing. However, the Pearson correlation coefficient revealed no significant relationship between final gait distance and weight bearing status (P = .113). In addition, even after adjusting for weight-bearing status through analysis of variance (ANOVA), a significant difference still remained between groups (P = .006). Although it has been shown that multiple variables can influence ambulation ability following total knee arthroplasty,45 none of these baseline variables differed significantly between our study groups.
There was, however, a large degree of variability in the gait distances achieved by individual patients in both groups, evident by the large ranges in standard deviations (34.23 ± 21.46 meters for staff-treated patients, 43.07 ± 21.92 meters for student-treated patients). Because of the wide variability in ambulation distances achieved, a larger sample size might have been helpful in producing refined results.
While patient-level outcomes have become an increasingly important area for investigation in medical education research, PT education research has largely focused on the learning outcomes of students (technical competency, problem-solving, collaborative learning, reflective activities). In fact, only 2 studies have examined the clinical effectiveness of PT students, but proved too underpowered to be conclusive.17,18
To our knowledge, ours is the first study with a significant sample size in which to compare the outcomes of student-treated versus staff-treated patients in the acute care setting and the first to focus on a targeted diagnostic group of patients. Our retrospective cohort design with subject selection based on surgical date resulted in well-balanced groups with similar baseline characteristics. In addition, unlike previous studies, this study used appropriate power analysis and analyzed potential confounding variables.
One goal of this study was to identify any potential gaps in the clinical effectiveness of PT students in the treatment of patients following total knee arthroplasty in the acute care setting. In acute care, therapist competency and efficiency are paramount to ensure optimal patient outcomes in a fast-paced, complex environment. Effective acute care physical therapy requires the ability to activate appropriate processes within a complex clinical system, collaborate with other medical team members to coordinate discharge planning, and successfully engage the patient in order to achieve results.9 Our findings suggest that PT students in a collaborative education model achieve similar patient outcomes as staff clinicians for the provision of care to patients following total knee arthroplasty in the acute care setting. Patients in both groups achieved positive functional outcomes with less assistance required for transfers, ambulation, and stair negotiation at the time of discharge. These results support the findings of previous studies that also demonstrated that patients treated by student therapists achieved positive outcomes in outpatient settings.17,18,25 Future investigation of student clinical effectiveness in the treatment of other patient populations and in different clinical education models (ie, collaborative versus 1-on-1) may be indicated.1
The level of assistance that a patient requires has been reported as one of the primary determinants of discharge location after hospitalization.46–48 Our study found that there was no significant difference in discharge location between student-treated and staff-treated patients. Overall, patients who discharged to home had higher mean FOM scores at discharge (13 points) than those who discharged to a skilled nursing facility (8.8 points). Therefore, the use of a tool like the FOM in acute care may assist clinical decision-making and discharge planning by identifying patients who have mobility impairment and require assistance after hospitalization.
Another goal of this study was to examine the efficiency of care delivered by PT students. Efficiency is paramount in acute care, as patient complexity increases while length of hospital stay simultaneously decreases.21,49 Furthermore, the relationship of student efficiency to the CI's productivity is an important consideration for clinics, as economic factors are increasingly cited as the reason that a clinical site declines hosting a student.50 Our findings suggest that the PT students were as efficient as licensed staff in all areas measured in this study. There were no differences between groups in the average FOM point gains at discharge, the average number of therapy sessions, the average amount of treatment time provided per session, or in the total amount of physical therapy treatment provided over the course of the hospitalization (Table 7).
In the Mayo Collaborative Model of Clinical Education, the full-time CI has been found to be over 2 times more productive on average than a staff therapist in the same department that does not have students.25 Several other studies have also reported higher CI productivity using a collaborative clinical education model.51–55 The results of this study further strengthen the possible benefits of this model, as there was no compromise in patient outcomes. Overall, this model may also have contributed to more cost-effective patient care due to the improved efficiency of the CI.25
Our intent was to contribute to an initial body of evidence that supports the provision of quality patient care by PT students (under the guidance of their CIs) for patients undergoing primary total knee arthroplasty. While our findings captured meaningful practicebased evidence,56 there are several limitations.
One limitation was that the retrospective study utilized a convenience sample and relied exclusively on data that was already in the medical record. As a result, groups were not randomized, data for preoperative joint range of motion were incomplete, and the interater/intrarater reliability of providers was unknown. Another limitation was that student-provided care was benchmarked against staff clinicians using the non-validated FOM, meaning that the study may have been underpowered to detect FOM score differences between groups that were less than 30%. Future research efforts to use a randomized prospective study design and a reliable, validated outcome measure would allow for a more rigorous analysis and a stronger level of evidence.
Finally, our study was implemented in a single hospital with a comprehensive joint arthroplasty regime, less racial diversity, a greater prevalence of obesity (68.13%) compared to national data, and a strong historic collaborative educational model.25 Therefore, multiple variables may have simultaneously worked to influence patient outcomes, and findings are not generalizable to other student-treated primary total knee arthroplasty patient populations where racial demographics, medical management, therapy practices, or clinical education models may differ significantly.
Further research to investigate patient outcomes with other patient populations (age ranges, diagnoses, complexity levels, etc), different settings, and using other clinical education models is necessary. Understanding educationally sensitive variables that may impact student performance and influence patient outcomes may assist with the development of PT education initiatives.
This study compared the functional outcomes of staff-treated and student-treated patients after undergoing primary total knee arthroplasty and standardized physical therapy in the acute care setting. Based on our findings, we conclude that patients who receive acute care physical therapy services after total knee arthroplasty may achieve comparable functional outcomes during implementation of a standardized clinical pathway, whether they are treated by licensed staff clinicians or PT students in a collaborative clinical education model. Moreover, we found no differences in provider efficiency between licensed physical therapy staff or PT students on any measure examined (FOM efficiency, total number of therapy minutes, or number of therapy sessions).
The authors would like to thank Heidi Dunfee, Marty Tuma, Aaron Rindflesh, Yolonda Loetcher, Ghennadiy Batrachenko, Dirk Larson, Seth Sletterdahl, Mary LaBrash, and the statisticians at Mayo's Center for Translational Science Activities for their assistance in data collection, study design, and the development of this manuscript.
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