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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Med Care. 2022 Mar 16;60(6):444–452. doi: 10.1097/MLR.0000000000001708

Association of Physical Therapy Treatment Frequency in the Acute Care Hospital with Improving Functional Status and Discharging Home

Joshua K Johnson *,†,‡, Michael B Rothberg ‡,§, Kellie Adams †, Brittany Lapin ‖,, Tamra Keeney **,††, Mary Stilphen †, Francois Bethoux *, Janet Freburger ‡‡
PMCID: PMC9106906  NIHMSID: NIHMS1782974  PMID: 35293885

Abstract

Background:

Physical therapists (PTs) are consulted to address functional deficits during hospitalization, but the effect of PT visit frequency on patients’ outcomes is not clear.

Objective:

To examine whether PT visit frequency is independently associated with functional improvement, discharge home, and both outcomes combined.

Research Design:

Retrospective cohort study.

Subjects:

Patients discharged from hospitals in one health system between 2017 and 2020, stratified by diagnostic subgroup: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic.

Measures:

PT visit frequency was categorized as ≤2 visits/week, >2–4 visits/week, >4–7 visits/week, >7 visits/week. Functional improvement was defined as ≥5-point improvement in Activity Measure for Post-Acute Care mobility score. Other outcomes were discharge home and both outcomes combined.

Results:

There were 243,779 patients included. Proportions within frequency categories ranged from 11.0% (>7 visits/week) to 40.5% (≤2 visits/week) and varied by subgroup. In the full sample, 36% of patients improved function, 64% discharged home, and 27% achieved both outcomes. In adjusted analyses, relative to ≤2 visits/week, the adjusted relative risk (aRR) for functional improvement increased incrementally with higher frequency (aRR=1.20, 95% confidence interval [CI]: 1.14–1.26 for >2–4 visits to aRR=1.78, 95% CI: 1.55–2.03 for >7 visits). For all patients and within subgroups, higher frequency was also associated with greater likelihood of discharging home and achieving both outcomes.

Conclusions:

More frequent PT visits during hospitalization may facilitate functional improvement and discharge home. Most patients, however, receive infrequent visits. Further research is needed to determine the optimal delivery of PT services to meet individual patient needs.

INTRODUCTION

Patients admitted to the acute care hospital often experience sudden or exacerbated declines in functional independence.1,2 Physical therapists (PTs) are typically consulted to evaluate and treat these patients. In doing so, PTs serve dual roles:3 1) contribute to discharge planning,4,5 and 2) intervene using functional activity, exercise, and education to maintain or improve functional status.6

Evidence suggests that a therapist’s discharge recommendations are most useful near the time of discharge to prevent readmissions7 and increase the appropriateness of post-acute care referrals.8 More frequent PT interventions in the hospital is associated with positive outcomes in some patient populations, including shorter hospital length of stay and decreased readmission risk.9–16 Recent prospective trials17,18 have shown that high-frequency exercise interventions in the hospital limit functional decline, but the interventions in these trials were not conducted by PTs and are not broadly implemented. Surprisingly little is known about the effect of real-world PT interventions on function, the primary outcome those interventions are meant to modify.

Functional impairments may necessitate a post-acute care facility stay for rehabilitation,19,20 despite most patients preferring to discharge home.21–23 Historically, prospective payment via diagnosis related grouping has incentivized short hospital stays, minimal use of cost centers like physical therapy, and shifting care to post-acute settings.24 Value-based payment models that bundle acute and post-acute care, however, are realigning incentives to encourage discharge to home.25–28 While therapy remains an unreimbursed cost, this upfront investment could pay off if it increases functional independence and allows patients to discharge home. Evidence is needed to understand how PT visit frequency affects patients’ functional status and ability to discharge home.

We aimed to identify whether PT visit frequency in the acute care hospital is independently associated with functional improvement, discharge to home, and a composite of both. We examined these relationships in a single large cohort of hospitalized patients and within broad diagnostic subgroups of that cohort: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic. These clinical subgroups were selected in order to explore potential differences between them in PT delivery patterns and related patient outcomes. We hypothesized that higher visit frequency would be associated with better outcomes and that both frequency and outcomes would vary by clinical subgroup.

METHODS

Study Design and Data

This was a retrospective cohort study, examining electronic health record data from 11 hospitals in one health system. Hospitals were in urban (N=3), suburban (N=6), and rural (N=2) locations and ranged in size from 148 to 1,300 registered beds.

Study Sample

Patients were included if they met the following criteria: age ≥18 years at admission, discharged between January 1, 2017 and December 31, 2020, and admitted for at least one overnight. Patients were excluded if they were admitted for maternal or psychiatric care, if they died in the hospital, were discharged against medical advice, or were not seen by a PT for at least one visit. Patients in the final cohort were categorized into one of five clinical subgroups based on the primary medical service of record for the hospitalization.

Physical Therapy Frequency

The primary independent variable was the frequency of PT visits defined as the number of completed visits divided by the patient’s length of stay, in days. This provides a standardized metric representing PT service intensity, simultaneously accounting for the variability in both length of stay and the number of completed visits. The latter can be influenced by therapists’ practice patterns and patients’ appropriateness for therapy, willingness to participate, and availability.6,29 Visit frequency was standardized to a 7-day period to be interpreted as a weekly frequency, which is the most common mode of planning and evaluating physical therapy frequency in the hospitals, and was categorized: ≤2 visits/week, >2–4 visits/week, >4–7 visits/week, and >7 visits/week.

Outcome Measures

Functional improvement was assessed using the Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks basic mobility short form, version 2.0. This measure is completed by the PT at each visit and assesses a patient’s independence in rolling in bed, moving from lying to sitting, moving to a chair, standing from a chair, walking, and negotiating a few stairs. It is valid as a clinician-scored instrument for assessing functional status in the hospital,30 has excellent inter-rater reliability,31 and is predictive of discharge disposition.32–35 AM-PAC 6-Clicks mobility raw scores (ranging 6–24) were converted to AM-PAC mobility T-scale scores (ranging 16.6 to 57.7), previously calibrated using item-response theory.36 Higher scores indicate greater functional independence; the minimal detectable change of the AM-PAC mobility T-scale is estimated as 4.8 points.30 We calculated the change in AM-PAC mobility score from the first to the last therapist visit and then created a binary outcome variable indicating whether there was a change ≥5 points. Individuals with only one PT visit (i.e. only one AM-PAC mobility score) were excluded from the analysis of this outcome. Discharge to home (with our without home health care services) versus a facility was also a binary outcome.

Our composite outcome was positive if a patient had both functional improvement and was discharged home. Analysis of this composite outcome is important as it explores the potential role of physical therapists to add value to a patients’ care by contributing to adequate functional improvement that could enable discharge home.

Covariates

Covariates included sociodemographic variables (age, race, sex, primary payer, home setup [i.e. single- vs. multi-level], number of stairs to enter the home, and amount of assistance available at home from unpaid caregivers) and clinical variables (pre-hospital functional level, functional status at PT evaluation, Charlson comorbidity score, elective vs. emergent admission, surgical vs. medical episode, intensive care unit length of stay, hours from admission to the first PT visit, and number of occupational therapist visits).

Pre-hospital functional level was based on patients’ report at PT evaluation and were collapsed into four categories: independent, assistance with activities of daily living (ADLs), assistance with instrumental activities of daily living (IADLs), or not documented. Categories of functional status at PT evaluation were created based on AM-PAC mobility score and clinical rationale. These were very low (16.6–28.1), low (30.3–37.0), moderate (38.3–41.1), high (42.5–45.6), and very high (47.4–57.7). Charlson comorbidity scores,37 which range from 0–24 with higher scores indicating greater burden, were categorized based on quartile distribution.

Statistical Analysis

For the full sample and each clinical subgroup, we described demographic and clinical characteristics, PT visit frequency, and the proportion achieving each outcome. We used chi-square tests to compare the characteristics of patients with one visit to those who had more than one.

We estimated the adjusted relative risk (aRR) of each outcome relative to PT visit frequency category using multivariable modified Poisson regression models with robust variance estimation,38,39 which controlled for the non-independence of measures within hospitals. Separate models were estimated for each of the three outcomes for the full sample and across each of the five clinical subgroups. In addition, we examined associations between each covariate and the outcomes of interest in all patients and within each subgroup using regression coefficient plots.

In the models examining discharge home and the composite outcome, we controlled for all sociodemographic and clinical covariates. In the models examining improved function alone, we removed primary payer, home setup, number of stairs to enter the home, and assistance at home since these variables are not likely to influence functional change in the hospital.

For the outcome of discharge home, we conducted a post-hoc sensitivity analysis excluding those with only one visit since these patients differed in meaningful ways from those who had more than one visit. Further, we recognized that since our measure of frequency is influenced by length of stay (i.e. patients with only one visit over a short stay were categorized in a high frequency group) there may be bias toward patients with shorter stays, who are more likely to go home. This bias was diminished in the sensitivity analysis, which included a chi-square test of the difference in the proportion of patients discharged home among the group with >1 visit relative to those with only one visit, and multivariable regression modeling to examine the relationship between frequency and discharge home.

The significance level for all analyses was p<0.05. According to Zou,38 the minimum sample size criterion for the modified Poisson regression technique we employed is 100. Of the 54 models we estimated, this criterion was met for all but three (those in the oncology subgroup with >7 visits/week; total N=69). Because this study focused on effect estimates to inform future hypotheses, there was no formal adjustment for multiple comparisons. All statistical analyses were completed using Stata version 15.1 (College Station, Texas, USA).

This study was approved by Cleveland Clinic Institutional Review Board.

RESULTS

Our sample included 243,779 patients (Figure 1). Patients seen by general medical/surgical services accounted for the largest subgroup (43.2%) followed by cardiothoracic and vascular services (21.1%). As shown in Table 1, 64.0% were over 65 years old, 75.2% were white, and 53.2% were females. Most patients (75.3%) were hospitalized for >4 days and 28.7% required intensive care; 54.6% had to access only a single floor at home, but the majority (62.1%) also had to navigate steps to enter. Most had unpaid caregivers at home – 46% reported 24-hour caregiver availability and 50% reported occasional availability.

Figure 1. Cohort flow diagram.

Figure 1.

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PT, physical therapist; AMA, against medical advice

Table 1.

Patient demographic and clinical characteristics

Clinical Subgroups
Characteristic, N (%) All Patients Cardiothoracic & Vascular General Medical/Surgical Neurological Oncology Orthopedic
Sample size 243,779 51,408 (21.1%) 105,308 (43.2%) 29,960 (12.3%) 7,384 (3.0%) 49,719 (20.4%)
Patient age
 18–53 30,867 (12.7%) 4,755 (9.2%) 12,275 (11.7%) 5,646 (18.8%) 901 (12.2%) 7,290 (14.7%)
 54–65 56,979 (23.4%) 10,685 (20.8%) 21,911 (20.8%) 7,687 (25.7%) 1,774 (24.0%) 14,922 (30.0%)
 66–75 67,708 (27.8%) 14,308 (27.8%) 27,647 (26.3%) 8,426 (28.1%) 2,085 (28.2%) 15,242 (30.7%)
 ≥76 88,225 (36.2%) 21,660 (42.1%) 43,475 (41.3%) 8,201 (27.4%) 2,624 (35.5%) 12,265 (24.7%)
Race
 White 183,424 (75.2%) 37,494 (72.9%) 76,476 (72.6%) 22,827 (76.2%) 5,625 (76.2%) 41,002 (82.5%)
 Black 49,397 (20.3%) 11,500 (22.4%) 24,232 (23.0%) 5,662 (18.9%) 1,454 (19.7%) 6,549 (13.2%)
 Other 9,375 (3.8%) 2,138 (4.2%) 4,048 (3.8%) 1,261 (4.2%) 269 (3.6%) 1,659 (3.3%)
 Not reported/documented 1,583 (0.6%) 276 (0.5%) 552 (0.5%) 210 (0.7%) 36 (0.5%) 509 (1.0%)
Female sex 129,804 (53.2%) 24,955 (48.5%) 57,483 (54.6%) 15,391 (51.4%) 3,986 (54.0%) 27,989 (56.3%)
Primary Payer
 Traditional Medicare 94,228 (38.7%) 20,804 (40.5%) 43,551 (41.4%) 10,487 (35.0%) 2,898 (39.2%) 16,488 (33.2%)
 Medicare HMO 79,079 (32.4%) 18,526 (36.0%) 36,454 (34.6%) 8,457 (28.2%) 2,229 (30.2%) 13,413 (27.0%)
 Medicaid 21,926 (9.0%) 3,830 (7.5%) 9,940 (9.4%) 3,054 (10.2%) 702 (9.5%) 4,400 (8.8%)
 Commercial 43,149 (17.7%) 7,217 (14.0%) 13,425 (12.7%) 7,117 (23.8%) 1,433 (19.4%) 13,957 (28.1%)
 Self-Pay/ Other 5,397 (2.3%) 1,031 (2.0%) 1,938 (1.9%) 845 (2.8%) 122 (1.7%) 1461 (3.0%)
CharlsonComorbidity Index
 0–1 69,800 (28.6%) 11,010 (21.4%) 20,997 (19.9%) 11,302 (37.7%) 585 (7.9%) 25,906 (52.1%)
 2–3 58,371 (23.9%) 12,211 (23.8%) 25,079 (23.8%) 7,716 (25.8%) 1,623 (22.0%) 11,742 (23.6%)
 4–5 47,737 (19.6%) 12,185 (23.7%) 23,177 (22.0%) 4,937 (16.5%) 1,242 (16.8%) 6,196 (12.5%)
 ≥6 67,871 (27.8%) 16,002 (31.1%) 36,055 (34.2%) 6,005 (20.0%) 3,934 (53.3%) 5,875 (11.8%)
Elective admission 66,666 (27.3%) 11,039 (21.5%) 11,821 (11.2%) 9,742 (32.5%) 718 (9.7%) 33,346 (67.1%)
Surgery during admission 108,170 (44.4%) 22,203 (43.2%) 26,866 (25.5%) 14,167 (47.3%) 4 (0.1%) 44,930 (90.4%)
Admission was 30-day readmission 40,527 (16.6%) 9,341 (18.2%) 21,704 (20.6%) 3,611 (12.1%) 2,144 (29.0%) 3,727 (7.5%)
Hospital LOS (days)
 1 29,222 (12.0%) 3,586 (7.0%) 5,759 (5.5%) 3,155 (10.5%) 310 (4.2%) 16,412 (33.0%)
 2–3 30,990 (12.7%) 4,829 (9.4%) 10,037 (9.5%) 4,913 (16.4%) 670 (9.1%) 10,541 (21.2%)
 4–6 80,218 (32.9%) 14,410 (28.0%) 37,801 (35.9%) 11,950 (39.9%) 2,331 (31.6%) 13,726 (27.6%)
 ≥7 103,349 (42.4%) 28,583 (55.6%) 51,711 (49.1%) 9,942 (33.2%) 4,073 (55.2%) 9,040 (18.2%)
ICU LOS (days)
 0 173,805 (71.3%) 27,085 (52.7%) 72,830 (69.2%) 22,404 (74.8%) 6,101 (82.6%) 45,385 (91.3%)
 1–2 27,461 (11.3%) 8,119 (15.8%) 13,445 (12.8%) 3,566 (11.9%) 593 (8.0%) 1,738 (3.5%)
 3–6 32,037 (13.1%) 11,961 (23.3%) 14,359 (13.6%) 3,132 (10.5%) 544 (7.4%) 2,041 (4.1%)
 ≥7 10,476 (4.3%) 4,243 (8.3%) 4,674 (4.4%) 858 (2.9%) 146 (2.0%) 555 (1.1%)
Home setup
 First floor setup 133,124 (54.6%) 28,922 (56.3%) 57,210 (54.3%) 16,083 (53.7%) 4,077 (55.2%) 26,832 (54.0%)
 Split level 10,175 (4.2%) 2,085 (4.1%) 4,155 (3.9%) 1,271 (4.2%) 406 (5.5%) 2,258 (4.5%)
 Multi-level 45,673 (18.7%) 9,005 (17.5%) 17,311 (16.4%) 6,827 (22.8%) 1,454 (19.7%) 11,076 (22.3%)
 Not documented 54,807 (22.5%) 11,396 (22.2%) 26,632 (25.3%) 5,779 (19.3%) 1,447 (19.6%) 9,553 (19.2%)
Stairs to enter home
 No 71,486 (29.3%) 15,626 (30.4%) 34,463 (32.7%) 7,715 (25.8%) 2,040 (27.6%) 11,642 (23.4%)
 Yes 151,321 (62.1%) 31,654 (61.6%) 59,836 (56.8%) 19,784 (66.0%) 4,745 (64.3%) 35,302 (71.0%)
 Not documented 20,972 (8.6%) 4,128 (8.0%) 11,009 (10.5%) 2,461 (8.2%) 599 (8.1%) 2,775 (5.6%)
Pre-hospital level of function
 Independent 125,160 (51.3%) 26,544 (51.6%) 42,604 (40.5%) 17,263 (57.6%) 3,137 (42.5%) 35,612 (71.6%)
 Assist with IADLs 48,065 (19.7%) 10,991 (21.4%) 24,542 (23.3%) 4,988 (16.6%) 1,741 (23.6%) 5,803 (11.7%)
 Assist with ADLs 61,790 (25.3%) 12,062 (23.5%) 33,952 (32.2%) 6,617 (22.1%) 2,164 (29.3%) 6,995 (14.1%)
 Not documented 8,764 (3.6%) 1,811 (3.5%) 4,210 (4.0%) 1,092 (3.6%) 342 (4.6%) 1,309 (2.6%)
Assistance available
 24 hours 112,120 (46.0%) 22,853 (44.5%) 46,768 (44.4%) 14,324 (47.8%) 3,645 (49.4%) 24,530 (49.3%)
 Occasionally 121,801 (50.0%) 26,665 (51.9%) 54,040 (51.3%) 14,544 (48.5%) 3,507 (47.5%) 23,045 (46.4%)
 Never 8,095 (3.3%) 1,582 (3.1%) 3,597 (3.4%) 886 (3.0%) 189 (2.6%) 1,841 (3.7%)
 Not documented 1,763 (0.7%) 308 (0.6%) 903 (0.9%) 206 (0.7%) 43 (0.6%) 303 (0.6%)
Functional status at PT evaluation
 Very Low 28,014 (11.5%) 4,412 (8.6%) 13,730 (13.0%) 3,848 (12.8%) 639 (8.7%) 5,385 (10.8%)
 Low 46,295 (19.0%) 9,076 (17.7%) 20,238 (19.2%) 5,494 (18.3%) 1,230 (16.7%) 10,257 (20.6%)
 Moderate 67,017 (27.5%) 13,520 (26.3%) 26,328 (25.0%) 7,771 (25.9%) 1,787 (24.2%) 17,611 (35.4%)
 High 47,494 (19.5%) 10,765 (20.9%) 20,615 (19.6%) 5,222 (17.4%) 1,582 (21.4%) 9,310 (18.7%)
 Very High 54,959 (22.5%) 13,635 (26.5%) 24,397 (23.2%) 7,625 (25.5%) 2,146 (29.1%) 7,156 (14.4%)
Duration (hours) from admission to PT evaluation
 <24 hours 64,299 (26.4%) 9,204 (17.9%) 22,470 (21.3%) 7,315 (24.4%) 1,553 (21.0%) 23,757 (47.8%)
 24–48 hours 71,574 (29.4%) 12,244 (23.8%) 28,226 (26.8%) 12,279 (41.0%) 1,901 (25.7%) 16,924 (34.0%)
 48–96 hours 61,497 (25.2%) 14,404 (28.0%) 31,901 (30.3%) 7,199 (24.0%) 2,127 (28.8%) 5,866 (11.8%)
 >96 hours 46,409 (19.0%) 15,556 (30.3%) 22,711 (21.6%) 3,167 (10.6%) 1,803 (24.4%) 3,172 (6.4%)
Number of OT visits
 0 58,875 (24.2%) 17,566 (34.2%) 28,662 (27.2%) 4,817 (16.1%) 2,056 (27.8%) 5,814 (11.7%)
 1 126,405 (51.9%) 22,840 (44.4%) 54,548 (51.8%) 15,236 (50.9%) 3,609 (48.9%) 30,172 (60.7%)
 2–3 48,063 (19.7%) 8,347 (16.2%) 18,319 (17.4%) 7,714 (25.8%) 1,397 (18.9%) 12,286 (24.7%)
 ≥4 10,435 (4.3%) 2,654 (5.2%) 3,819 (3.6%) 2,193 (7.3%) 322 (4.4%) 1,447 (2.9%)
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HMO, health maintenance organization; LOS, length of stay; IADLs, instrumental activities of daily living; ADLs, activities of daily living; OT, occupational therapist

Sociodemographic and clinical characteristics varied significantly across the clinical subgroups. Notably, comorbidity burden was lower in the neurological and orthopedic subgroups (20.0% and 11.8% with a Charlson score ≥6, respectively) than in others. Patients in the orthopedic subgroup also had a shorter length of stay (54.2% discharged within 3 days) than others. Intensive care was most prevalent among those in the cardiothoracic and vascular subgroup (47.4%), followed by those in the general medical/surgical group (30.8%). Pre-hospital functional independence was most prevalent among those in the orthopedic subgroup (71.6%), but fewer of these patients (14.4%) were functioning at a very high level at the time of the PT evaluation than those in other groups.

Observed Visit Frequency

In the full sample, 98,799 patients (40.5%) had ≤2 PT visits per week and 26,808 (11.0%) had >7 visits per week (Table 2). Significant visit frequency variability was observed across the clinical subgroups. Patients with orthopedic conditions were seen at the highest frequency (73.6% with >4 visits/week), followed by the neurological subgroup (29.8% with >4 visits/week.) Other groups had fewer visits; in each of the cardiothoracic and vascular, general medical/surgical, and oncology groups, >50% of patients had ≤2 visits per week.

Table 2.

Weekly frequency of physical therapist visits, by clinical subgroup

Clinical Subgroup
Weekly Frequency of PT Visits, N (%) All Patients Cardiothoracic & Vascular General Neurological Oncology Orthopedic
≤ 2 98,799 (40.5%) 26,864 (52.3%) 53,524 (50.8%) 8,412 (28.1%) 4,326 (58.6%) 5,673 (11.4%)
> 2–4 79,082 (32.4%) 18,204 (35.4%) 38,346 (36.4%) 12,613 (42.1%) 2,424 (32.8%) 7,495 (15.1%)
> 4–7 39,090 (16.0%) 5,527 (10.8%) 11,220 (10.7%) 7,980 (26.6%) 565 (7.7%) 13,798 (27.8%)
> 7 26,808 (11.0%) 813 (1.6%) 2,218 (2.1%) 955 (3.2%) 69 (0.9%) 22,753 (45.8%)
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Of the full sample, 107,452 (44.0%) had only one PT visit and were excluded from analyses examining functional improvement. They differed from those with more than one visit (See Table, Supplemental Digital Content 1, which illustrates the differences between the two groups). The distribution of visits in the sensitivity analysis including patients with > 1 PT visit appears in the Table included as Supplemental Digital Content 2.

Observed Patient Outcomes

Overall, 36.4% of patients had functional improvement, 64.2% were discharged home (30.0% for self-care and 34.2% with home health care), and 26.8% achieved both outcomes (Figure 2). Functional improvement was most prevalent among the orthopedic population (50.1%), followed by the cardiothoracic and vascular population (36.1%). These groups also had the highest prevalence of discharge home (70.6% and 70.0%, respectively) and the composite outcome (41.8% and 26.8%, respectively). In general, there was a trend toward a greater occurrence of each outcome relative to increased frequency (Figure 2). We observed in the sensitivity analysis that the proportion of patients discharged home was greater among those with only one visit than those with >1 visit (75.5% vs. 55.3%, respectively; p<0.01).

Figure 2. Proportion of patients improving function, discharging home, and achieving both, relative to physical therapist visit frequency.

Figure 2.

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Note: N=107,452 patients (44% of full sample) missing follow-up functional scores were excluded from the samples of improved function and achieving both outcomes.

Association of PT Visit Frequency with Patient Outcomes

Functional Improvement

More frequent PT visits increased the likelihood of improved function for all patients (Figure 3). Compared to ≤2 visits/week, the aRR (95% confidence interval) for improved function was 1.20 (1.14–1.26) for >2–4 visits/week, 1.31 (1.19–1.44) for >4–7 visits/week, and 1.78 (1.55–2.03) for >7 visits/week. This trend was consistent across all clinical subgroups except oncology, where patients with >7 visits/week did not demonstrate improved likelihood of functional improvement. Patients with orthopedic conditions were most likely to improve their function in the hospital with higher PT visit frequency.

Figure 3. Adjusted relative risk of improving function, discharging home, and achieving both, relative to physical therapist visit frequency.

Figure 3.

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Note: Patients with ≤ 2 visits/week were the reference group in all regression models.

Supplemental Digital Content 3 includes the regression coefficient plots for all three outcomes. Other variables independently associated with improved function for all patients were elective admissions, surgical (vs. medical) admissions, and stays in the intensive care unit of any duration. For all patients, improved function was less likely for those with progressively worse initial function in the hospital, older patients, and those with greater functional dependence prior to hospitalization. These associations were significant and independent within all clinical subgroups, except oncology.

Discharge Home

Higher visit frequency was also associated with increased likelihood of discharge to home, though the magnitude of the effect was smaller. Compared to patients with ≤2 visits/week, the aRR (95% confidence interval) for discharge home was 1.05 (1.00–1.10) for >2–4 visits/week, 1.04 (0.97–1.12) for >4–7 visits/week, and 1.22 (1.15–1.30) for >7 visits/week. The trend for statistically significant associations between higher visit frequency and greater likelihood for discharge home was observed in all clinical subgroups except orthopedic, where discharge home was not associated with visit frequency. However, in the sensitivity analysis, orthopedic patients with >7 visits/week did demonstrate increased likelihood of discharge to home (aRR=1.22, 95% CI: 1.08–1.37). Findings for other groups in the sensitivity analysis were consistent with those of the primary analysis, with greater effect sizes; for all patients, and within each subgroup, progressively higher visit frequencies were associated with increased likelihood of discharge to home (see Figure, which illustrates the adjusted relative risk of discharging home relative to physical therapist visit frequency in sensitivity analysis, including only patients with >1 physical therapist visit, Supplemental Digital Content 4).

Other variables independently associated with discharge home for all patients were greater initial functional independence in the hospital—with coefficients much larger than PT visit frequency, non-white race, a Medicare HMO or commercial payer (vs. traditional Medicare), and an elective admission. For all patients, discharge home was less likely for older patients, those with greater functional dependence prior to hospitalization, and those without or only occasional assistance available at home. These associations were also significant within each clinical subgroup, except for that between race and discharge home in the orthopedic cohort, where the relationship was not statistically significant.

Functional Improvement and Discharge Home

Higher visit frequencies were also associated with the composite outcome, improved function with discharge home. Compared to ≤2 visits/week, the aRR (95% confidence interval) for achieving both outcomes was 1.19 (1.10–1.30) for >2–4 visits/week, 1.27 (1.10–1.47) for >4–7 visits/week, and 1.84 (1.54–2.20) for >7 visits/week. This trend was consistent across clinical subgroups but most pronounced for orthopedic patients.

Other variables independently associated with higher likelihood of the composite outcome for all patients were initial functional status in the hospital (in the low, moderate, and high range), having a commercial payer, elective admissions, surgical admissions, and stays in the intensive care unit of any duration. For all patients, improved function was less likely for older patients and those with greater functional dependence prior to hospitalization. All of these associations were significant and independent within the clinical subgroups, except in oncology.

DISCUSSION

In this study of 243,779 patients discharged from 11 hospitals in one health system who were treated by a PT during hospitalization, more frequent PT visits were independently associated with patients’ improving their function, discharging home, and achieving both outcomes. This trend was consistent across subgroups of patients with cardiothoracic and vascular, general medical/surgical, neurological, oncology, or orthopedic conditions. The distribution of visits, however, was skewed heavily toward patients with orthopedic conditions while those in other clinical populations were treated less frequently.

Our findings are consistent with those of previous studies. Increasing the total number or frequency of PT visits in the hospital decreases length of stay.9 Shorter length of stay, fewer days of mechanical ventilation, and reduced incidence of delirium are positive effects of physical therapy in intensive care units.10,12,14,40 Among patients with stroke15 and pneumonia,16 more PT visits in the hospital are associated with decreased mortality and readmission. For patients with COVID-19, more frequent PT visits improve functional status at discharge and the likelihood of discharge home.23

When considering the covariates in our models, it is not surprising the most pronounced significant association was between initial functional status in the hospital (as measured by the 6-Clicks mobility score) and discharge home. The 6-Clicks has been shown in several studies to predict discharge to home versus to a facility.32–34,41 Consistent with clinical reason, a patient’s poor pre-hospital functional status appears to hinder his or her ability to recover function and/or discharge home. Importantly, however, the relationship between visit frequency and each outcome, including the composite outcome, was independent after controlling for pre-hospital function and all other covariates.

Our data suggest that patients with orthopedic problems are prioritized for PT interventions, a practice supported by evidence.42–46 After total joint arthroplasty, early and frequent physical therapy may decrease length of stay, improve mobility prior to discharge, and facilitate discharge home.42,43 Similar outcomes have been observed for patients treated by PTs in the hospital for hip fracture44,45 and following elective spine surgeries.46 Bundling payments for acute and post-acute care following total joint arthroplasty has served as a catalyst to change PT practice patterns and is associated with decreased hospital length of stay, fewer discharges to post-acute care facilities, and non-inferior functional outcomes.27,43,47

Implementing bundled payment programs and other alternative payment strategies more broadly may serve to realign incentives in other patient populations. Such models contribute to hospitals prioritizing patients’ discharge home to avoid costly facility-based post-acute care.22,48 Our findings suggest that increasing PT visits could support that goal by improving function. For patients whose functional deficits persist, briefly extending the hospital stay to allow more PT visits could be cost-effective, if interventions focus on those limitations impeding discharge to home.49 Alternatively—or additionally—high intensity post-acute rehabilitation could be shifted from facilities to patients’ homes.48,50 Either strategy may offer higher value than facility-based post-acute care.

Our results indicate a need to explore strategies to optimize the frequency of PT visits during hospitalization, particularly among non-orthopedic populations. While the findings suggest benefit of increasing PT visits for patients in all clinical populations, we acknowledge that more frequent visits are not indicated for all patients. Additionally, in the current climate, globally increasing the frequency of PT visits is not feasible since therapists are a finite resource.6 Thus, additional research should focus on the efficient identification of 1) patients most likely to benefit from PT services and 2) the appropriate PT visit frequency to achieve each patient’s desired outcomes. These are likely to be best understood as we explore any interaction effect between PT visit frequency and a patients’ pre- or within-hospital functional status (or other notably significant covariates from this analysis) on the outcomes of interest.

Strengths and Limitations

Specific strengths of our study were the large sample size, including within each of the clinical subgroups, and use of a valid measure of patients’ function that was captured consistently at therapy visits. We also controlled for multiple patient-level factors, many of which are important to PT decision-making in the hospital, but not often used in large retrospective studies as they are rarely standardized in clinical documentation (e.g. pre-hospital functional level, home setup, and caregiver assistance available).

A primary clinical limitation is our reliance on visit frequency to describe PT treatment in the hospital. The content of each visit (e.g. addressing the specific functional deficits that are prohibiting discharge home) may be more important than frequency for improving function and discharge home. Unfortunately, details of treatment are not discretely documented in clinical notes.

Additional limitations exist relative to external and internal validity. First, our study results should be generalized only to patients evaluated by a PT in the hospital since we excluded 366,556 patients (58.6% of the original sample) who were not. Second, in assessing functional improvement and the composite outcome, we had to exclude an additional 107,452 patients (44.1% of the analysis sample) who had only one PT visit since only one AM-PAC mobility score was recorded. This limitation in our data makes it unclear whether additional visits could have influenced functional improvement for these patients. However, our data do indicate that most of these patients were functioning well at their initial PT visit and most were discharged home, suggesting that additional visits may not have been necessary to improve their function. Third, our study was retrospective so cannot determine causality. Lastly, while our adjustment was robust, it was not comprehensive so unmeasured confounders could influence the relationships observed in our data.

Conclusion

We found a positive independent association between PT visit frequency and improved function and discharge home for patients treated in 11 acute care hospitals from one health system. The effects were generally similar across clinical subgroups. However, visit frequency across subgroups was highly variable suggesting opportunities for better identifying optimal allocation of finite PT resources.

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)_1

Supplemental Digital Content 1. Comparison of patients with > 1 vs. only 1 physical therapist visit

Supplemental Data File (.doc, .tif, pdf, etc.)_2

Supplemental Digital Content 2. Weekly frequency of physical therapist visits in sensitivity analysis, including only patients with >1 physical therapist visit

Supplemental Data File (.doc, .tif, pdf, etc.)_3

Supplemental Digital Content 3. Regression coefficient plots, for all patients and by clinical subgroup

Supplemental Data File (.doc, .tif, pdf, etc.)_4

Supplemental Digital Content 4. Adjusted relative risk of discharging home relative to physical therapist visit frequency in sensitivity analysis, including only patients with >1 physical therapist visit

Funding:

Funded in part by the Learning Health Systems Rehabilitation Research Network (LeaRRn), a research center supported by the National Institutes of Health under award number 1P2CHD101895–01 through the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Nursing Research.

Footnotes

Conflicts of interest: The authors declare no conflicts of interest.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Data File (.doc, .tif, pdf, etc.)_1

Supplemental Digital Content 1. Comparison of patients with > 1 vs. only 1 physical therapist visit

NIHMS1782974-supplement-Supplemental_Data_File___doc___tif__pdf__etc___1.pdf (276.8KB, pdf)
Supplemental Data File (.doc, .tif, pdf, etc.)_2

Supplemental Digital Content 2. Weekly frequency of physical therapist visits in sensitivity analysis, including only patients with >1 physical therapist visit

NIHMS1782974-supplement-Supplemental_Data_File___doc___tif__pdf__etc___2.pdf (208.9KB, pdf)
Supplemental Data File (.doc, .tif, pdf, etc.)_3

Supplemental Digital Content 3. Regression coefficient plots, for all patients and by clinical subgroup

NIHMS1782974-supplement-Supplemental_Data_File___doc___tif__pdf__etc___3.pdf (640.4KB, pdf)
Supplemental Data File (.doc, .tif, pdf, etc.)_4

Supplemental Digital Content 4. Adjusted relative risk of discharging home relative to physical therapist visit frequency in sensitivity analysis, including only patients with >1 physical therapist visit

NIHMS1782974-supplement-Supplemental_Data_File___doc___tif__pdf__etc___4.pdf (141.2KB, pdf)

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