Minority and lower-income populations are less likely to have orthopedic surgery – and more likely to experience poor outcomes when they do.

Untreated musculoskeletal conditions can result in sedentary behavior that leads to or worsens co-morbidities, including diabetes, obesity, depression and opioid misuse.

Access challenges are partly to blame. Disadvantaged populations face many barriers to care, including low referral rates, lack of Medicaid acceptance and transportation difficulties.

Telehealth experts say that offering remote education and physical therapy to patients can improve access for vulnerable populations, including:

● Patients in rural communities who live far away from brick-and-mortar care facilities.

● Patients who cannot afford copays for doctor or outpatient PT appointments.

● Patients in urban communities whose mobility issues make leaving home difficult.

● Patients whose inability to take time off work or secure childcare limits in-person visits.

● Patients who speak English as a second language.

Healthcare IT News interviewed physical therapist Bronwyn Spira, founder and CEO of Force Therapeutics, to discuss the challenges and opportunities surrounding this area of virtual care.

Q. Why are minority and lower-income populations less likely to have orthopedic surgery – and more likely to experience poor outcomes when they do?

A. Musculoskeletal disorders are extremely common in our country. At least 60% of American adults are affected by a musculoskeletal disorder, and more than 75% of those 65 and older are living with at least one musculoskeletal condition, which ranges from tendonitis to arthritis, degenerative disc disease, and chronic lower back pain.

Lower-income and minority populations face multiple barriers to accessing the right healthcare and are typically less likely to utilize orthopedic care, which can result in significant functional impairment. Untreated musculoskeletal conditions also can result in sedentary behaviors that lead to or worsen co-morbidities such as diabetes, obesity and depression.

In one study of more than 7,000 individuals with arthritis, the incidence rates of developing disabilities in activities of daily living (ADL) over a six-year period were significantly higher for Blacks (28%) and Spanish-speaking Hispanics (28.5%), as compared to whites (16.2%).

As I mentioned, disadvantaged populations often lack sufficient access to care, which can manifest in a few different ways. Many cannot afford the financial burden of copays, childcare, transportation, time off work or the out-of-pocket cost of receiving care when uninsured.

The Commonwealth Fund found that 50% of low-income adults in the U.S. skipped at least one medical visit, test, treatment or prescription per year due to its cost.

Patients with state-funded Medicaid and federally funded Medicare plans also encounter logistical barriers to securing musculoskeletal care, including lower referral rates to orthopedic surgeons. Orthopedic specialists are 13% less likely to accept new Medicaid patients than they are Medicare patients or those with commercial insurance plans.

Lastly, more than a third of Americans (36%) have low health literacy, which can be defined as the degree to which individuals can obtain, process and understand health information. Older age, minority membership and low socioeconomic status are disproportionately correlated with poor functional health literacy in both urban and rural populations.

Language barriers also impact care utilization and success rates, as individuals who cannot fully understand the directions they are given will not be able to adhere to a care plan. One study on healthcare utilization among Hispanic adults found that limited English proficiency contributes to the underuse of medical services.

For all of these reasons, members of disadvantaged populations are far less likely to have orthopedic surgery to correct their musculoskeletal conditions. The data also indicates stark disparities in orthopedic care utilization among racial and ethnic minority groups.

Researchers have found that even after adjustments are made for age, sex and income, Black patients are 30% less likely to receive a total hip or knee replacement than white patients.

A systematic review of the literature reveals that members of minority populations who do have joint replacement surgery also are at a higher risk for early complications within the first 90 days, leading to higher hospital readmission rates.

While there is no consensus as to the cause of these disparities, research suggests that multiple co-morbidities, lower income, poor health literacy, provider bias and insufficient interventions are contributing factors.

Q. How does offering remote education and remote physical therapy to patients improve access for vulnerable populations?

A. First and foremost, remote education and physical therapy platforms reduce the need for patients to attend appointments in person. When hospitals, health systems and ambulatory surgical centers (ASCs) implement care management and remote monitoring tools, they set the stage for achieving greater health equity by removing some of the physical barriers to care.

At the start of a surgical episode, for example, replacing preoperative in-person appointments with virtual education classes means that patients can get all the information they need to prepare for surgery without leaving the house.

Educating patients about what they can expect for their surgery – including what outcomes are typical, and how long their healing will take – helps them set appropriate goals for their recovery.

All remote education content must be tailored to the patient and their condition, and ideally should reflect their co-morbidities, medication and social determinants of health, as these factors influence how a patient is likely to respond to treatment.

Content should be delivered in the patient's native language, and should feature clear and easily understood directions. Engaging a care partner who can support the patient's recovery journey also can be extremely beneficial. Many patients find it helpful to return to valuable content as questions arise, and care partners can assist by reinforcing the care team's instructions along the way.

Content also should be easily digestible and should arrive at the appropriate point in the patient's journey, so as not to overwhelm patients with too much information.

For example, before surgery, patients need information about how long they will be out of commission and how to prepare their space for moving around with an assistive device. A few days after surgery, they need information on how to manage their swelling and control their pain.

Many hospitals and ASCs also are offering patients the option of virtual PT to supplement or replace traditional outpatient PT, as remote therapy delivers similar results at a much lower opportunity cost for the patient.

Randomized trials have shown that virtual PT produces similar outcomes to outpatient PT after total knee and hip arthroplasty procedures, as long as the virtual program is prescribed by the treating clinical team.

In addition to the time savings involved, replacing traditional PT with remote PT can save patients hundreds of dollars in copays and convenience, as patients can complete the rehab in their own home at a convenient time.

Q. How does telehealth technology serve as a digital bridge to, for example, patients who cannot afford copays for doctor or outpatient PT appointments, patients in urban communities whose mobility issues make leaving home difficult, patients whose inability to take time off work or secure childcare limits in-person visits, and patients who speak English as a second language?

A. Digital therapeutics can help orthopedic teams build stronger relationships with their patients, especially those who are members of disadvantaged populations and who are likely to need additional support.

Standardizing patient access to preoperative and postoperative education through remote technology can help practices correct against implicit bias and ensure consistent communication with all patient populations, including the 13% of Americans who speak Spanish at home.

For patients living in rural communities, telehealth tools can close the access gap imposed by geography. For patients in urban areas, who may struggle to use public transportation or navigate the stairs in a fifth-floor walk-up, telehealth tools can mean the difference between skipping necessary appointments and following their care plan.

Ideally, telehealth technology can serve as a digital bridge to connect vulnerable patients to their care teams. However, the infrastructure of any such tool must support all patient populations, including the 43% of lower-income adults without broadband services at home.

In many low-income communities, insufficient access to a computer also hinders the use of digital care management and remote monitoring solutions. Applications must compensate for the digital divide in their system design to ensure content does not require internet access, which can be poor or non-existent in certain areas.

Patients should be able to access their care plans via mobile device with a secure login.

According to the Pew Research Center, 27% of adults living in households earning less than $30,000 a year are smartphone-only internet users.

As disadvantaged populations are far less likely to own a tablet, laptop or desktop computer, telehealth tools must be mobile-friendly and SMS-enabled. Two-way text messaging between patients and clinicians is a proven health intervention tool, as patients are much more likely to read and respond to a text than an email.

Direct messaging via telehealth platforms also can improve outcomes for disadvantaged populations. When postoperative patients have a question about their pain levels, they can text their care team for answers instead of making an unnecessary trip to urgent care or the ER – or simply ignoring the problem until later, when interventions are less likely to be successful.

Research shows that providing a care management platform with direct messaging decreases readmission rates across musculoskeletal procedures.

Q. On a personal note, how does telehealth help you, the provider, with all these challenges?

A. Early on in my career as a physical therapist, I managed and founded a number of orthopedics and sports medicine clinics in New York. My colleagues and I were constantly frustrated by how basic patient challenges – from inadequate healthcare access to poor health literacy and a lack of motivation – impacted our patients' outcomes.

Similarly, we had very little or no visibility into how patients were managing at home, and whether the patients were achieving the outcomes that mattered to them. There wasn't a reliable closed-loop connection that provided the data we needed to make the right care decisions. Many patients would drop out of a treatment regimen due to access or cost challenges.

There often were protracted gaps in care, and by the time the patient returned for treatment, they had often regressed or developed complications.

That period led me to believe that evidence-based remote therapy and education could play a pivotal role in helping disadvantaged populations follow their postoperative care plan.

In the traditional system, clinicians spend much of their valuable time in preoperative education visits, repeating the same things over and over to patients who are not likely to retain the bulk of this information. After surgery, nurses and care coordinators then work overtime to return patients' phone calls and fill in the knowledge gaps for patients.

Digital care management systems allow orthopedic practices to scale valuable in-person time by automating low-touch interactions, while identifying the patients who need targeted one-to-one intervention. With the benefit of technology, practices can create high-value, repeatable workflows to fully prepare patients for surgery by giving patients what they need to know as they need to know it.

This phased, segmented approach to education has been proven to correct for the retention gap of in-person education.

The addition of patient messaging and remote monitoring tools enables the delivery of patient-reported outcomes data and care plan progression feedback to be returned in real time to the care team, who then can intervene as necessary.

Orthopedic practices are much less likely to miss a patient who has stalled in their recovery and is at a high risk of developing complications. When digital therapeutics are designed to be inclusive of all patient populations, they can transform the way we practice orthopedics to improve health equity.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.