Patient Satisfaction with In-Home Telerehabilitation After Total Knee Arthroplasty: Results from a Randomized Controlled Trial

Abstract

Background and Introduction: Telerehabilitation after total knee arthroplasty (TKA) is supported by strong evidence on the effectiveness of such intervention and from a cost-benefit point of view. Satisfaction of patients toward in-home telerehabilitation after TKA has not yet been examined thoroughly in large-scale clinical trials. This study aims to compare satisfaction level of patients following in-home telerehabilitation (TELE) after TKA to one of the patients following a usual face-to-face home visit (STD) rehabilitation. Secondarily, to determine if any clinical or personal variables were associated to the level of satisfaction. Materials and Methods: This study was embedded in a multicenter randomized controlled trial with 205 patients randomized into two groups. Rehabilitation intervention was the same for both groups; only approach for service delivery differed (telerehabilitation or home visits). Participants were assessed at baseline (before TKA), at hospital discharge, and at 2 and 4 months postdischarge (E4) using functional outcomes. Patient satisfaction was measured using the validated Health Care Satisfaction Questionnaire (HCSQ) at E4. Results: Characteristics of all participants were similar at baseline. Satisfaction level of both groups did not differ and was very high (over 85%). It was neither correlated to personal characteristics nor to improvements of functional level from preoperative to E4. Satisfaction was rather found associated to walking and stair-climbing performances. Conclusions: These results, in conjunction with evidences of clinical effectiveness and cost benefits demonstrated in the same sample of patients, strongly support the use of telerehabilitation to improve access to rehabilitation services and efficiency of service delivery after TKA.

Introduction

In-home telerehabilitation can be defined as rehabilitation services delivered at home from a remote location through a telecommunication system and information technology.¹ This innovative way of delivering rehabilitation services has been the source of growing interest in the healthcare community, especially because of its potential for reducing costs, for improving access to services, and for increasing efficiency of delivering rehabilitation services to the community.^2,3 Rehabilitation telecare has been trialled successfully for people with various medical conditions as follows: patients who have had a stroke,⁴ breast cancer,⁵ cardiopulmonary diseases,⁶ etc. Telerehabilitation represents a promising solution for more cost-effective rehabilitation programs for community-based physical therapists burdened by the large number of total knee arthroplasties (TKAs) performed each year in Quebec, Canada.⁷

Some studies have indeed demonstrated that telerehabilitation after TKA is effective,^8
–10 and our team has recently demonstrated in a large group clinical effectiveness and noninferiority to regular face-to-face interventions.¹¹ Providing rehabilitation telecare can however endeavor many challenges such as user-friendliness of the equipment, technical reliability, constancy of the communication network, etc. Beyond technicalities, some patients might also feel preoccupied by the quality of a distant therapeutic relationship. Those variables may be in relation with the perceived satisfaction of the users of rehabilitation services. Indeed, satisfaction in healthcare management can be described as both a healthcare recipient's cognitive evaluation and an emotional response to his or her experience of healthcare.¹²

Modern conceptualization of satisfaction recognizes both one's legitimate expectation of having his needs met and his perception of the actual experience.^13,14 Despite some controversies,^15,16 satisfaction has often been used as one of the important indicators of quality in healthcare, as it can both influence adherence to treatment plan and improve clinical outcomes.¹² However, the concept of satisfaction is complex and appears to be related to various aspects of healthcare such as availability of resources, qualification of healthcare professionals, the relationship between the patient and the therapist, and the overall organization of care.¹⁷ This is particularly true after TKA. A Becker et al. study showed that it is the combination of physical and mental well-being that determines postsurgical outcomes.¹⁸

Satisfaction levels toward telerehabilitation from users have shown to be good despite the thought-out obstacles.^19,20 However, satisfaction of patients toward in-home telerehabilitation after TKA has not yet been examined thoroughly in large-scale clinical trials, yet it appears to be critical to adopt such services widely. The main objective of the present study was to compare the level of satisfaction regarding the received rehabilitation between patients after an in-home telerehabilitation program following TKA and patients following a usual face-to-face home visit program. Secondarily, it was aimed to determine if any of the clinical and personal variables were associated to the level of satisfaction.

Materials and Methods

Design Overview

The present study was embedded in a large, multicenter randomized controlled trial evaluating the noninferiority of telerehabilitation interventions compared with face-to-face home visits after TKA.¹¹ The trial was registered at www.controlled-trials.com with the International Standard Randomized Controlled Trial Number ISRCTN66285945. This study was approved by the ethics committee of each participating hospital, and written consent was obtained for all participants.

Setting and Participants

People on a surgical waitlist for a TKA were recruited from eight different hospitals in the province of Quebec, Canada. Potential participants were approached by the hospital physiotherapist to determine their interest in engaging in the study. Patients were included if they met the following criteria: (1) waiting for a primary TKA after a diagnosis of osteoarthritis, (2) returning back home after hospital discharge, (3) living in an area served by high-speed Internet services (at least 512 kilobits per second [Kbps] in upload), and (4) living within a 1-h driving distance from the treating hospital. Patients were excluded if they: (1) had significant health conditions that could impede with tests or the rehabilitation program, including lower limb surgery in the last 9 months, (2) were planning a second lower limb surgery within 4 months, (3) had cognitive or collaboration problems, (4) had major postoperative complications, or (5) had weight-bearing restrictions for a period longer than 2 weeks after surgery.

Randomization and Interventions

After the surgery and just before their hospital discharge, the participants were block randomized into two groups as follows: telerehabilitation (TELE) group or home visits (STD) group. During their participation to the project, all participants received a total of four assessments: a baseline evaluation before surgery (E1), one at hospital discharge (E2), another after physiotherapy interventions (E3), and a last one at 4-months postdischarge (E4). An independent assessor conducted the evaluations at the local research center and remained blinded to group allocation at all times. The physiotherapy intervention program was similar for both groups; it was based on a functional approach (mobility, strengthening, gait and transfer training, and balance). Sixteen interventions of 45- to 60-min duration were planned biweekly during an 8-week period. A home-exercise program was instructed by the therapist at the end of each treatment. Exercise difficulty and intensity were customized according to patient's tolerance.

The telerehabilitation program was delivered using a technological platform that included various components installed at the patient's home and the clinician site. The core of the platform was a videoconferencing system (Tandberg 550 MXP; Cisco Systems, San Jose, CA) with a pan-tilt-zoom (PTZ) clinician-controlled camera with wide-angle lens and omnidirectional microphone. On the patient side, the videoconferencing system was mounted over a 20″ LCD screen with external speakers. Connections and camera functions were controlled remotely by the clinician using a dedicated software interface running on a computer. Video and audio data were encrypted and transmitted over a high-speed Internet connection to allow real-time two-way interactions. This platform has been tested and was described in previous studies.^7,10,11 As for the interventions of the STD group, the physiotherapists travelled by car to deliver the treatment sessions in the patient's home.

Outcomes

Satisfaction

Patient satisfaction for received healthcare services was measured using the validated Health Care Satisfaction Questionnaire (HCSQ), in either French or English versions, accordingly.²¹ This questionnaire was developed using a clear conceptualization of satisfaction, including both dimensions of perceived performance and expectation assessment.²¹ It assesses satisfaction through three different dimensions: satisfaction with the relationship with the professional (D1), satisfaction with the delivery of services (D2), and satisfaction with the organization of services (D3). The questionnaire includes a total of 23 items. Each item was first assessed using the question “Do you feel that …” to assess participant's perceived performance of received services and afterward using the question “How important is that …” to assess participant's expectations regarding each item. The items were answered using a 4-point Likert scale to describe their satisfaction level, where “1” represented “not at all” and “4,” “extremely.” The scores for perceived performance (P) and for expectations (E) were afterward combined using this formula: E (2P − E), which produces an item product reflecting the two main elements from which satisfaction is composed. The HCSQ shows good internal consistency (Cronbach's alpha coefficient = 0.9) and good test-retest reliability (Intraclass Correlation Coefficient .72 [95% confidence interval = 0.5–0.8]) for the overall scale. This questionnaire was only administered at E4 (4 months after hospital discharge), where investigators were still blinded to group allocation of the participants.

Function

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC version 5, LK3.1) was used as a primary outcome to rate knee function in relation to pain, stiffness, and general function.²² The Knee injury and Osteoarthritis Outcome Score (KOOS), a questionnaire which was used as a secondary outcome addressing symptoms, function in activities of daily living (ADLs), sports and recreational activities, and quality of life of patients with knee disorders.²³ Other secondary functional outcomes were performance on the Six-minute walk test^24,25 and the Timed stair test.²⁶ Range of motion of operated knee in flexion and extension using goniometry²⁷ and maximal isometric pain-free strength of knee flexors and extensors using Biodex dynamometry²⁸ were also measured. All functional measures were assessed at E1, E3, and E4, except for Biodex dynamometry, which was not conducted at E3.

Statistical Analysis

Descriptive statistics for each baseline characteristics of the participants and the functional outcomes was used to detail the two samples. Student t tests were used to compare both groups upon their baseline characteristics. As a precaution, two analyses were conducted to compare the level of satisfaction of the STD and TELE groups. First, nonparametric (Wilcoxon rank sum tests) analyses were used since normal distribution could not be assumed for our variables. Second, because of the large sample size, parametric (Student t tests) analyses were additionally run to confirm the initial findings. For the association analyses, Pearson correlation coefficients were used between personal and clinical continuous variables. To avoid a very large number of correlations in studying the relationship between satisfaction and clinical characteristics, we first verified whether the correlation between satisfaction and clinical characteristics had to be tested within each group or in two groups combined. This was achieved by adjusting linear regression models using, one at a time, each satisfaction variable as the dependent variable and each clinical characteristic as the independent variable together with group membership and adding an interaction term between group and clinical characteristic. If an interaction term was found significant, it provided evidence that the relationship between clinical characteristics and satisfaction depended on the group membership, whereas a nonsignificant interaction implied that the relationship could be tested in the whole sample. All analyses were performed using SAS 9.3 software (SAS Institute, Inc., Cary, NC).

Role of the Funding Source

This project was funded by the Canadian Institutes of Health Research (CIHR). The source of funding did not play a role in the investigation.

Results

A total of N = 205 subjects were randomized and 198 completed the study. Baseline characteristics were similar between groups for most variables such as age (STD: 67 ± 8, TELE: 65 ± 8 years, p value: 0.13), gender (male; STD: 55%, TELE: 42%, p value: 0.06), operated knee (right-knee operated; STD: 51%, TELE: 48%, p value: 0.63), and body mass index (BMI; STD: 33 ± 6, TELE: 34 ± 7, p value: 0.13). Some differences were observed for a few variables; significantly, more subjects from the TELE group were living alone (STD: 10%, TELE: 21%, p value: 0.03) and were having asthma (STD: 8%, TELE: 18%, p value: 0.03) and depression (STD: 7%, TELE: 16%, p value: 0.04) as comorbid conditions. Functional measures such as total score to the WOMAC questionnaire (STD: 54 ± 17, TELE: 53% ± 19%, p value: 0.73), distance on the Six-minute walk test (STD: 348 ± 110, TELE: 324 ± 123 m, p value: 0.15), range of motion for knee flexion (STD: 115 ± 13, TELE: 114° ± 15°, p value: 0.56), and extension (STD: −6 ± 6, TELE: −5° ± 5°, p value: 0.34) were all similar at baseline between groups except for the slightly longer time taken by the TELE group for the Timed stair test (STD: 37 ± 18, TELE: 44 ± 33 s, p value: 0.04). To consult the flow diagram for this study and additional group baseline characteristics, please refer to Moffet et al.¹¹

The results for the satisfaction level of each group are found in Table 1. Twelve questions (Nos. 1–3, 9, 12, 14, 16–21) were related to the first dimension on relationship with the professional, six questions (Nos. 6, 10–11, 13, 22–23) reflected the second dimension on delivery of services, and five questions (Nos. 4–5, 7–8, 15) concerned the third dimension on organization of services. To be included in the per-protocol analysis, subjects had to have completed the four planned evaluations (E1−E4) and at least 75% of the treatment sessions. N = 182 participants (N = 84 in TELE group and N = 98 in STD group) could be included in this analysis. There were no significant differences between groups for each individual dimension of perceived performance (satisfaction scores), nor for total score (Table 1). Similar results were obtained from analyses with Student t tests. The mean satisfaction score for each question ranged between 3.2 and 3.8 for the STD group and between 3.1 and 3.8 for the TELE group. The lowest score for both groups (3.2 and 3.1) was found for the same question: “the professionals encourage you to get support from your family and friends.” Only five questions had scores <3.5/4 for the STD group and six for the TELE group. The mean importance score for each question ranged between 3.0 and 3.6 for the STD group and 2.8 and 3.5 for the TELE group. The lowest score was again found at the same question for both groups: “the professionals encourage you to get support from your family and friends.” For item product between performance and expectations (combined scores), no significant differences were found for any of the questions of the HCSQ as can be observed in Table 2. Range of combined scores in percent for individual questions was 77.2–92.2 for STD group and 73.6–91.1 for TELE group.

Table 1.

Comparison of Perceived Satisfaction at the Health Care Satisfaction Questionnaire Between Groups at Four Months After Hospital Discharge (E4)

	STD GROUP N = 98			TELE GROUP N = 84			WILCOXON TEST (TWO SIDED)
	N	Mean	SD	N	Mean	SD	Z	p
Satisfaction scores (%)
Relationship with the professional	98	92.6	9.1	82	91.3	9.4	−1.1	0.27
Delivery of services	96	85.8	13.3	78	84.6	11.9	−0.9	0.38
Organization of services	97	90.4	10.9	82	90.0	10.5	−0.5	0.59
Total	98	90.3	9.9	82	89.3	9.6	−1.0	0.34
Importance scores (%)
Relationship with the professional	98	87.0	12.9	83	83.8	14.1	−1.7	0.09
Delivery of services	98	82.1	13.4	82	78.8	14.4	−1.6	0.10
Organization of services	96	85.0	12.7	83	82.2	14.2	−1.4	0.17
Total	98	85.3	12.3	83	82.1	13.7	−1.6	0.10

SD, standard deviation.

Table 2.

Comparison of Combined Satisfaction Scores at the Health Care Satisfaction Questionnaire Between Groups at Four Months After Hospital Discharge (E4)

	STD GROUP N = 98			TELE GROUP N = 84			WILCOXON (TWO SIDED)
	N	MEAN	SD	N	MEAN	SD	Z	p
Scores to individual questions of the HCSQ (%)
1. The professionals treat you with respect	98	90.1	13.4	82	88.5	13.6	−1.1	0.27
2. The professionals respect your privacy	98	90.4	12.7	82	87.8	13.5	−1.4	0.16
3. The professionals treat your information confidentially	96	88.5	13.7	80	87.4	14.1	−0.6	0.57
4. You don't have to go through too many steps when you want to contact a professional	94	86.5	15.7	79	87.0	15.8	0.1	0.90
5. You didn't have to go through too many steps when you wanted to get help	93	84.0	18.3	79	85.9	16.5	0.3	0.79
6. The professionals inform you about the available services	96	83.1	19.9	81	80.7	17.8	−1.1	0.28
7. The appointments you make with the professionals are obtained quickly	96	87.8	13.7	81	87.5	15.3	−0.1	0.94
8. The professionals take the necessary time to take care of you	97	91.6	15.3	82	90.1	13.8	−1.3	0.19
9. The professionals you met take your problem seriously	98	89.8	14.8	82	87.3	14.4	−1.6	0.11
10. The professionals encourage you to get support from your family and friends	91	77.2	20.2	77	73.6	19.6	−1.1	0.26
11. The professionals take your lifestyle into account	97	82.1	16.5	79	81.4	15.6	−0.5	0.64
12. The professionals talk to you in words you can understand	98	90.1	13.0	83	87.3	14.4	−1.6	0.11
13. The professionals give you all the information you need about where to go, what to do, and what not to do	98	87.7	18.4	82	88.1	14.3	−0.7	0.50
14. The same professional looks after you each time	98	87.8	15.0	82	85.7	16.2	−1.0	0.33
15. The professionals are accessible at times that are convenient for you	98	85.6	15.7	83	82.1	16.2	−1.5	0.14
16. The professionals you met seem competent	97	91.6	13.7	83	91.1	13.1	−0.7	0.51
17. The professionals really understand your needs	97	86.6	16.9	83	85.4	14.7	−0.9	0.35
18. The professionals are courteous	98	92.2	11.7	83	89.8	12.7	−1.8	0.08
19. You can trust the professionals	97	91.3	13.8	83	89.3	13.7	−1.5	0.14
20. You receive honest answers to your questions	98	91.2	13.1	83	87.3	14.4	−1.8	0.07
21. The professionals show a sense of responsibility toward you	98	87.6	16.5	83	86.5	14.7	−0.8	0.44
22. The professionals tell you about the different choices you have	97	79.8	20.4	79	75.5	18.6	−1.8	0.07
23. The professionals give you advice regarding how to prevent a problem from recurring	94	84.8	19.1	79	84.5	14.9	−0.5	0.61

HCSQ, Health Care Satisfaction Questionnaire.

As for the results from association analyses, it was first demonstrated that no significant interaction was present in the regression modeling, and therefore, correlations between personal or clinical characteristics and level of satisfaction are presented only for the two groups combined. It was determined that only few characteristics appear correlated to satisfaction. Some of these correlation analyses are detailed in Table 3. Two functional measures from E3 and E4 were associated to the level of satisfaction: the Six-minute walk test and the Timed stair test. The Six-minute walk test was positively correlated to the relationship with the professional dimension, the organization of services dimension, and with satisfaction's total score. The Timed stair test was negatively correlated to satisfaction of the relationship with the professional dimension, organization of services, and total score for satisfaction, meaning that the longer the time taken to execute the Timed stair test (less functional), the less satisfied the participants were. Positive correlation coefficients of significant probability ranged between 0.2 and 0.3, while negative correlation coefficients ranged from −0.2 to −0.3, all being fairly low correlation coefficients. No significant correlation was found regarding gains from preoperative values (E1) to 4 months postdischarge (E4). No significant relationship between satisfaction and personal characteristics of participants such as age, gender, or BMI was found either.

Table 3.

Association Between Clinical Characteristics and Level of Satisfaction in the Whole Sample of Participants (n = 182), at the End of the Intervention Period (E3) and Two Months Later (E4)

	SATISFACTION SCORES (%)
CLINICAL CHARACTERISTICS	RELATIONSHIP WITH THE PROFESSIONAL	DELIVERY OF SERVICES	ORGANIZATION OF SERVICES	TOTAL
E3
WOMAC (%)
Pain	0.01^a	0.10^a	0.16^a,b	0.10^a
Stiffness	0.07	0.07	0.12	0.11
Function	0.08	0.12	0.22^c	0.17^b
Total	0.07	0.11	0.20^c	0.15^b
KOOS (%)
Symptoms	0.09	0.15^b	0.14	0.15^b
Pain	0.06	0.15	0.21^c	0.15^b
Activities of daily living	0.05	0.13	0.16^b	0.11
Sports and recreational activities	0.06	0.08	0.02	0.06
Quality of life	−0.02	0.03	0.10	0.05
Six-minute walk test (m)	0.26^d	0.11	0.23^c	0.24^c
Timed stair test (s)	−0.19^b	−0.06	−0.15^b	−0.17^b
Range of motion of involved knee (°)
Flexion	0.10	0.05	0.11	0.11
Extension	0.00	0.11	0.03	0.05
E4
WOMAC (%)
Pain	−0.02	0.01	0.04	0.02
Stiffness	0.08	0.04	0.15^b	0.10
Function	0.01	0.01	0.12	0.06
Total	0.02	0.02	0.12	0.07
KOOS (%)
Symptoms	0.12	0.11	0.15^b	0.16^b
Pain	0.03	0.07	0.11	0.09
Activities of daily living	0.02	0.02	0.13	0.07
Sports and recreational activities	0.08	0.09	0.01	0.09
Quality of life	−0.02	0.05	0.13	0.06
Six-minute walk test (m)	0.22^c	0.11	0.20^c	0.20^c
Timed stair test (s)	−0.21^c	−0.08	−0.16^b	−0.18^b
Range of motion of involved knee (°)
Flexion	0.05	−0.00	0.05	0.04
Extension	0.06	0.07	0.08	0.08
Isometric strength of involved knee (Nm)
In flexion at 60° of flexion	0.01	−0.01	0.02	0.01
In flexion at 30° of flexion	0.04	−0.04	0.01	0.01
In extension at 60° of flexion	0.02	−0.01	0.00	0.00
In extension at 30° of flexion	−0.04	−0.06	−0.03	−0.05

Values represent Pearson correlation coefficients (r).

Probability: ^b p < 0.05; ^c p < 0.01; ^d p < 0.001.

KOOS, Knee injury and Osteoarthritis Outcome Score; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Discussion

This embedded study aimed at comparing the level of satisfaction toward treatments of patients receiving in-home telerehabilitation post TKA to standard face-to-face interventions using the HCSQ questionnaire. It has been raised before as to how measurement of satisfaction can be biased by not addressing the dual nature of satisfaction, meaning both patients' expectations and perceived performance.^12,29 Moreover, the aspects of relationship with the professional, of service delivery, and of services' organization are all essential components of an operationalized definition of satisfaction.^21,30 A review by Kairy et al. mentioned the lack of measures of satisfaction that are robust and standardized in the articles studying telerehabilitation for various physical disabilities.³¹ In the present study, a valid measure of satisfaction addressing three acknowledged dimensions of satisfaction was used; therefore, we are confident that our results reflect multiple components of the satisfaction concept. We can confirm from our results that the patients' level of satisfaction after using telerehabilitation for TKA was comparable to patients receiving face-to-face interventions. This is in accordance to what other studies have concluded about the satisfaction of telerehabilitation users for their rehabilitation interventions after other conditions such as stroke¹⁹ or shoulder surgery.³² The results from this study are limited to people receiving TKA for knee arthroplasty, and the applicability of telerehabilitation for any patient must be examined carefully by both health professionals and caregivers involved. However, this is the first study that we know of that determines the level of satisfaction of users of telerehabilitation after TKA in a large sample using a multidimensional measure of satisfaction. Telerehabilitation after TKA is supported by strong evidence on the effectiveness of such intervention¹¹ and from a cost-effectiveness point of view also.⁷ All these results support the use of interventions from a remote location for post TKA rehabilitation from a user's satisfaction standpoint.

Secondarily, it was aimed to determine which clinical or personal variables for the whole sample were associated to the level of satisfaction. In this study, no correlation was established between satisfaction and personal characteristics such as age, gender, or BMI. The absence of correlation presented in this study between age and satisfaction level is in disagreement to what other studies have reported before for other populations. Age was related to satisfaction levels toward various healthcare services, where older patients seemed more satisfied than younger patients.^33
–35 This appears to not be the case for the TKA population of the present study. However, age range of our sample was smaller than in most of these previously published studies, which may also explain this discrepancy. Some studies have also reported greater dissatisfaction from patients after TKA if they had complained of higher preoperative knee pain,³⁶ which was not the case in our study. In addition, it has been demonstrated previously that the greater the improvements on functional questionnaires such WOMAC and KOOS, the greater the level of satisfaction of the patients.³⁶ In our study, however, the variables presenting the strongest associations to the level of satisfaction were from functional tests (i.e., Six-minute walk test distance, time on the Timed stair test, etc.). This is in agreement with what was published by Vissers et al., where the Six-minute walk test distance achieved by the participants 6 months after TKA was significantly different between the “satisfied” group and the “less satisfied” group.³⁷ We did not observe any significant correlation between the level of satisfaction and the gains from preoperative to 4 months' postoperative function. Other authors have reported that greater dissatisfaction after TKA was mostly linked to organization of service elements such as shorter treatment duration and relationship with the professional elements, such as having the same professional doing all the treatments.³⁸ In the present study, high satisfaction demonstrated by a combined score on HCSQ >85% was found in the two groups for both of these aspects.

In conclusion, a comparison of the level of satisfaction between patients receiving in-home telerehabilitation after TKA to face-to-face rehabilitation demonstrated that both groups had a similar level of satisfaction regarding delivery of healthcare services. This level of satisfaction was not correlated to personal characteristics such as age and BMI nor from improvements of functional level from preoperative function to 4 months post hospital discharge. Satisfaction was rather found associated to locomotive performances in tasks such as walking and climbing stairs. These results, in conjunction with evidences of clinical efficacy and cost benefits demonstrated in the same sample of subjects,^7,11 strongly support the use of telerehabilitation to improve access to rehabilitation services and efficiency of service delivery after TKA.

Footnotes

Acknowledgments

The authors are grateful to all participants, physical therapists, and orthopedic surgeons of each participating center for their contributions to this study. The authors also thank the research personnel for their assistance in the study coordination, data management, and analysis.

Disclosure Statement

No competing financial interests exist.

References

Bashshur

, et al. The taxonomy of telemedicine. Telemed J E Health, 2011; 17:484–494.

Lingard

, Berven

, Katz

. Management and care of patients undergoing total knee arthroplasty: Variations across different health care settings. Arthritis Care Res, 2000; 13:129–136.

Naylor

, et al. Status of physiotherapy rehabilitation after total knee replacement in Australia. Physiother Res Int, 2006; 11:35–47.

Lloréns

, et al. Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for balance recovery after stroke: A randomized controlled trial. Arch Phys Med Rehabil, 2015; 96:418–425.e2.

Galiano-Castillo

, et al. Telehealth system (e-CUIDATE) to improve quality of life in breast cancer survivors: Rationale and study protocol for a randomized clinical trial. Trials, 2013; 14:187.

Hwang

, et al. A systematic review of the effects of telerehabilitation in patients with cardiopulmonary diseases. J Cardiopulm Rehabil Prev, 2015; 35:380–389.

Tousignant

, Moffet

. Cost analysis of in-home telerehabilitation for post-knee arthroplasty. J Med Internet Res, 2015; 17:e83.

Russell

. Telerehabilitation: A coming of age. Aust J Physiother, 2009; 55:5–6.

Russell

, et al. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: A randomized controlled trial. J Bone Joint Surg Am, 2011; 93:113–120.

10.

Tousignant

, et al. A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare, 2011; 17:195–198.

11.

Moffet

, et al. In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: A noninferiority randomized controlled trial. J Bone Joint Surg Am, 2015; 97:1129–1141.

12.

Shirley

, Sanders

. Patient satisfaction: Implications and predictors of success. J Bone Joint Surg Am, 2013; 95:e69.

13.

Pascoe

. Patient satisfaction in primary health care: A literature review and analysis. Eval Program Plann, 1983; 6:185–210.

14.

Jackson

, Chamberlin

, Kroenke

. Predictors of patient satisfaction. Soc Sci Med, 2001; 52:609–620.

15.

Chang

, et al. Patients' global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med, 2006; 144:665–672.

16.

Fenton

, et al. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med, 2012; 172:405–411.

17.

Donabedian

. The quality of care. How can it be assessed?. JAMA, 1988; 260:1743–1748.

18.

Becker

, et al. Expectation, satisfaction and clinical outcome of patients after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2011; 19:1433–1441.

19.

Piron

, et al. Satisfaction with care in post-stroke patients undergoing a telerehabilitation programme at home. J Telemed Telecare, 2008; 14:257–260.

20.

Tousignant

, et al. Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: An embedded study in a randomized trial. Telemed J E Health, 2011; 17:376–382.

21.

Gagnon

, et al. Development and validation of the Health Care Satisfaction Questionnaire (HCSQ) in elders. J Nurs Meas, 2006; 14:190–204.

22.

McConnell

, Kolopack

, Davis

. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): A review of its utility and measurement properties. Arthritis Rheum, 2001; 45:453–461.

23.

Roos

, et al. Knee Injury and Osteoarthritis Outcome Score (KOOS)—Development of a self-administered outcome measure. J Orthop Sports Phys Ther, 1998; 28:88–96.

24.

Guyatt

, et al. The 6-minute walk: A new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J, 1985; 132:919–923.

25.

Parent

, Moffet

. Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch Phys Med Rehabil, 2002; 83:70–80.

26.

Perron

, Malouin

, Moffet

. Assessing advanced locomotor recovery after total hip arthroplasty with the timed stair test. Clin Rehabil, 2003; 17:780–786.

27.

Ebert

, Munsie

, Joss

. Guidelines for the early restoration of active knee flexion after total knee arthroplasty: Implications for rehabilitation and early intervention. Arch Phys Med Rehabil, 2014; 95:1135–1140.

28.

Gagnon

, et al. Reliability and validity of static knee strength measurements obtained with a chair-fixed dynamometer in subjects with hip or knee arthroplasty. Arch Phys Med Rehabil, 2005; 86:1998–2008.

29.

Oliver

. Cognitive, affective, and attribute bases of the satisfaction response. J Cons Res, 1993; 20:418–430.

30.

Hall

, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Phys Ther, 2010; 90:1099–1110.

31.

Kairy

, et al. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil, 2009; 31:427–447.

32.

Eriksson

, Lindstrom

, Ekenberg

. Patients' experiences of telerehabilitation at home after shoulder joint replacement. J Telemed Telecare, 2011; 17:25–30.

33.

Rahmqvist

, Bara

. Patient characteristics and quality dimensions related to patient satisfaction. Int J Qual Health Care, 2010; 22:86–92.

34.

Jaipaul

, Rosenthal

. Are older patients more satisfied with hospital care than younger patients?. J Gen Intern Med, 2003; 18:23–30.

35.

Young

, Meterko

, Desai

. Patient satisfaction with hospital care: Effects of demographic and institutional characteristics. Med Care, 2000; 38:325–334.

36.

Bourne

, et al. Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not?. Clin Orthop Relat Res, 2010; 468:57–63.

37.

Vissers

, et al. Functional capacity and actual daily activity do not contribute to patient satisfaction after total knee arthroplasty. BMC Musculoskelet Disord, 2010; 11:121.

38.

Johnson

, et al. Patient dissatisfaction with rehabilitation following primary total knee arthroplasty. J Knee Surg, 2013; 26:417–421.