A comparative evaluation of organizational models of physiotherapy through measures reported by patients

Abstract

Background: Identifying the value and quality of organisational models supports the performance of the overall healthcare system and the effectiveness of its processes.

Purpose: Based on an organizational case of physiotherapy care delivery, this study compares a traditional organizational model with the most recent fast-track approach within the total hip replacement (THR) surgery pathway.

Research Design: Through a Propensity Score Matching (PSM) application, the study aims to analysing the impact of two different models on patient-reported outcomes.

Study Sample: Patient-Reported Outcome Measures (PROMs) data collected between 2018 and 2023 through the PROMs Observatory in the Tuscany region (Italy) were used.

Results: The results, based on 417 responses, suggest that the two organizational models produce equivalent outcomes reported by patients’ voices at different timepoints, while the models have different organizational characteristics that result in increased allocative value in terms of shorter length of stay (LOS) and associated reduced resource use.

Conclusions: From a Lean Management perspective, the managers’ decision-making process is supported by evidence on the adoption of the most valuable organizational model using both clinical and organizational data from the patient’s point of view.

Keywords

PROMS organizational models physiotherapy fast-track lean management length of stay

Introduction

In healthcare facilities, organizational changes are sometimes introduced in the services provided which, although new compared to the past, are not necessarily better. However, such changes are pivotal in driving continuous improvement and adaptation to the evolving landscape of healthcare. Through effective change management, healthcare institutions should harness advancements in technologies, procedures, and clinical evidence to enhance patient care and outcomes through the fittest organizational model, ultimately creating added value to the system.¹ As in the tradition of Mintzberg studies, organizational models are configurations of structural and situational elements such as resources or processes that allow the general system to function accordingly with the rising needs. Increasing evidence supports that how these organizational elements are combined influences the quality of services and value perceived by the patients.^1,2

In this regard, Lean Management promotes the central role of the patient as the cornerstone of the continuous renewal of healthcare value.¹ The primary focus area for the Lean approach should be quality, safety, access, and the overall care experience, as these are the most important aspects from the patient’s perspective.¹ Care providers should prioritize the integration of patient’s perspective in Lean healthcare by defining value and improving value streams based on both clinical expertise and patient preferences.³ In this sense, as healthcare organizations serve the needs of patients, it is suggested that organizational change and possible model innovations should be measured primarily through the perspective of the most hierarchically important stakeholder: the patient in person.

Our study adopts the perspective of Lean Management by embracing its focus on maximizing value for the customer while minimizing waste. The classic formulation of Lean is based on five core principles, first introduced by James Womack and Daniel Jones in Lean Thinking.⁴ They include: (i) value definition in from the customer’s perspective; (ii) value stream, which is aimed at identifying all the steps involved in delivering the product or service and distinguish between value-adding and non-value-adding steps (waste); (iii) flow that is ensuring that the value-creating steps flow smoothly without interruptions or delays; (iv) pull that means production of only what is needed, when it is needed, and in the amount needed; and (v) perfection (Kaizen), which strives for continuous improvement in all areas of the organization. Accordingly, our study is grounded in the Lean Management approach, as it emphasizes the identification and comparison of organizational models based on their ability to maximize value for the patient while minimizing waste. By focusing on outcomes reported directly by patients (i.e. the PROMs) and measuring resource use (e.g. the length of stay), the analysis supports data-driven decision-making aimed at improving flow and efficiency within the surgical care pathway. The comparison of traditional and fast-track models reflects Lean’s core principles of value definition, process optimization, and continuous improvement in healthcare delivery.⁴

The case of the fast-track model usage after orthopaedic surgery for osteoarthritis (OA) represents a critical change in physiotherapy inside rehabilitation care delivery. The aging of the population has increasingly affected the prevalence of OA⁵ and, consequently, costs associated with related interventions, such as Total Hip Replacement Surgery (THR). Indeed, OA is a common and debilitating disease, with a prevalence in the population ranging from 12.3% to 21.6% that is among the main causes of disability and absence from work in most Western countries, implying high costs of care and a relevant social impact as well.⁶ In Italy, the most recent data report that 130.407 hospitalizations for hip replacement were managed in 2023. In the same year, 3741 elective hip replacements were performed in the Tuscany region. Thus, the relevance of assuring a good and quick restoration of functionalities and quality of life to patients undergoing elective THR is self-evident also at the social and economic levels.⁷

By streamlining the pathway from surgery to physiotherapy care, fast-track approach aims to optimize patient outcomes, reduce wait times, and improve resource utilization.⁸ Through multidisciplinary collaboration and patient-centered care principles and education, this model ensures, over the traditional approach, that patients receive timely interventions tailored to their individual needs, enhancing their functional outcomes and ultimately their quality of life. Fast-track programs are based on surgical methods that allow for rapid rehabilitation of functional abilities and clinical outcomes that result in the shortest possible hospital stay as a logistical improvement.⁹

Background

While THR is considered the gold standard treatment for OA, also for evidence of cost-effectiveness,¹⁰ several organizational aspects can influence the short-term outcome after that surgery. From an organizational model perspective, physiotherapy is the accepted standard and the pathway step that follows THR surgery, in order to maximizing joint functionality and minimizing complications.¹¹ However, there is mixed evidence on whether and how the physiotherapy affects the THR outcomes.¹²

On the one side, the literature suggests that early mobilization of patients during the hospital stay improves walking capabilities and functional mobility,¹³ and reduces other complications and consequent hospital stay.¹⁴ Departments adopting fast-track hip arthroplasty present a short length of stay and facilitate quick rehabilitation.¹⁵ Current physiotherapy’s emphasis on proactive healthcare models has led to a shift towards early intervention and patient empowerment, aligning with the principles of patient-centered care thus proposing more and more organizational models such as fast-track over traditional. In particular, the mobilization on the day of THR surgery reduces the length of stay,¹⁶ while later initiation of rehabilitation was associated with a higher probability of 90-days readmission in hip arthroplasty.¹² Other studies emphasize the need for rehabilitation to optimize patient outcomes and satisfaction before and after surgery and to reduce healthcare costs.¹⁷ A recent review underlines that ongoing rehabilitation after discharge is among the successful strategies for defining an efficient and effective patient pathway of arthroplasty surgery, considering the so-called “outpatient arthroplasty”.¹¹

On the other side, the value of additional rehabilitation interventions during the immediate inpatient period is not proven and evidence is fragmented, while physiotherapy at home or in groups after surgery has been shown to improve outcomes.¹³ Regarding physiotherapy after discharge, a recent clinical trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physiotherapy may not be required.¹⁸ Moreover, there is a high variability among the healthcare organizations or professionals’ approach to post-discharge rehabilitation.¹⁹ In the UK, referral to outpatient physiotherapy following THR is not a routine pathway of care: ongoing physiotherapy is usually provided depending upon clinical needs.²⁰ Efforts have been made by some countries to develop physiotherapy guidelines, to ensure that patients receive appropriate rehabilitative care. In USA and Canada, expert clinicians, researchers, and patients have been involved in defining key recommendations for post-acute rehabilitation after primary THA.²¹ Furthermore, orthopaedic professionals and associations of physiotherpay are working on developing quality indicators to guide clinical practice and health service delivery specific for THR rehabilitation.²²

Nevertheless since clinical effectiveness evidence is uncertain, the organizational side could add valuable insights to support the rehabilitative phase. Therefore, the opportunity to introduce and maintain a fast-track model for THR surgery rehabilitation has been especially crucial in light of the significant disruptions to elective surgeries during the initial phase of the COVID-19 pandemic. With a widespread reduction of over 30% in elective surgeries, healthcare systems were compelled to prioritize urgent and essential procedures, resulting in prolonged waiting lists and increased disease burden for individuals suffering from conditions such as OA.^23,24 The fast-track approach emerges as a particularly advantageous organizational choice in this context, offering a more efficient alternative to traditional rehabilitation methods in accelerating patients’ recovery²⁵ together with other factors based on demographic, societal, and clinical data.²⁶ By expediting post-operative recovery and enabling earlier discharge, the fast-track model helps alleviate the backlog of elective surgeries while providing timely care for patients with functional constraint conditions. Moreover, this approach minimizes the strain on healthcare resources and reduces the risk of disease transmission within healthcare facilities, contributing to the overall resilience and sustainability of the healthcare system among the ongoing challenges posed by emergencies.

The fast-track organizational model, characterized by its emphasis on accelerated recovery and early discharge, aligns perfectly with value-adding and waste reduction objectives. By implementing a fast-track approach when clinically appropriate, healthcare facilities can continue to optimize resource utilization, reduce the burden on hospitals also after the pandemic has passed, enhance patient safety by minimizing the duration of hospital stays, and ensure their daily life functionality.

This paper examines the impact of adopting a fast-track physiotherapy protocol versus a traditional one on patient-reported outcomes, with the aim of determining whether implementing this approach can enhance the health status of patients undergoing THR surgery and reduce associated organizational waste.

Methods

The main difference between a traditional approach to physiotherapy and a fast-track approach occur in the early stages, which take place within the hospital setting (Table 1).

Table 1.

Approaches to post-operative care following total hip replacement (THR) in traditional physiotherapy and fast-track pathways.

Organizational model characteristics	Traditional path	Fast-track
Rehabilitation progression	Gradual progression through postoperative phases of recovery, often spanning weeks to months	Rapid progression through postoperative phases of recovery, with a focus on achieving functional milestones quickly
Hospital stay	Longer hospital stay, typically several days to a week or more after surgery	Shorter hospital stay, often discharged within a few days post-surgery
Recovery timeline	Emphasis on cautious mobilization and limited weight-bearing initially	Early mobilization and weight-bearing are encouraged shortly after surgery, sometimes within hours
Mobilization	Gradual mobility exercises focused on gradual improvement of strength, range of motion, and functional abilities	Early mobilization, pain management, and rapid return to normal activities with rapid restoration of strength, range of motion, and functional independence
Functionality	Gradual and over an extended period	Swift recovery and early return to function
Anesthesia	Pain management based on traditional modalities	Enhanced pain management techniques (such as local anesthesia) to facilitate early mobilization and discomfort minimization
Patients’ participation	Caution with close monitoring for complications or setbacks	Emphasis on patient education and empowerment to actively participate in their recovery process

Data collected from 2018 to 2023 from the Patient-Reported Outcome Measures (PROMs) Observatory in Tuscany Region (Italy) were used. The Observatory was a regional web-based, longitudinal, and systematic initiative built to collect prospective and multi-site information on health care experience, outcomes and medical conditions directly reported by patients through longitudinal surveys.²⁷

The questionnaires also investigate sociodemographic characteristics and information on the experience with health care services along the multi-setting and multi-provider patient path before and after surgery. Similar to other studies,^28,29 the questionnaires follow the patient pathway, which is essential in the Lean process since optimizing the patient flow can play a pivotal role in triggering lean implementation.³⁰ As so, the questionnaires used in this study map several steps in the patient journey within the specific services they experience and the entire pathway, identifying what constitutes waste and what adds value.¹ The patient-reported measures are key indicators of quality that help in evaluating and improving performance in healthcare through value co-creation.^31,32 These measures have the power to give a multidimensional and multi-perspective value to traditional performance evaluation systems.^33,34 Patients’ measures have been increasingly integrated into clinical practice to be translated into valuable information to guide and improve the quality and value of patient care.^35–37 The measures on the experience with the health care services used in this study, extracted from questions inside the PROMs Observatory and therefore patient-reported, include several aspects such as the first day of rehabilitation in hospital, and the number of days of hospitalization, which allowed to compute the length of stay (LOS) in hospital. LOS was operationalised based on the literature,³⁸ considering discharge before or on day 5 and after. For robustness checks, we considered both LOS as a dichotomous variable (less than or equal to 5 days and more than 5 days) and on a 5-point scale (1 day, 2 days, 3 days, 4 days, 5 or more days).

Patients were divided into two cohorts based on their responses to the question about the timing of the start of rehabilitation. Patients who reported to have initiated their rehabilitation on the same day of the procedure were assigned to the fast-track cohort, whereas all other patients were assigned to the control cohort (i.e. traditional model). Patients older than 80 years of age were excluded from the analysis.³⁹

The key measure of THR outcome collected by the PROMs Observatory is the Oxford Hip Score (OHS) scale. It is monitored four times per patient⁴⁰ enrolment before surgery after clinical evaluation (T0), 30 days after surgery (T1), 6 months after surgery (T2) and 12 months after surgery (T3). Some other questions explore pre- and post-operative patient experience with several aspects, including the rehabilitative phase of physiotherapy.

The assessment of health status improvement was based on delta scores and delta change indexes. Delta scores are calculated as the difference between the follow-up and the baseline score, while a dummy variable has been used to verify the positive or negative change in this difference at each time point (0 if worsened or stable, +1 if improved).

A comparison of baseline characteristics between the two study cohorts was conducted using the Chi-square test for categorical variables, and Two-sample Kolmogorov–Smirnov test for continuous variables. To consider the influence of COVID-19 on rehabilitation models,²⁴ a control variable was introduced into the model. This variable categorizes patients into either the pre-COVID period or the post-COVID period. Patients who underwent THR before March 2020 were designated to the pre-COVID cohort, while those who underwent THR in or after March 2020 were assigned to the post-COVID cohort.

Propensity score matching (PSM) was computed via logistic regression to compare the two cohorts, based on the following variables: sex, age, comorbidities, baseline PROM score, Body Mass Index (BMI), and COVID-19.⁴¹ Outcome variables comprised delta scores at 30 days, 6 months, and 12 months, as well as delta change indexes. The Average Treatment Effect on the population (ATE) via PSM was assessed for these outcome variables. Patients were paired using nearest-neighbor matching, ensuring that each fast-track patient was matched with at least one control patient. The treatment effect on outcomes was then evaluated within the propensity score matched sub-sample.⁴²

Following the matching process, an assessment was conducted to ascertain whether the propensity score had produced a matched sample with comparable distributions of measured baseline covariates between treated and untreated subjects. T-tests were conducted to examine the equality of means in both treated and non-treated groups, while standardized biases were computed both before and after matching. These metrics were then compared to evaluate the goodness of the model. Furthermore, we conducted sensitivity analyses using Rosenbaum bounds.⁴³ All the analyses were performed using STATA 17 software.

Results

417 complete responses were valid for the analyses, with 59 patients treated according to the fast-track protocol and 358 patients initiated their rehabilitation the day after the surgery or later. Therefore, the post-hoc power analysis indicated a statistical power of 0.1057. Only 17 patients did not initiate physiotherapy during their hospitalization after surgery. Descriptive statistics on socio-demographic variables and outcome variables for the two cohorts are reported in Table 2.

Table 2.

Results from descriptive statistics on socio-demographic variables and outcome variables for the two considered patients’ cohorts.

	Fast-track	Traditional	p-value
N	59 (14%)	374 (86%)
Sex			0.545
Man	27 (46%)	187 (50%)
Woman	32 (54%)	187 (50%)
Age mean (Stdev)	65 (8.43)	64 (11.35)	0.442
Comorbidities			0.944
None	16 (27%)	94 (26%)
1	25 (42%)	151 (41%)
≥2	18 (30%)	120 (33%)
BMI mean (Stdev)	28.5 (4.4)	27.1 (4.3)	0.011
Nationality			0.827
Italian	58 (99%)	369 (99%)
Other	1 (1%)	5 (1%)
COVID-19			0.009
Pre-COVID	25 (42%)	226 (60%)
COVID	34 (58%)	148 (40%)
Baseline PROM score mean (Stdev)	18.5 (8.2)	19.6 (9.3)	0.389
LOS (dichotomic)			0.000
Less than or equal to 5 days	36 (92%)	93 (53%)
More than 5 days	3 (8%)	81 (47%)
LOS (5-point scale)			0.000
1 day	0 (0%)	1 (1%)
2 days	0 (0%)	0 (0%)
3 days	4 (10%)	7 (4%)
4 days	11 (28%)	18 (10%)
More than 5 days	24 (62%)	148 (85%)

As reported in Table 2, no significant differences were found regarding sex, age, comorbidities, and nationality between the two cohorts. The BMI significantly differs between the two groups, as does the assignment to the Pre- or Post-COVID group. Regarding the baseline PROMs’ score assessed at the enrolment before surgery, the two groups showed no significant difference. The LOS shows a clear and significant difference between the two groups, with 40% more patients experiencing hospital stays longer than 5 days in the cohort undergoing the traditional model of physiotherapy.

Figure 1 shows the differences in delta scores at the selected time points for the two cohorts of patients. Observing the box plots it is noted that the most significant improvement, reported as an increase in score, occurs between 30 days after surgery and 6 months.

Figure 1.

Differences in delta scores at the selected time points for the fast-track and control group (traditional) cohorts of patients.

A preliminary correlation analysis shows that no statistically significant difference is detected when comparing the delta scores at all the follow-up time points for patients assigned to the fast-track cohort and patients who initiated the rehabilitation the day after the surgery or later (i.e. traditional approach).

The findings from the PSM and calculation of selected patient-reported clinical outcomes are presented in Table 3. A total of 59 patients for the fast-track cohort were matched with 362 patients in the control cohort. No significant differences were found between the two cohorts in terms of both delta score and delta change index. Table 3 reports the logistic regression coefficients for the two clinical outcomes, namely delta scores and delta change indexes, at 30 days, 6 months, and 12 months after surgery. For all outcomes with non-significant ATEs, the Rosenbaum bounds confirm that these null findings are robust to moderate hidden bias.

Table 3.

Results of propensity-score matching for the fast-track cohort compared to the control (traditional) cohort in terms of clinical outcome. The level of significance is set at p<0.05.

Clinical outcome	Fast-track vs control (95% CI)	Fast-track vs control (95% CI)	Fast-track vs control (95% CI)
Clinical outcome	β - 30 days	β - 6 months	β - 12 months
Delta score	0.50 (−2.77 to 3.76)	−0.94 (−3.37 to 1.49)	1.60 (−1.14 to 4.34)
Delta change indexes	0.05 (−0.05 to 0.15)	0.71 (−0.12 to 0.26)	0.01 (−0.19 to 0.21)

As shown in Figure 2, differences were found between the two cohorts in terms of LOS (5-point scale). Similarly, Figure 3 shows differences among the control group and fast-track by LOS (dichotomic).

Figure 2.

Differences in LOS on a 5-point scale (in days) for fast-track and control group (traditional) cohorts of patients.

Figure 3.

Differences in the LOS dichotomic variable (in days) for the fast-track and control group (traditional) cohorts of patients.

Further, PSM among the 59 patients for the fast-track cohort and the 362 patients in the control cohort and the calculation of selected organizational outcomes are shown in Table 4. There are significant differences between the two cohorts and the result is robust to both ways of operationalizing LOS. Table 4 presents the logistic regression coefficients and odds ratios for the organizational outcome, the LOS at the hospital discharge for both the dichotomic and 5-point scale.

Table 4.

Results of the propensity-score matching (coefficients and odds ratio) for the fast-track cohort compared to control (traditional) for organizational outcome (LOS in the two operationalization ways). The level of significance is set at p < 0.05.

Organizational outcome	Fast-track vs control (95% CI)	Fast-track vs control (OR; 95% CI)
LOS (dichotomic)	−0.48 (−5.71 to −3.93)	0.62 (0.57 to 0.67)
LOS (5-point scale)	−0.75 (−1.01 to −0.48)	0.47 (0.36 to 0.61)

Discussion

In healthcare, it is crucial to study the added value of implementing a new organizational model, regardless of its novelty or innovativeness. From a comprehensive managerial perspective, as the two sides of the same coin, the value is conditioned by both clinical and organizational outcomes from the patients’ standpoint as suggested in a Lean Management perspective.

This study focuses on the evaluation of organizational models from two complementary points of view that focus on patients to understand where value is created and destroyed. Value created considering organizational model with different characteristics (fast-track or traditional model) could emerge from clinical outcomes (e.g. PROMs) or from organizational efficiency indicators (e.g. LOS in hospitals). The results of our study display non-superiority in clinical outcomes between the fast-track and traditional models, indicating that both approaches yield comparable health-related results for patients. However, a notable advantage of the fast-track model is its ability to reduce the length of hospital stay, which can lead to increased operational efficiency and potentially lower costs associated with prolonged hospitalization due to rehabilitation.⁴⁴ As shown in Table 2, the fast-track model shows significant reduction in the LOS after THR surgery compared to the traditional approach. Even if the sensitivity analysis reveals that unmeasured confounding could explain the observed effect, in the fast-track model, 91% of patients stay for less than or equal to 5 days, whereas only 51% of patients in the traditional approach experienced such short stays. Conversely, just 9% of patients in the fast-track require more than 5 days, compared to 49% in the traditional approach, indicating a substantial reduction of the LOS with the fast-track approach. This insight is particularly important in the current context of constraints in public healthcare systems. LOS is a critical organizational outcome because its reduction compared to benchmarks or baselines of traditional approaches indicates system performance, reduced waste, and patient value. This improved efficiency could lead to significant financial savings by reducing hospitalization costs and optimizing resource utilization within the healthcare system.

Despite these benefits, it is essential to consider the financial implications of transitioning to a fast-track model where fewer resources are spent. Implementing such a change may involve initial investments in training, infrastructure, and process reengineering. Therefore, future research should focus on conducting comprehensive cost-benefit analyses to determine the overall financial impact of adopting the fast-track model, by taking into account both short-term expenditures and long-term savings. Such studies will be crucial in providing healthcare decision-makers with the necessary evidence to make informed choices about potential transitions to more efficient care delivery models.⁴⁵ Moreover, while the study indicates that the two organizational models hesitate in comparable outcomes from the patient’s perspective, future research should also take into account factors such as the role of clinicians’ personal influence and the potential impact of patient preferences. In this regard, qualitative investigations may offer valuable insights into organizational dynamics. Likewise, future analyses should include additional variables (such as socioeconomic status, preoperative functional condition, and hospital characteristics) that could additionally enhance the comparability between organizational models.²⁶

In reshaping the organizational models, our study suggests that, in a Lean Management perspective, managers should rethink the value of the entire process, from surgery to rehabilitation. When changing a piece of the organizational process, also the clinical practices need to be reconsidered. From a Lean Management perspective, there are also several avenues for further research, there are several doors for further research. This case study allows us to focus on physiotherapy after THR surgery, one of the most critical phases of the OA patient’s healthcare pathway, while stream mapping was not applied because of the focus on a micro part of the patient pathway (i.e. the hospital rehabilitation). A broader patient journey perspective could capture more sources of waste and enhance the overall value stream. Furthermore, a specific focus on physiotherapy would benefit from a mapping of the implemented models in the different hospitals that could be compared to better study also the implications of other treatments together with the fast track model.

In this regard, managers play a strategic role in encouraging professionals to adopt innovative practices that enhance the overall value of the care process. When managers consider only the initial part of the pathway (i.e. the surgery), despite it classically represents most of the value (i.e. in terms of resources used and outcomes reached), without the related part of the subsequent rehabilitation and return to everyday life, they neglect a part of the value, and related waste, for the patient and for the entire healthcare system.

Finally, regarding practical implications, given the current historical context, where policymakers and healthcare managers are increasingly challenged by an aging population with growing numbers of frail persons and patients with multiple chronic conditions, the operational efficiency of the fast-track model, along with its potential for cost reduction and better resource utilization, represents a strategic way for ensuring system sustainability. In this context, the introduction and reinforcement of innovative rehabilitation models – such as integrating physiotherapy into primary healthcare or implementing territorial initiatives to ensure continuity of care throughout the patient journey – enable timely and safe discharges or care management.⁴⁶ These approaches align with Lean Management principles by optimizing the flow, reducing inefficiencies, and creating value from the perspective of patients, healthcare organizations, and society as a whole.

Conclusion

The results presented in this study are consistent with no superior clinical effectiveness of physiotherapy based on the organizational model with which it is delivered (i.e. traditional approach or fast-track). However, from an organizational side, by expediting post-operative recovery and enabling earlier discharge, the fast-track model helps to enhance the rate of elective surgery delivery while providing effective care. When clinically appropriate, implementing a fast-track approach can help healthcare systems to optimise resource utilisation, reduce the burden on hospitals, enhance patient safety by minimising the duration of hospital stays, and ensure their daily life functionality earlier.

Footnotes

ORCID iDs

Alessandra Da Ros

Francesca Pennucci

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the Direzione Diritti di cittadinanza e coesione sociale of Tuscany Region; Regional Act n.4182 adopted on 3 April 2017 and Finalised ministerial network project 2018; NET-2018-123680771.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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