{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T15:14:10Z","timestamp":1790781250333,"version":"4.1.0"},"reference-count":31,"publisher":"American Medical Association (AMA)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Group-based physical therapy (PT) for knee osteoarthritis is an effective, efficient strategy for delivering care, but little is known about optimal strategies for implementing new clinical programs like group PT.<\/jats:p><\/jats:sec>Objective<\/jats:title>To compare 2 implementation support approaches\u2014foundational support and a combination of foundational support and more intensive enhanced support involving individual external facilitation\u2014for delivering group PT.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This cluster randomized clinical trial was conducted from January 31, 2022, to March 18, 2024, in outpatient PT departments at Department of Veterans Affairs (VA) Healthcare sites that agreed to deliver group PT to patients with symptomatic knee osteoarthritis. Sites were randomized to receive foundational or enhanced implementation support for delivering 6 sessions of group PT over 12 months that included exercise and educational content.<\/jats:p><\/jats:sec>Interventions<\/jats:title>The foundational support approach included self-guided tools and monthly learning collaborative calls. The enhanced support approach added tailored support (eg, external facilitation) for sites that did not meet a priori benchmarks for adoption at 6 months or sustainment at 9 months.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Site-level implementation outcomes were measured during months 7 to 12 and included penetration (primary outcome, assessed as the mean number of patients enrolled per month) and fidelity (mean number of classes attended per patient, out of a maximum of 6). Generalized linear models were used to examine differences in implementation outcomes between the enhanced and foundational support arms.<\/jats:p><\/jats:sec>Results<\/jats:title>Nineteen sites (10 enhanced support, 9 foundational support) enrolling across 3 cohorts delivered group PT to 144 patients (68 enhanced support, 76 foundational support) during months 7 to 12. Patients were predominantly male (130 [90.3%]), with a mean (SD) age of 67 (9.2) years. Mean penetration estimates were 1.0 (95% CI, 0.2-1.7) patients enrolled per month for the enhanced support and 1.0 (95% CI, 0.1-1.9) for the foundational support arm, with an estimated mean difference between arms of \u22120.1 (95% CI, \u22121.1 to 1.0) patients enrolled (P<\/jats:italic>\u2009=\u2009.92). Mean fidelity estimates were 5.0 (95% CI, 4.3-5.7) classes attended per patient in the enhanced support arm and 4.1 (95% CI, 3.2-4.9) in the foundational support arm, with an estimated mean difference between arms of 0.9 (95% CI, 0.0-1.9) classes per patient (P<\/jats:italic>\u2009=\u2009.06).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cluster randomized clinical trial, an enhanced implementation support approach for delivering group PT did not outperform foundational support. Penetration was modest, illustrating the challenge of fostering referrals.<\/jats:p><\/jats:sec>Trial Registration<\/jats:title>ClinicalTrials.gov Identifier: NCT05282927<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.35038","type":"journal-article","created":{"date-parts":[[2025,10,2]],"date-time":"2025-10-02T15:31:38Z","timestamp":1759419098000},"page":"e2535038","source":"Crossref","is-referenced-by-count":2,"title":["Implementation of Group Physical Therapy for Knee Osteoarthritis"],"prefix":"10.1001","volume":"8","author":[{"given":"Kelli D.","family":"Allen","sequence":"first","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Medicine, University of North Carolina at Chapel Hill"},{"name":"Thurston Arthritis Research Center, University of North Carolina at Chapel Hill"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Webb","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cynthia J.","family":"Coffman","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Livia","family":"Anderson","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Graham","family":"Cummin","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Connor","family":"Drake","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Tucker","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Webster","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina","family":"Sperber","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leah L.","family":"Zullig","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaime M.","family":"Hughes","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina"},{"name":"Section on Gerontology and Geriatric Medicine, Division of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lindsay A.","family":"Ballengee","sequence":"additional","affiliation":[{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauren M.","family":"Abbate","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"VA Eastern Colorado Geriatric Research Educational and Clinical Center, Aurora"},{"name":"University of Colorado School of Medicine, Aurora"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen","family":"Hoenig","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina"},{"name":"Department of Medicine, Duke University School of Medicine, Durham, North Carolina"},{"name":"Physical Medicine and Rehabilitation Services, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natalie","family":"Fullenkamp","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Courtney H.","family":"Van Houtven","sequence":"additional","affiliation":[{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan N.","family":"Hastings","sequence":"additional","affiliation":[{"name":"Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina"},{"name":"Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina"},{"name":"Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina"},{"name":"Department of Medicine, Duke University School of Medicine, Durham, North Carolina"},{"name":"Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,10,2]]},"reference":[{"issue":"11","key":"zoi250983r1","doi-asserted-by":"publisher","first-page":"1578","DOI":"10.1016\/j.joca.2019.06.011","article-title":"OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.","volume":"27","author":"Bannuru","year":"2019","journal-title":"Osteoarthritis Cartilage"},{"issue":"2","key":"zoi250983r2","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1002\/acr.24131","article-title":"2019 American College of Rheumatology\/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee.","volume":"72","author":"Kolasinski","year":"2020","journal-title":"Arthritis Care Res (Hoboken)"},{"issue":"9","key":"zoi250983r3","doi-asserted-by":"publisher","first-page":"2435","DOI":"10.1016\/j.mayocp.2021.03.017","article-title":"Synopsis of the 2020 US Department of Veterans Affairs\/US Department of Defense clinical practice guideline: the non-surgical management of hip and knee osteoarthritis.","volume":"96","author":"Krishnamurthy","year":"2021","journal-title":"Mayo Clin Proc"},{"issue":"9","key":"zoi250983r4","doi-asserted-by":"publisher","first-page":"1487","DOI":"10.1016\/j.joca.2016.04.004","article-title":"Clinical algorithms to aid osteoarthritis guideline dissemination.","volume":"24","author":"Meneses","year":"2016","journal-title":"Osteoarthritis Cartilage"},{"key":"zoi250983r5","article-title":"Demographic and clinical factors associated with non-surgical osteoarthritis treatment use among patients in outpatient clinics.","author":"Abbate","journal-title":"Arthritis Care Res (Hoboken)"},{"issue":"1","key":"zoi250983r6","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.arthro.2013.09.002","article-title":"An epidemiologic analysis of clinical practice guidelines for non-arthroplasty treatment of osteoarthritis of the knee.","volume":"30","author":"Dhawan","year":"2014","journal-title":"Arthroscopy"},{"issue":"5","key":"zoi250983r8","doi-asserted-by":"publisher","first-page":"597","DOI":"10.2522\/ptj.20150194","article-title":"Group versus individual physical therapy for veterans with knee osteoarthritis: randomized clinical trial.","volume":"96","author":"Allen","year":"2016","journal-title":"Phys Ther"},{"issue":"2","key":"zoi250983r9","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1016\/j.cct.2012.12.007","article-title":"Group physical therapy for veterans with knee osteoarthritis: study design and methodology.","volume":"34","author":"Allen","year":"2013","journal-title":"Contemp Clin Trials"},{"issue":"1","key":"zoi250983r10","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1186\/s12891-020-3079-x","article-title":"Implementation of a group physical therapy program for veterans with knee osteoarthritis.","volume":"21","author":"Allen","year":"2020","journal-title":"BMC Musculoskelet Disord"},{"issue":"3","key":"zoi250983r11","doi-asserted-by":"publisher","first-page":"604","DOI":"10.1093\/geront\/gnac130","article-title":"Intensification of implementation strategies: developing a model of foundational and enhanced implementation approaches to support national adoption and scale-up.","volume":"63","author":"Hughes","year":"2023","journal-title":"Gerontologist"},{"issue":"1","key":"zoi250983r12","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1186\/s43058-023-00502-7","article-title":"Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial.","volume":"4","author":"Webb","year":"2023","journal-title":"Implement Sci Commun"},{"issue":"1","key":"zoi250983r13","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1370\/afm.1312","article-title":"Systematic review and meta-analysis of practice facilitation within primary care settings.","volume":"10","author":"Baskerville","year":"2012","journal-title":"Ann Fam Med"},{"issue":"Suppl 4","key":"zoi250983r14","doi-asserted-by":"publisher","first-page":"904","DOI":"10.1007\/s11606-014-3027-2","article-title":"Outcomes of a partnered facilitation strategy to implement primary care-mental health.","volume":"29","author":"Kirchner","year":"2014","journal-title":"J Gen Intern Med"},{"issue":"3","key":"zoi250983r16","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1097\/MLR.0b013e3182408812","article-title":"Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact.","volume":"50","author":"Curran","year":"2012","journal-title":"Med Care"},{"key":"zoi250983r17","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.e5661","article-title":"CONSORT 2010 statement: extension to cluster randomised trials.","volume":"345","author":"Campbell","year":"2012","journal-title":"BMJ"},{"issue":"3","key":"zoi250983r21","doi-asserted-by":"publisher","first-page":"386","DOI":"10.1016\/j.joca.2022.10.009","article-title":"Recommendations for the delivery of therapeutic exercise for people with knee and\/or hip osteoarthritis: an international consensus study from the OARSI Rehabilitation Discussion Group.","volume":"31","author":"Holden","year":"2023","journal-title":"Osteoarthritis Cartilage"},{"key":"zoi250983r22","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1186\/1748-5908-2-42","article-title":"Implementing evidence-based interventions in health care: application of the Replicating Effective Programs framework.","volume":"2","author":"Kilbourne","year":"2007","journal-title":"Implement Sci"},{"issue":"1","key":"zoi250983r23","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1186\/s40359-015-0089-9","article-title":"An introduction to implementation science for the non-specialist.","volume":"3","author":"Bauer","year":"2015","journal-title":"BMC Psychol"},{"key":"zoi250983r24","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1186\/s13012-015-0209-1","article-title":"A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.","volume":"10","author":"Powell","year":"2015","journal-title":"Implement Sci"},{"key":"zoi250983r25","doi-asserted-by":"publisher","DOI":"10.1007\/s43477-024-00119-5","article-title":"Getting to fidelity: consensus development process to identify core activities of implementation facilitation.","author":"Smith","journal-title":"Glob Implement Res Appl"},{"issue":"2","key":"zoi250983r26","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1093\/geront\/gns071","article-title":"Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years.","volume":"53","author":"Rikli","year":"2013","journal-title":"Gerontologist"},{"issue":"9","key":"zoi250983r27","doi-asserted-by":"publisher","first-page":"1096","DOI":"10.1016\/j.jpain.2017.05.001","article-title":"Responsiveness and minimally important differences for 4 Patient-Reported Outcomes Measurement Information System short forms: physical function, pain interference, depression, and anxiety in knee osteoarthritis.","volume":"18","author":"Lee","year":"2017","journal-title":"J Pain"},{"issue":"14","key":"zoi250983r30","doi-asserted-by":"publisher","first-page":"8333","DOI":"10.3390\/ijerph19148333","article-title":"National implementation of a group-based program promoting patient engagement and peer support in the Veterans Health Administration: a multi-methods evaluation.","volume":"19","author":"Drake","year":"2022","journal-title":"Int J Environ Res Public Health"},{"issue":"2","key":"zoi250983r31","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1080\/02701367.1999.10608028","article-title":"A 30-s chair-stand test as a measure of lower body strength in community-residing older adults.","volume":"70","author":"Jones","year":"1999","journal-title":"Res Q Exerc Sport"},{"key":"zoi250983r28","doi-asserted-by":"crossref","DOI":"10.1007\/978-1-4899-3242-6","volume-title":"Generalized Linear Models","author":"McCullagh","year":"1989","edition":"2nd ed"},{"key":"zoi250983r29","volume-title":"Design and Analysis of Group-Randomized Trials","author":"Murray","year":"1998"},{"key":"zoi250983r7","unstructured":"American Physical Therapy Association. A model to project the supply and demand of physical therapists, 2010-2025. April 17, 2017. Accessed November 18, 2024. https:\/\/www.shpep.org\/wp-content\/uploads\/2022\/09\/Physical-Therapy-SHPEP.pdf"},{"key":"zoi250983r15","unstructured":"Ritchie? MJDK, Miller? CJ, Smith? JL, . Using implementation facilitation to improve healthcare: implementation facilitation training manual. Version 3.1. Behavioral Health Quality Enhancement Research Initiative (QUERI), Veterans Health Administration. December 1, 2020, and May 2025. Accessed May 30, 2023. https:\/\/www.queri.research.va.gov\/tools\/Facilitation-Manual.pdf"},{"key":"zoi250983r18","unstructured":"Office of Rural Health. Clinical resource hubs. US Department of Veterans Affairs. April 2024. Accessed February 11, 2025, https:\/\/www.ruralhealth.va.gov\/docs\/issue-briefs\/CRH_Fact_Sheet_508c.pdf"},{"key":"zoi250983r19","unstructured":"US Dept of Veterans Affairs. VHA directive 1220(1): facility procedure complexity designation requirements to perform invasive procedures in any clinical setting. May 13, 2019. Amended February 11, 2020. Accessed January 24, 2025. https:\/\/www.va.gov\/vhapublications\/ViewPublication.asp?pub_ID=8365"},{"key":"zoi250983r20","unstructured":"Office of Rural Health. How to define rurality. US Dept of Veterans Affairs. December 2023. Accessed January 24, 2025. https:\/\/www.ruralhealth.va.gov\/docs\/ORH_RuralityFactSheet_508.pdf"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2839540\/allen_2025_oi_250983_1758815520.95047.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,2]],"date-time":"2025-10-02T15:31:40Z","timestamp":1759419100000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2839540"}},"subtitle":["A Cluster Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2025,10,2]]},"references-count":31,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2025,10,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.35038","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,2]]}}}