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Digital musculoskeletal care reduced spending versus in-person therapy
A remote digital musculoskeletal program was linked to lower total and musculoskeletal-related health care spending than starting in-person physical therapy in matched insurance claims.
*Retrospective matched cohort (claims) study; Level 2b (OCEBM).

Citation

Pereira AP, Seet AM, Janela D, et al. Economic Impact of Digital Musculoskeletal Care Versus In-person Physical Therapy: A US Claims Analysis of Health Care Utilization and Outcomes. Archives of Physical Medicine and Rehabilitation. 2026;107:665–675. doi:10.1016/j.apmr.2025.09.010

Background

Exercise-based physical therapy is recommended as first-line care for many muscle and joint problems, but access and follow-through can be difficult, which may lead to more imaging or surgery. This study compared real-world costs and service use after starting a digital, home-based program versus in-person physical therapy.

Patients

United States adults (18 years or older) with commercial insurance and a muscle/joint-related index event (March–October 2023) and at least 12 months of claims before and after (matched groups: 2,183 vs 2,183). Excluded: claims suggesting pregnancy/perinatal status, cognitive impairment, or ongoing cancer treatment.

Intervention

Employer-offered remote digital program with guided exercises, education, and behavior-change support, monitored asynchronously by a physical therapist, using a motion-tracking device for exercise feedback.

Control

Initiation of in-person physical therapy, identified by evaluation billing claims.

Outcome

(Primary) Total health care spending and muscle/joint-related spending per person per year; spending components (surgery, imaging, office visits). Intervention group also reported symptom and productivity changes.

Follow-up Period

12 months before vs 12 months after the index event.

Results

Outcome (post-index) Savings with digital care (USD per person-year) 95% confidence interval
Muscle/joint-related spending (primary) $2,025.7 $1,362.0 to $2,689.4
Total health care spending (primary) $2,369.5 $1,305.4 to $3,433.7
Surgery spending (driver) $1,910.5 $1,271.7 to $2,549.2
Imaging spending (driver) $47.6 $29.4 to $65.8
Medical office visit spending (driver) $54.2 $13.7 to $94.8
The digital group had many more rehabilitation sessions but similar rehabilitation spending. The paper reports fewer surgeries overall in the digital group (counts), and productivity-related savings at program end of $518.1 per participant (self-reported; no control data).

Limitations

Observational design with likely self-selection (motivation/technology comfort), so unmeasured differences may explain some savings. Billing data can be miscoded or incomplete. Clinical outcomes were not available for the in-person group, limiting value-for-money conclusions. Results may not generalize beyond commercially insured, employer-based populations.

Funding

Sword Health; European recovery/resilience project “Responsible AI.” Sponsor-employment and equity conflicts.

Clinical Application

For commercially insured adults with common muscle/joint pain, consider digital-first physical therapy programs to reduce downstream imaging and surgery while supporting home-based rehabilitation.

Top Journal Rankings - August 2026

776 abstracts scored across 7 criteria. Click any article to expand criterion scores.
1. 8.2
Opioid agonist treatment and risk of mortality in French primary care: a nationwide, retrospective cohort study.
Overall: A large national primary-care cohort shows a strong, precise association between being on opioid agonist treatment—especially buprenorphine—and substantially lower all-cause and cause-specific mortality, though residual confounding limits causal certainty and practical implementation details are sparse.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 9.0
Evaluates opioid agonist treatment use and outcomes specifically in a nationwide primary-care context, addressing a common and high-stakes generalist decision (continuing vs being off OAT).
Validity, Bias Control & Precision 7.5
Very large, population-based cohort with long follow-up and time-dependent exposure modeling plus multivariable adjustment, yielding precise estimates; however, retrospective observational design leaves substantial residual confounding/indication bias (explicitly acknowledged).
Patient-Oriented Outcomes 10.0
Primary endpoint is all-cause mortality (and secondary cause-specific mortality including overdose and suicide), which are direct patient-important outcomes.
Magnitude of Net Benefit 8.5
Associations are large and consistent over time (e.g., adjusted HR 0.41 at 1 year with an absolute risk difference ~21 per 1000 person-years), and include reductions in multiple specific causes of death; harms and treatment burden are not reported in the abstract.
Implementability & Practicality 7.0
OAT (notably buprenorphine) is a real-world, primary-care deliverable intervention, but implementation typically involves prescribing controls, follow-up, and coordination needs; the abstract provides limited detail on practical barriers.
Practice-Changing Potential 7.5
Findings strongly support maintaining/expanding OAT in primary care with compelling mortality associations, but the nonrandomized design and potential indication bias limit how definitively it should change practice beyond reinforcing existing recommendations.
2. 7.9
Long-term cardiovascular risks after atrial fibrillation diagnosis: a systematic review and meta-analysis.
Overall: Large contemporary systematic review/meta-analysis quantifying major clinical event rates after AF diagnosis with precise estimates and time-trend analyses; highly relevant to outpatient AF management and highlights heart failure as a persistent leading complication, though it does not evaluate an intervention’s net benefit.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 8.0
Atrial fibrillation is common in primary care, and the quantified long-term risks (stroke, heart failure, MI, cardiovascular death) inform counseling, follow-up intensity, and comorbidity management decisions relevant to generalists.
Validity, Bias Control & Precision 8.5
Systematic review/meta-analysis of contemporary longitudinal cohorts with very large cumulative sample size and person-years, random-effects pooling, meta-regression, PROSPERO registration, and reported CIs support reasonably strong credibility and precision, though heterogeneity and observational confounding remain inherent.
Patient-Oriented Outcomes 9.0
Outcomes are clearly patient-important clinical events (heart failure, ischemic stroke, myocardial infarction, cardiovascular death) rather than surrogates.
Magnitude of Net Benefit 4.5
This is descriptive prognostic evidence and does not test an intervention, so net benefit (benefits vs harms/burden) cannot be directly assessed from the abstract.
Implementability & Practicality 7.5
Findings are straightforward to apply for risk communication and prioritizing prevention focus (notably heart failure) without requiring new tools, but the abstract does not translate risks into a specific actionable protocol or decision aid.
Practice-Changing Potential 10.0
By showing heart failure as the most frequent and non-improving adverse outcome despite declines in stroke/MI/death over time, it provides a clear signal likely to shift clinical and guideline emphasis toward heart-failure prevention/monitoring in AF care.
3. 7.8
Adolescent Cardiorespiratory Fitness and the Trade-Off Between Atrial Fibrillation Risk and Cardiovascular Benefits: A Nationwide Sibling-Controlled Cohort Study.
Overall: A very large sibling-controlled cohort with patient-important cardiovascular outcomes suggests that high adolescent fitness confers greater long-term CVD benefit than AF harm, offering credible reassurance for primary-care prevention counseling despite observational limitations and modest absolute effects.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 8.5
Addresses long-term cardiovascular outcomes and counseling about youth fitness—highly relevant to prevention discussions and risk communication in general practice, though the cohort is limited to Swedish men.
Validity, Bias Control & Precision 8.5
Very large nationwide cohort with registry follow-up and a sibling-control analysis to mitigate shared familial confounding; effect estimates include risk differences with 95% CIs, though residual confounding and observational design remain limitations.
Patient-Oriented Outcomes 8.5
Uses clinically meaningful outcomes (atrial fibrillation, stroke/ischemic heart disease composite, diagnosis or death) rather than surrogates.
Magnitude of Net Benefit 7.5
Shows small absolute excess AF risk alongside larger absolute reductions in non-AF CVD by mid-to-late adulthood (e.g., at 65 years RD −3.91% for non-AF CVD vs +2.30% for AF), suggesting a modest-to-moderate net benefit overall.
Implementability & Practicality 8.0
Implications mainly support promoting cardiorespiratory fitness—an implementable public health/primary-care counseling target—though the study does not test a specific, scalable intervention or workflow.
Practice-Changing Potential 6.0
More reassuring/clarifying than directive; it may refine counseling about AF concerns in very fit youth, but it is unlikely to change practice dramatically without linking to specific intervention strategies or guideline shifts.
4. 7.8
All-cause and cause-specific mortality assessment in patients receiving sodium glucose co-transporter-2 inhibitors.
Overall: Large RCT meta-analysis focusing on mortality suggests meaningful reductions in cardiovascular and renal death with SGLT2 inhibitors, but overall all-cause mortality is neutral and implementation/harms details are not provided in the abstract.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 8.0
Addresses SGLT2 inhibitor use across diabetes, heart failure, and chronic kidney disease—conditions commonly managed or co-managed in primary care with frequent prescribing decisions.
Validity, Bias Control & Precision 8.5
Systematic review and random-effects meta-analysis of 18 RCTs with a very large pooled sample (95,913) and reported 95% CIs; however, the abstract provides limited detail on risk-of-bias assessments and heterogeneity.
Patient-Oriented Outcomes 10.0
Evaluates all-cause and cause-specific mortality, which are unequivocally patient-important outcomes.
Magnitude of Net Benefit 6.5
All-cause mortality was not significantly reduced overall, while cardiovascular mortality showed a modest relative reduction (RR 0.86) and renal mortality a large relative reduction (RR 0.31) but with wide CI; harms/burdens are not reported in the abstract, limiting net-benefit assessment.
Implementability & Practicality 7.0
SGLT2 inhibitors are already used in outpatient care, but the abstract does not address practical barriers (cost, contraindications, monitoring, adverse events), so real-world ease of implementation cannot be fully judged.
Practice-Changing Potential 6.5
Supports and refines existing use by showing reductions in cardiovascular and renal mortality, but the neutral overall all-cause mortality and exploratory subgroup findings make it more confirmatory than clearly practice-changing.
5. 7.6
A Randomized Controlled Trial of Social Prescribing: Comparing a Comprehensive Navigation Model With Signposting.
Overall: This primary-care RCT shows a clinically meaningful improvement in patient-reported access to needed resources and some equity-related benefits, though conclusions are tempered by attrition and reliance on self-reported outcomes with limited data on harms, costs, or downstream clinical impacts.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 9.0
Conducted in primary care practices among patients with health and/or social needs, evaluating a real-world care-navigation approach that primary care teams commonly consider.
Validity, Bias Control & Precision 7.0
Randomized controlled design with a reported effect size and 95% CI, but notable attrition (73% follow-up) and reliance on self-reported outcomes; blinding not described.
Patient-Oriented Outcomes 6.5
Primary outcome is self-reported access to needed resources and secondary measures include care experience/engagement; meaningful to patients but not hard clinical endpoints (e.g., morbidity, utilization).
Magnitude of Net Benefit 8.0
Moderate-to-large absolute improvement in access (14.5% absolute difference; CI 3.9% to 25.2%) plus improved experience/engagement and better language-concordant access for Francophones; harms/burdens not reported.
Implementability & Practicality 7.0
Intervention requires comprehensive, longitudinal navigation with informational/instrumental/emotional support, which is feasible but likely needs staffing and workflow investment beyond simple signposting.
Practice-Changing Potential 8.0
Provides randomized evidence that a comprehensive navigation model outperforms signposting for improving access and equity-relevant outcomes, making it plausible to influence primary care social prescribing program design.
6. 7.5
Digital Mental Health Treatment and Symptoms of Depression and Anxiety in Breast Cancer Survivors: A Randomized Clinical Trial.
Overall: A reasonably strong randomized trial suggests a scalable app-based intervention modestly improves anxiety symptoms in breast cancer survivors versus education, with good practicality but limited evidence for depression benefit and limited reporting on harms and patient-centered endpoints beyond symptom scales.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 7.5
Addresses depression/anxiety symptoms in breast cancer survivors—common outpatient/primary-care comorbidity—but the population is cancer-survivorship specific and limited to women within 5 years of stage I–III diagnosis with smartphone access.
Validity, Bias Control & Precision 8.0
Randomized clinical trial with an active control and intention-to-treat analysis; follow-up to 12 months. However, outcomes are self-reported and the abstract does not describe blinding or detailed attrition handling beyond noting fewer included in primary analyses.
Patient-Oriented Outcomes 6.5
Primary outcomes are validated symptom scales (GAD-7, PHQ-8), which are patient-relevant but not hard clinical outcomes (e.g., function, quality of life, remission, health care use).
Magnitude of Net Benefit 7.0
Compared with education control, anxiety improved with an AME of −1.43 on GAD-7 (95% CI −2.49 to −0.38), while depression did not reach significance (P=0.06). Harms, adverse effects, and dropout burden are not reported; the intervention appears low-intensity.
Implementability & Practicality 8.5
A publicly accessible, self-guided smartphone-based program is scalable and low resource; optional coaching increases engagement modestly. Still requires smartphone/data plan and sustained app use over 8 weeks.
Practice-Changing Potential 7.5
Provides RCT evidence that a digital program can yield greater anxiety symptom reduction than education in this survivorship group, suggesting a feasible care-pathway add-on; lack of clear depression benefit and limited reporting on harms may temper immediate broad adoption.
7. 7.4
Changing Clinician Behavior in Geriatrics: Point-of-Care Alerts for Prostate-Specific Antigen Screening.
Overall: This pragmatic cluster-randomized primary-care study shows a precise, clinically meaningful reduction in PSA overtesting in men >75 using point-of-care decision support plus brief education, with evidence of heterogeneity by clinician characteristics. The intervention appears implementable in EHR-based practices and could influence de-implementation efforts. However, outcomes are primarily process-based (testing rates) without patient-level benefits/harms, and subgroup findings come from a secon
View 6 Criterion Scores
Primary-Care Relevance & Applicability 9.0
Conducted in 59 primary care practices and targets a common primary-care decision (PSA screening in men >75 years), directly aligning with outpatient preventive care and de-implementation of low-value testing.
Validity, Bias Control & Precision 8.5
Secondary analysis of a pragmatic cluster-randomized trial with a clear comparator (CDS+education vs education alone) and a precise main effect estimate with a 95% CI; however, this is a secondary analysis and clinician-level subgroup/interaction findings raise multiplicity concerns.
Patient-Oriented Outcomes 4.0
Primary outcome is a clinician behavior/process measure (overtesting rate). No patient-level outcomes such as quality of life, complications, downstream procedures, cancer outcomes, or harms from missed diagnoses are reported in the abstract.
Magnitude of Net Benefit 7.5
Shows a sizable absolute reduction in overtesting (12.1 fewer tests per 100 eligible patients over 18 months), consistent with meaningful reduction in low-value care; net patient benefit is implied rather than demonstrated because downstream harms/benefits are not measured.
Implementability & Practicality 8.0
Point-of-care clinical decision support plus brief education is a scalable intervention in many EHR-enabled primary care settings, though it requires CDS build/maintenance and may contribute to alert fatigue; mixed response among persistent alert triggers suggests workflow/engagement challenges.
Practice-Changing Potential 7.5
Provides pragmatic trial evidence that CDS can materially reduce PSA overtesting in older men, supporting de-implementation strategies; practice change may depend on local EHR capacity and buy-in, and lack of patient outcome data may limit immediate guideline-level impact.
8. 7.4
Heatstroke Over the Past Decade: Risk Factors, Long-Term Health Consequences, and Preventive Measures.
Overall: This systematic review is highly relevant to frontline care and prevention, supports cold-water immersion as the fastest cooling approach, and highlights important long-term risks after heatstroke, but heterogeneity and mixed evidence certainty limit how definitively it can change practice beyond reinforcing rapid cooling and risk-targeted prevention.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 8.5
Covers a common, high-stakes condition with clear outpatient/public-health prevention angles (elderly, athletes) and actionable early management advice that generalists and urgent/prehospital clinicians may influence.
Validity, Bias Control & Precision 6.5
Systematic review with multi-database search, risk-of-bias and GRADE assessment, but results are narrative due to heterogeneity and include many observational studies; some key long-term outcome estimates are explicitly low certainty from inconsistency/imprecision.
Patient-Oriented Outcomes 7.5
Includes patient-important outcomes (organ damage prevention framing, acute MI and CKD risks after heatstroke), though several findings are associations rather than direct intervention effects and certainty varies.
Magnitude of Net Benefit 7.0
Cooling-rate differences are large (cold-water immersion much faster than cold IV saline), plausibly tied to preventing harm, but the abstract provides limited direct clinical outcome effect sizes and little explicit harms/burden data.
Implementability & Practicality 7.0
Recommends cold-water immersion and “cool first, transport second,” which can be operationalized in some field/clinic/athletic settings, but may face logistical barriers (equipment, staffing, environment) not addressed in the abstract.
Practice-Changing Potential 8.0
Provides a clear, actionable management priority and targeted prevention groups; however, much of the evidence base is heterogeneous and some key claims (e.g., predictive wearables) are low certainty.
9. 7.4
Evolocumab in Patients With High-Risk Diabetes: Results From the VESALIUS-CV Trial.
Overall: A large, placebo-controlled randomized trial in high-risk diabetes reports reduced major cardiovascular events and lower all-cause mortality with evolocumab over 4.6 years, but the abstract provides limited information on harms and real-world treatment burden, which constrains confidence in net benefit and immediate broad implementation.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 7.5
Addresses prevention of first cardiovascular events in high-risk patients with diabetes—highly relevant to outpatient chronic disease management—though PCSK9 inhibitor use often sits in a specialist/insurance-intensive pathway rather than routine primary-care initiation.
Validity, Bias Control & Precision 8.8
Large randomized, placebo-controlled trial (n=6,002) with long follow-up (median 4.6 years) and prespecified analysis; effect estimates include hazard ratios with reasonably tight confidence intervals, supporting precision.
Patient-Oriented Outcomes 8.0
Primary endpoints are clinical events (CHD death, MI, ischemic stroke, revascularization) and all-cause death is reported, making outcomes patient-important rather than surrogate-only.
Magnitude of Net Benefit 6.8
Shows meaningful relative reductions in MACE (HR 0.71 and 0.79) and lower all-cause death (8.8% vs 11.0%), but absolute risk reduction for the primary endpoints and adverse effects/treatment discontinuation are not provided in the abstract, limiting assessment of net benefit.
Implementability & Practicality 5.5
Evolocumab requires ongoing subcutaneous injections every 2 weeks and typically involves access/coverage logistics; the abstract does not address monitoring needs, adherence, or practical barriers, so real-world ease is uncertain.
Practice-Changing Potential 7.8
Demonstrates event reduction in high-risk diabetes without prior MI/stroke and across subgroups, which could expand preventive lipid-lowering strategies; however, missing safety/burden details in the abstract and practical access barriers may temper immediate widespread change.
10. 7.3
Leisure-Time Physical Activity and Mortality in Chronic Obstructive Pulmonary Disease: A Nationwide Cohort Study.
Overall: A large national cohort links higher leisure-time physical activity with lower mortality in COPD with fairly precise estimates, but residual confounding and lack of randomized evidence limit how strongly it can drive new practice.
View 6 Criterion Scores
Primary-Care Relevance & Applicability 8.0
COPD is commonly managed in primary care, and counseling about leisure-time physical activity is a realistic outpatient decision point with broad applicability.
Validity, Bias Control & Precision 6.0
Large nationwide retrospective cohort with long follow-up and adjusted hazard ratios with confidence intervals, but nonrandomized exposure leaves substantial risk of residual confounding and healthy-user bias.
Patient-Oriented Outcomes 10.0
All-cause and cause-specific mortality are clearly patient-important outcomes and were ascertained via a national death registry.
Magnitude of Net Benefit 7.0
Associations are sizeable (e.g., HR 0.62 for ≥800 MET-min/wk vs none) and directionally consistent for cardiovascular and cancer mortality, but net benefit is less certain because causality and harms/burdens of increased activity are not quantified in the abstract.
Implementability & Practicality 8.0
Encouraging leisure-time physical activity is generally feasible in routine outpatient care without specialized equipment, though achieving and sustaining ≥800 MET-min/wk may require ongoing support.
Practice-Changing Potential 5.0
Findings support existing recommendations to stay active in COPD, but observational design limits its ability to change practice beyond reinforcing current counseling.
Score Guide: 9-10 Exceptional 7-8 Strong 5-6 Moderate 3-4 Weak 1-2 Poor
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