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If You’re Going, You Might As Well Get There

[list][/list]Sometimes, it’s pure and simple logic that prevails as the best solution to something. This was the case in an important new study published ahead of print in Spine. You may have seen the presser released by APTA, AAOMPT on the matter. They’re exuberant, and they should be. Well, mostly.

The study, published by Drs. Julie Fritz, John Childs, Rob Wainner, and Tim Flynn, examined a payor database and looked at over 32,000 data sets of patients with low back pain with the purpose of describing physical therapy utilization in primary care settings. Further, they looked at both associated healthcare costs and the question of whether the physical therapy care being provided was either adherent with practice guidelines for an active treatment or non-adherent. Treatments were classified as non-adherent when they included things like ultrasound that are not proven interventions for patients with low back pain. While not a perfect practice, the researchers used billing codes as their determination factor for treatment adherence.

The findings of this study are fascinating to me. Albeit, many public health studies that look at low back pain and care patterns and/or costs are fascinating to me, so I’ll let you be the judge.

The key findings of the study were:

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    • For patients receiving physical therapy, early referral (within 14 days) was associated with less overall healthcare utilization, which included lower use of surgery, fewer doctor visits, less injections, and less advanced imaging that those with delayed referral (14-90 days).
    • For patients receiving adherent care, overall health utilization was also lower, but to a lesser degree that that seen with the early referral group.

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Graph demonstrating health utilization costs related to low back pain. Series 1 is costs for patients in early referral (gray) vs. delayed (orange). Series 2 shows costs for adherent care (gray) vs. non-adherent care (orange).

 

As you can see by the graph above, significant savings were realized by early referral to physical therapy and by adherent physical therapy care. Logic sure does shine forth here. If you’re going to go somewhere, well you might as well just get there. Significantly, the finding in this study is important because it runs counter to the suggestions by many LBP practice guidelines that suggest primary care physicians delay referral to other services as many patients are likely to improve anyway. Overall trends to reduce the medicalization of LBP are important, but this study reflects a trend whereby physicians are referring about half of patients to physical therapy within 14 days anyway. It turns out, this may end up being an evidence-supported practice.

Not all was rosy, however. Here are some other findings that were important:

Overall patient data sets and 7% utilization for patients with low back pain.

 

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    • Overall utilization for physical therapy for patients with low back pain in this data set was only 7%.
    • Overall healthcare costs were higher for patients receiving physical therapy. This might reflect increased severity, co-morbidities, etc, we just don’t know.
    • Only 21% of the physical therapy care provided was able to be classified as adherent. This could reflect an imperfect measuring tool, but I suspect there’s a problem here.
    • Wide geographic variability persists in the management of LBP, including physical therapy utilization and adherence to guidelines.

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This study is full of many other gems. It’s gated at Spine, so apologies for not including a full text link. The good new: Spine is a huge journal and this will be seen. As with many studies, this leaves more questions to ask. Such as, what factors make the patients who are referred early have lower subsequent utilization. The authors hypothesize it may have to do with the concept of self-efficacy. I like it.

I like it so much, in fact, that I’m involed in a related study with some of the authors to examine a similar question in a Department of Defense database. I’m eager to see what we find.

This study was jointly funded by grants from the Orthopaedic and Private Practice sections of the APTA, AAOMPT, and a faculty research grant from Texas State University.
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APTA Vision 2020: What’s your grade?

Alan Besselink, blogger and Austinite extraordinaire has written a thoughtful post entitled, “APTA’s Vision 2020: My 12 Year Report Card.” In the post, Alan breaks down the components of Vision 2020 and provides his summary of the progress toward each.

To review, here’s the Vision 2020 statement from the APTA:

“By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”

I’m sure certain parts of this resonate more with different folks. For Alan, the issue of Direct Access takes center stage. I agree with his critique of the APTA PR machine, which labels 40 something states as having some form of direct access to physical therapists…while in actuality, many of those states are not very gate-keeper free at all. Alan points out that the state we both practice in, Texas, is listed as a Direct Access state by APTA. I consider that false.

Here are Alan’s grades for each section:

  • Autonomous Practice: F
  • Direct Access: F
  • Doctor of Physical Therapy and Lifelong Education: F
  • Evidence-based Practice: F
  • Practitioner of Choice: F
  • Professionalism: A
  • Overall: F

 

Now, I’m not sure I agree with Alan on all of these grades (specifically the EBP and DPT grades), but he makes a good argument for each of his choices in his post. My question to you is, what do you think about the progress we’ve made on Vision 2020. As Alan points out, “As they say, if you do what you’ve done, you will get what you’ve got. Sadly, what we’ve got isn’t much different than what we had 12 years ago.” This may be a good opportunity to take stock and make some changes in strategy before we get too close to 2020 to change!

[icon style=”notice”]I’ll summarize the results of this poll in another post prior to the APTA Annual Conference.[/icon]

How do you Grade APTA Vision 2020 Progress

Physical therapist Blogger, Alan Besselink has already submitted his grade. What's yours?
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Phrase of the Day: Prospective Surveillance

Recently, the open-access journal, Cancer, included a special issue: Supplement: A Prospective Surveillance Model for Rehabilitation for Women With Breast Cancer. This model has been described by researcher, Nicole Stout, as a “proactive approach to periodically examining patients and providing ongoing assessment during and after disease treatment, often in the absence of impairment, in an effort to enable early detection of and intervention for physical impairments known to be associated with cancer treatment(1).” In other words, checking early and often so that issues can be dealt with at a mangeable stage and not in a catastrophic end-stage presentation. Theoretically, this model of approach can mitigate many of the known poor related outcomes for patients following cancer treatment.

The model of prospective surveillance has been developed over the last decade at the National Naval Medical Center in Bethesda-now part of the Walter Reed National Military Medical Center. It’s the standard of care for all patients there and serves as a great base for research into the clinical effectiveness of this approach. While bottom-line cost savings numbers aren’t apparent yet, this seems a likely outcome, as overall, patients consume less care when issues are dealt with in early stages when their prognosis is still strong. Regardless, it’s a cool phrase!

The prospective surveillance model attempts to cover many aspects of cancer treatment, including awareness of known side-effects to the sometimes persistent upper extremity pain and dysfunction that so many women share following treatment for breast cancer. Describing and quantifying the séquelle of post-treatment effects that are common following treatment that can be ameliorated through rehabilitation are part in parcel in studying this model, and are dealt with as well in the supplemental Cancer issue. Check it out and get smart!

Nicole Stout
Eric Robertson and Nicole Stout, President’s Reception. Chicago, IL 2012

This issue hits close to home for me. My mother is a breast cancer survivor. As she recovered, I was well aware of the musculoskeletal dysfunction in her upper extremity, yet was confounded at the lack of attention that received from her care providers. Research into this area is a critical, emerging field of physical therapy and one that makes me proud. There are also new neuropathic pain treatments that can help with this.

As an aside, Nicole Stout is a member of the  APTA Board of Directors (Scroll to Bottom). She is in candidate status this year and I’m sure would appreciate any support one could be in the position to be in as elections approach in June. She does important work.

1. Stout NL. Cancer prevention in physical therapist practice. Phys Ther. 2009; 89( 11): 1119-1122.

 

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Alphabet Soup Redux

Credential Soup word cloud

In 2009 at the Annual Meeting and Exposition of the American Physical Therapy Association in Baltimore, MD, the Oxford Debate took up the issue of alphabet soup. The issue debated was, “Are the use of multiple credentials a distraction or an attraction to our profession?” The team in favor of eliminating the excessive use of credentials included, Robert Landel, PT, DPT, OCS, CSCS; Stephen C. F. McDavitt, PT, DPT, FAAOMPT, and Robert H. Rowe, PT, DPT, DMT, MHS, FAAOMPT. A well-credentialed bunch, indeed.

I recall siding with that team, as I have always had an eye toward PR and branding and consider too many credentials as being bad for a brand. Successful branding includes paying attention to your brand’s identity, as Philip Davis points out in this well-crafted blog post. This can be anything from making sure your fonts and colors are the same to making sure you dress according to how you want your brand to be perceived. If fonts and colors are important, a myriad of obscure credentials are most certainly critical as well.

This weekend’s visceral debate on Kyle’s post brought this larger issue to the forefront once again. What do you think about this issue of alphabet soup? Join the #SolvePT discussion tomorrow, hosted by @SnippetPhysTher.

[icon style=”notice”]Update: Check out the summary of the tweet chat on 5/22/12 here. [/icon]

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Happy Mother’s Day: Get Real

[icon style=”notice”]Update: Be patient with the Samahope.org site as they roll out over the next few days… [/icon]

Welcome to PT Think Tank’s new website design and Happy Mother’s Day to all the mom’s out there!

Today, we’re going to jump right in and get real on Mother’s Day. So real, in fact, that we’re going to talk about fistulas. Obstetric fistulas, to be specific. The kind that form mostly in impoverished countries after childbirth, we’re birth trauma causes tissue death and connects parts of the mother’s pelvic anatomy that should never, ever be connected. Women suffering with obstetric fistulae are ostracized by husbands and communities and suffer from infections, poor quality of life, and even death.

According to The Fistula Foundation, the occurence of new obstetric fistulae number about 50,000-100,000 annually, while the global capacity to treat this condition is only around 20,000. While this condition is extremely rare in developed countries, the World Health Organization estimates that between 2 to 3 million mothers in poor countries struggle with it. While the cause of obstetric fistulae are complex,  with as little as $450-$1000, the condition can be effectively repaired surgically.

My very compassionate and talented fried, Michelle Greer let me know about Samahope. Samahope.org is attempting to tackle this problem. This new venture is working to crowd-fund this procedure for women who can’t afford it. In an elegant interplay between philanthropy and technology, Samahope.org allows donors to select the individuals you want to help, donate simply using PayPal, and even track the outcomes for the surgeries they helped fund. Samahope.org is a project of Samasource.org, a non-profit based out of Silicon Valley who is working to reduce poverty through creating jobs via the innovate idea of mircrowork, connecting people with jobs over the internet. Leila Janah, the founder of Samasource, spoke recently at a TED event in Brussels:

[youtube id=”319sQ9s-lyQ#!” width=”550″ height=”300″ align=”center”]

Get involved and for this Mother’s Day, in addition to that nice pot of flowers and brunch we all like to confer upon our maternals, give the gift of life. If you’re feeling a bit quirky, consider browsing through some Weird Gifts to add a delightful twist to the traditional Mother’s Day celebrations. Those who are looking for custom gift options may consider visiting sites like Swagify to see more items.

Samahope.org is beginning their rollout today. In fact, they have but one tweet. It says, “How can you help change a life with only $20? Easy… I just did.“

[button style=”green” link=”http://www.samahope.org/donate.php” target=”_self” align=”left”]Donate Now[/button]

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Thought of the Week: Connect

Recently, the physical therapist social media world has been a buzz with #SolvePT. I added my thoughts on this in a separate post. This movement made me reflect on a Ted Video I watched and enjoyed recently. It got me thinking and it spawned this week’s thought.

Inspired by the video below by Brene Brown, we need vulnerability to connect. I believe the recent #SolvePT is a nice illustration of connection, albeit virtual, happening within the physical therapy profession. Now, taking the leap to join social media, and then leaping into the conversation means putting yourself out there in a virtual, but very real sense. It means expressing thoughts, views, and ideas. Ideas the world and other PT’s can read (and critique!). It is social media vulnerability, but we need it to truly connect.

Connect!

Now, what about in real life; what about the patients we serve? Many, if not all, come to us in vulnerable circumstances. Sharing their stories, their illness narratives, they are vulnerable. Are we, individually and collectively, creating an environment that welcomes and nurtures vulnerability in order to facilitate connection, understanding, and transformation?

You need vulnerability to connect. What can we do better in our personal and professional lives? Individually and collectively? What can we do better in education of our students and patients?

Thoughts? @Dr_Ridge_DPT

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Can we use Twitter to #SolvePT

Recently, a new hash tag has emerged in the physical therapy twittersphere: #SolvePT. Selena, via the Evidence in Motion Blog, shared her thoughts in a post The Pulse of Physical Therapy. Dr. E of the Manual Therapist also briefly highlighted this new hash tag in a post.

#SolvePT

Initially, discussions focused on financial issues of physician owned physical therapy services (POPTS), student loans, payment, and educational costs. But, today involvement and content was rich with various contributors and topics. Physical Therapist Twitter regulars such as myself (@Dr_Ridge_DPT), Larry Benz (@PhysicalTherapy) and @SnippetPhysTher were present. @PTThinkTank even tweeted a few insights. Other tweeps included:

Topics discussed today were extremely broad and covered many areas of practice:
  • Education: Cost, Length, Effectiveness, Organization
  • Clinical Education: Models, Need for change, Payment
  • Financial: Debt vs. Income, Payment by Setting, Incentives, Payment Models. You may seek Professional Financial Solutions if you are struggling with your financial liabilities.
  • Best Practice: Defining, measuring, incentivizing, and teaching
  • Outcomes: Which ones? How to Measure?
  • Value: Cost Savings, How to measure, How to communicate
A very interesting question that I took from the discussion was: Who is the physical therapy consumer or customer? I made the point that physical therapy has many consumers at various levels of the care delivery process. An individual receiving care from a physical therapist is an obvious and direct consumer. But, other customers of our services include referral sources, other health care providers, payers, hospitals, entities we work for, the health care system, and society as a whole. Our care, but also our knowledge or advocacy, can directly or indirectly affect these various stake holders.

Web 2.0 principles allow us to crowd source and brainstorm with a much wider audience; geographically, practice setting, and expertise. This hashtag will allow for the recording and analysis of a wide range of view points and ideas. We can follow the evolution of topics over time. This stream and  medium could be leveraged by larger, more formal organizations (are you listening APTA?) for idea generation  to guide future task forces and initiatives. In fact, some of the issues, solutions, and thoughts for future direction are solid. #SolvePT is already evolving into a task force.

My Insights and Thoughts

There was a lot of focus on “best practices” in physical therapy. Defining, measuring, communicating, and then teaching best practices is extremely challenging. Todd Davenport of @PacificDPTweet, made the observation that “best practice” is a moving target given the evolution of research, science, and understanding. I agree. Further, who defines best practice? I think we must look beyond a specific patient and episode of care when defining, analyzing, and teaching best practice. In addition, we must look at multi-level outcomes. For example, for an outpatient perspective we can not just look at the patient specific outcome of that episode of care, the time/number of visits, and it’s cost. That is a too narrowly focused frame of reference. We should broaden our lens, and our potential for impact. We need to also need to consider (and target?) recurrence, future health care costs, risk reduction for other medical conditions, and overall health/fitness. Cardiopulmonary fitness is maybe the most dramatic modifiable factor to prevent disease, morbidity, and mortality.

I brought up the topic of physical therapists in hospital intensive care units. Johns Hopkins performed a quality improvement project where they staffed 1 physical therapist for a 16 bed medical ICU. Their estimation is that by decreasing ICU length of stay and increasing patient mobility/function the hospital, and thus the health care system, saved an estimated 5 million dollars over a 1 year period. The internal investigation lead to the hospital staffing 2.2 full time physical therapists solely in a 16 bed medical ICU. This is a dramatic change in practice focused not on productivity or reimbursement, but on VALUE, risk reduction, and other broader outcomes.

Unfortunately, in discussing best practice no attention was brought to the actual content of current PT programs. In my opinion, pain science/physiology, basic neuroscience, critical thinking, philosophy of science, cognitive biases, and metacognition are vastly lacking from our curriculums.

The teaching and study of pain should be integral in all PT education, both didactic and clinical. We have neuromuscular, musculoskeletal, cardiopulmonary, and or medicine tracks in our programs. Why do we not have a specific pain track? Or, at least a focus and integration of neuroscience and pain physiology into our other courses? Regardless of practice setting, the majority of our patients will have a primary or secondary complaint of pain. Joe Brence, who blogs at ForwardThinkingPT, started an online petition regarding this exact topic. I recommend you sign it HERE.

In order to be “evidence based” (or more accurately Science Based) we need extensive training in the philosophy of science and critical thinking including prior plausibility, research design, and article analyses. To assume that students entering PT programs received such instruction as undergraduates is, to put it nicely, a huge assumption. How are we to make appropriate clinical decisions if we do not understand our inherent cognitive traps and biases? How are we to correct them, if we can not even recognize them? The skill of appropriately analyzing a single article based on design, statistics, and results in the context of plausibility, basic science, and the state of other literature AND THEN applying that to everyday clinical practice is what being a master clinician-scientist is all about. And, that is what we need to strive for. The title of Tamara Little and Todd Davenport’s recent editorial in the Journal of Manual & Manipulative Therapy sums it up quite nicely: Should we be expert clinicians or scholars? The answer is yes.

How do we generate results from this passion and discussion?

  1. How do you think we should #solvePT?
  2. What are the most pressing issues in education, payment, practice, and our evolution?
  3. How can we focus some of the general issues and proposed ideas into specific and concrete action; solutions!?

#SolvePT has been thought provoking. Hopefully, it will continue to grow. I foresee big potential in this type of interaction.

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Thought of the Week: MOVE

Our inaugural PT Think Tank Thought of the Week was BE YOU.  This week’s thought stems from a video that has been circulating over the past few months. Inspired by the video below, this weeks thought is:

MOVE

Slow movements, fast movements, weird movements, new movements!! Time to get moving. Obviously, this video discusses some of the health implications of not moving, and the benefits of daily activity. As physical therapists, we are always trying to assist our patients with movement. How can we best assist them to not only become themselves (per the previous thought of the week), but MOVE more to illicit potentially powerful health, wellness, and quality of life benefits? Your thoughts?

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500 Word Letter to the Editor? $31.50…

…real scientific and professional discussion? Priceless.*

*And free

In a previous post, Publishing in Science: Are Industry Standards Serving Researchers, Clinicians, and Science?, @JasonSilvernail and I discussed some of the problems with the current publishing industry paradigm as well as our personal frustrations with the process. These insights stemmed from writing a letter to the editor of Manual Therapy, which is currently e-published ahead of print (in press, corrected proof). A link can be found here: Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant.

Well, unfortunately for you, reading that letter will cost you $31.50 unless you have a subscription to Manual Therapy, or are affiliated with an institution with accessing rights. For those of you doing mental math at home, that equates to 6.3 cents per WORD (references included at no extra charge!!) Of course, no abstracts accompany letters to the editor, but they do provide a 29 word preview (essentially 1.5 sentences). My question is: does anyone EVER buy a single letter to the editor? I sure hope not. Logically, I can’t imagine publishing companies profit significantly off 500 word letters to the editor, because I can’t imagine anyone buying them.

Now, if you would like to read our longer, better version that was denied prior to review check out this post:        SI Joint Mechanics in Manual Therapy: Relevance, Please? It even includes links to 2 other blog posts that have healthy discussions happening in the comments section. The references section contains links directly to abstracts.

  • Don’t agree? Have other insight? Want to comment? Click the comments section and fire away.
  • Want to share? Tweet, link back, Facebook, Google+, e-mail, and re-distribute the link freely.

Putting a 500 word letter to the editor behind a pay wall seems to accomplish nothing for science, discussion, clinicians, or even the publishing companies. We think it’s time for a change...

@JasonSilvernail   &   Dr_Ridge_DPT