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  • News at NEXT: Variation in Care Is the Profession's Greatest Challenge, Maley Lecturer Says

    Physical therapy cannot move forward as a profession until those who practice it resolve the issue of unwarranted variation in practice. Tara Jo Manal, PT, DPT, FAPTA, in her delivery of the 22nd John H. P. Maley Lecture, was unequivocal in sending this message to the profession. "The greatest challenge to the value of physical therapy is unwarranted variation—situations in which wide variation of care is not explained by the type or severity of the condition or by patient preferences," she said to a capacity audience on June 23 as part of APTA's NEXT Conference and Exposition.

    Physical therapy is not the only health care discipline with this problem; unwarranted variation is a challenge within all of health care in meeting the triple aim of improving societal health, enhancing the individual patient experience, and reducing costs. But even if physical therapy has not yet been in the "center of the crosshairs," Manal said, our profession increasingly has been identified as an area of interest as payment moves toward value-based systems in order to reduce waste in spending. The lack of standardization in physical therapist practice "puts all physical therapists at risk for reductions in covered rehabilitation services," she said.

    The profession's response must be to "invest inward to solidify our procedures, use what we already know to maximize our return on our clinical efforts, and solve this problem," Manal said. As a start, she suggested that the profession "stop looking to expand our scope and promote our ability to practice at the top of our license until we get our house in order, to ensure that all patients are cared for at the highest level in every physical therapy setting with every provider."

    Clinical practice today is "chaotic," Manal said. Some factors can't be modified, such as limitations set by payers and regulation. And it's hard to avoid "the chaos of the human factor," such as sick coworkers, appointment glitches, and equipment breakdowns. But what can be modified "is the disorganization and even confusion that occurs when we fail to standardize our physical therapy care," she said. When PTs take a "blank page" approach to every patient and treatment, clinical success is based on the premise that they "can remember all the information … for any given condition at any given moment" in applying treatment. "That is quite simply an unrealistic expectation."

    Creating and using evidence-based patterns of care will avoid the blank-page dilemma, Manal said, and how PTs and PTAs access needed knowledge to do so is key. Reading only primary literature isn't feasible—Manal cited a 2009 study concluding that for internists to stay current in their field they would need to read 34 articles daily, a "daunting" effort. Instead, she argued for reading synthesis documents such as clinical practice guidelines, which review, weigh, and grade available evidence.

    Among the reasons that clinical care patterns aren't more widely adopted, Manal said, are a lack of understanding of their added value to daily care and the belief of many clinicians that they already follow best practices.

    To the first reason, Manal countered that "standardized rules … add value by reducing clinical chaos and improving outcomes. [They] assess risk and suggest matched-treatment interventions to maximize the success of your physical therapy care." However, to make the most of standardized tests and measures, Manal said PTs must perform them at regular time intervals and as described in the literature, "not using our favorite modification." Further, tests with poor reliability and no validity need to be abandoned.

    This is not to say that evidenced-based care patterns are "cookie-cutter," Manal explained. "Some patients progress quickly and need no special efforts, while others require creativity and change—but guidelines ensure that milestones are met before progressions occur."

    To PTs who believe "I already do that," Manal argued that therapists who incorporate guidelines and use standardized patterns of care "unburden themselves from the fallacy of being all-knowing and, instead, benefit from the best we as a profession have to offer."

    Manal suggested that patient self-reporting and performance-based outcomes "can help tell you whether you are at or above the current best standard of care, or would benefit from adherence to standardized care patterns to decrease clinical chaos." She pointed to the APTA Physical Therapy Outcomes Registry as a tool to enable clinicians to compare themselves with colleagues. She noted, though, that, first, comparative data must exist, meaning "therapists must participate in collecting minimum data sets at specific time intervals" to make accurate comparisons.



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    • I thought your Maley lecture was excellent! I have been a practicing PT for 26 years now and for most of those 26 years, have worked hard to reduce the variability in practice wherever I have worked. It finally led me to stop trying to fix other peoples/groups clinics and open my own…where I could really make an impact. Many of the concepts you have touched on I have implemented in my daily practice and how I manage my offices and it has made an impact on referral sources. They know what to expect when they send patients to my offices and having standard (evidence based!) approaches to orthopedic care has make a big impact on having consistent outcomes. Hopefully more people feel the same way and will help push our profession forward.

      Posted by Michael Vacon on 6/27/2017 1:12 PM

    • that was a great idea

      Posted by Dr NNAMDI on 6/27/2017 5:33 PM

    • A very important aspect of our practice to consider. Working a clinical PT for a number of years, the value of using standardized tools for assessment and comparison has been invaluable. I have one concern, which is the reality of those who are in our profession who still look for the "quick and easy" way. Educators and peers need to speak up when they notice "assembly line" care. Utilizing standardized tools and documentation procedures still allow the PT to use their professional expertise to modify the direction of treatment when their "tools" tell them outcomes are not what they should be. We are here to do more than record results, we are professionals who need to make decisions to benefit our patients....not increase our MIPS score. Hopefully, if we do it right....we can do both.

      Posted by Diana Echert on 6/30/2017 6:40 PM

    • The topic of this lecture would be an interesting one for debate. On one hand, I agree that some level of standardization of care is necessary. However, I think the standardization should be more in general guiding principles and perhaps not so much in the specific execution of treatment. On the other hand, to consider unwarranted variation in care as "the greatest challenge" to our profession strikes me as hyperbole at the very least and a grossly inaccurate assessment of the importance of our many other professional challenges. Perhaps Dr. Manal's lecture included this information but no place in this article did I find the criteria by which variation in practice is determined to be unwarranted. Is there evidence for this contention? Where is the measurement and quantification of unwarranted variation? One person's unwarranted may be another person's valuable discovery. The annals of science are filled with examples of individuals who bucked the system, the science, and the prevailing thought of the time and turned out to be right on the mark. Personally, I find this movement to monitor, measure, and control one's every action and interaction to be stifling, both to innovation and creativity as well as to what it means to be a free and independent human being with practiced critical thinking skills and well developed intuition tempered by compassion and wisdom. We run the risk of becoming more robotic than human and that would be a shame. Of course, with advancements in AI, cybernetics, robotics, nanotechnology, materials science, etc., we may well be replaced in the future by vastly superior non-human physical therapists who follow orders to a T, maximize productivity, minimize expenses, never make an error, never have emotions, never fatigue, never miss a day or hour of work, constantly download the latest science and technology, etc. That may sound like an employer's heaven but it also sounds potentially nightmarish to this particular human being. There is an agenda at work here, known overtly to a very few but practiced and advocated by a growing number who don't really understand the end game but have been propagandized into believing that they do and are doing it for the best interests of all concerned (albeit mistakenly so). Look behind the curtain folks and understand the meaning of thesis, antithesis, and synthesis to know where you're being lead. It's a path you may one day regret.

      Posted by Brian Miller -> =KX[> on 7/1/2017 6:48 PM

    • I appreciate Dr. Malan's topic and the ensuing discussion. I agree with portions of the above comments from Brian Miller. After 33 years of private practice I am not sure I would have cited unwarranted variation as our biggest problem in PT. Rather, I would name acceptance and perpetuation of interventions that accomplish less than ideal as our biggest issue. When a study finds that 12 wks of yoga is as effective as 12 weeks of physical therapy, I would suggest that something is wrong with the physical therapy being administered. From my perspective this is not cause for celebration, but rather should prompt serious examination of our value. Yoga, compared to PT, is much cheaper for the participant, and also for the instructor in terms of educational preparation. Clinical practice guidelines, while providing some parameters, are extremely broad and still allow for quite a bit of variation, such as the recently published hip CPG in JOSPT June 2017. Additionally and to my point, I find it rather disheartening that this CPG cites 10 treatments of ultrasound over a 2 wk course as acceptable. Yet there is no mention of dry needling anywhere in this document, unless it might be considered in the category of soft tissue mobilization. Needling has an impressive and growing base of evidence behind it, and should be considered. Dr. David Hunter, in the Viewpoint of the same JOSPT issue, proposes the need for a change in our approach to OA. He cites part of the problem, "....in much of our management of this chronic disabling disease is focused on treatments that have no clinically meaningful benefit over placebo, are harmful, not cost-effective, or all of the above." In my opinion this is a huge problem for PT. Thank you for this forum.

      Posted by Colleen Whiteford, PT, DPT, OCS on 7/4/2017 12:27 PM

    • The value I see in this speech is the debate and thought that it should inspire. I would contend alternative thoughts that systemization of treatment is in itself a threat to the profession as it attempts to align itself with third party payers that seek to control and predict treatment plans for financial gain. Payments that pay therapists for their time and their results including the time to achieve those results and their robustness is arguably a better approach. This enables therapists to practice in the truest sense of the intention behind evidenced based practice - not summaries of systematic reviews. Our biggest priority are client results and our own. Where the results are the money will follow. In Stephen Coveys book the third alternative he articulates a better place for the profession to position themselves "on the edge of the coral where new life is"

      Posted by Tim Wolff on 7/8/2017 7:13 AM

    • I enjoyed reading Brian's and Tim's perspectives on this topic. As a physical therapist and clinician for 40 years, I do not think that practice variation is our biggest challenge at all. Our biggest challenge is to demonstrate the value of physical therapy care to our patients, policy makers, payers, and competitors external to the field of physical therapy. Value was defined by Michael Porter as achieving effective patient outcomes efficiently. Value was first introduced by the Institute of Medicine in 2001 with its prescient publication ‘Crossing the Quality Chasm’ and subsequently health care has been shifting (too slowly from my perspective) from volume of services to focus on quality of care. Patient-centered outcome measures are a key component for objectively demonstrating quality of our patient care. Yet most practicing physical therapists today do not use these measures but continue to rely on biomedical markers such as ROM, muscle tone, and strength to track patient progress. Going forward I believe our biggest challenge will be to educate physical therapists on 1) how to administer patient centered measures throughout the patient’s episode of care and 2) how to use patient reported outcome data to treat their patients and inform better clinical decisions to maximize patient outcomes during everyday practice. I also believe if physical therapists do not become proficient with patient reported outcome data utilization, their practice may disappear as other competitors realize the power behind patient centered outcomes data. Mark Werneke mwsurf75@gmail.com

      Posted by Mark Werneke -> =JVaA on 7/8/2017 5:10 PM

    • I love the talk. My PT colleagues and i run 12 programs using treadmills (20-30 min) for increasing walking speed, balance and endurance 2x/week Testing 6 min,gait speed, FGA, balance test.. Every week i get feedback that treadmill is dangerous! Over the 15 years we have seen 500 client's at all levels. Terry Steffen PhD, PT

      Posted by Teresa Steffen on 7/9/2017 10:25 AM

    • Dr. Manal makes a lot of great points about variation. There has to be continiuty of care for society to better understand the role of a physical therapist and shape their expectations. Mark Werneke makes a lot of great points in his comments above and I think his assessment of the ongoing challenges is most accurate. Most clinicians utilize EBP and CPGs. The variability comes with trying to combat reimbursement issues and providing service based care above and beyond the standards of practice. A physical therapist may be providing excellent evidence based care, but if the patient is not happy and does not value our care, then the physical therapist will reach beyond clinical practice standards to sell their treatment to the patient. That's where the variability come into play. Until we reach our 2020 vision (which will take longer), there will continue to be variability. We are licensed independent practitioners who are the only clinical experts in the healthcare field in the evaluation and treatment of movement dysfunction, yet patients with acute low back pain will go to a general practitioner who has 2 weeks of musculoskeletal training in medical school to dictate their care. That's a huge problem and disconnect. Until we become the practitioner of choice and fight the constraints placed on us by the American Medical Association, third party payers (dictated by the AMA), and better educate physicans and the community on our clinical expertise in our doctoring profession, things will not change. This is on us, we have to do better.

      Posted by Michael Stidham, PT, DPT, OCS, SCS on 7/12/2017 9:31 AM

    • For those interested in hearing the lecture- it is now posted. https://www.apta.org/NEXT/2017/MaleyLecture/

      Posted by Tara Manal on 8/16/2017 4:28 PM

    • I could not agree more with Mr. Stidham on fighting the onus of "value based care" affecting our reimbursement under rules developed and upheld by AMA. How ironic that we are side tracked on fighting a cap amount which is moot when payers like Medicare Advantage allow only 4 or 6 visits per episode of care, and their 950+ pp PT guidelines are authored by physicians. Or, that we have to defend outcomes reporting using subjective questionnaires often assigned to impairment categories by lay people in finance. In writing our CPG's I certainly hope we aren't digging our own graves by severely limiting use of interventions while so poorly defining movement screens across inter-regional body segments which typically move together. We call ourselves movement experts and we need to own this, not worry so much about taking on primary care which neither rewards nor acknowledges our place in general health management. Unless we're going to admit out loud that there just aren't enough GP's, I do not expect my PT training to put me in that role and I don't see how our direct access has raised our value in these services. To date we rely on isolated ROM and muscle tests which belie the complexity of motion, and we are far from standardized in our doctoral level curriculums for managing the very essence of our treatment domain. No wonder the worry about so much variation, when we continue diluting our original scope of practice and relying on others to dictate the standards of intervention.

      Posted by Katherine Humphrey -> =HT_DL on 9/14/2017 11:22 PM

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