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  • Choosing Wisely at 5: Is It Making a Difference (And What About the Next 5 Years)?

    Five years into the American Board of Internal Medicine (ABIM) Foundation's "Choosing Wisely" campaign, most health care providers and consumers who've heard about it agree that the initiative has something important to say about avoiding unnecessary tests and procedures, including some associated with physical therapy. But has that awareness increased significantly, and does it translate into changes in behavior? Some say no—or at least not yet.

    ABIM's recently released special report on the first 5 years of the Choosing Wisely program characterizes the initiative as a sorely needed effort that is gaining momentum. Since its beginnings in 2012, the collection of ineffective and overused treatments and tests has expanded to 525 recommendations from more than 80 specialty society partners, according to ABIM. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question."

    The initiative, which partnered with Consumer Reports, has received wide media attention during the past 5 years and has even expanded to 19 other countries around the world. "Clinicians and patients all across the United States—and now the world—are engaging in conversations about avoiding unnecessary care thanks to the efforts of medical specialty societies, health systems, clinical practices, consumer groups, and community collaborations to advance Choosing Wisely," the report states.

    But has the program gained traction? And more to the point, are the Choosing Wisely recommendations being followed on a wide scale? Answers to those questions may not be as positive, say researchers writing in Health Affairs.

    To find out the extent of Choosing Wisely's impact, researchers followed up on an ABIM survey of 600 practicing physicians conducted in 2014 with a survey of their own, conducted this year. Authors of the study wanted to find out if knowledge of the program has grown since 2014, and whether physicians were actually following Choosing Wisely recommendations.

    The results of the 2017 survey are based on an underwhelming response rate—just 5.5%—but the researchers pressed ahead, asserting that the low response rate may, if anything, skew results in favor of physicians who know and support Choosing Wisely and were thus more willing to participate.

    Authors of the study found that the percentage of physicians aware of the campaign in 2017 (42%) had not grown significantly since 2014 (39%), nor had the percentage of physicians who believe campaign is valuable, from 91% in 2014 to 93% in 2017.

    When asked for their opinions on what is driving the continued use of low-value care identified in Choosing Wisely, 87% of the 2017 respondents cited malpractice concerns (87%), followed by physicians' desire for more information (84%) and "just to be safe" (78%). As for changes to health care that would help to decrease use of low-value care, most physicians surveyed pointed to malpractice reform (92%), followed by spending more time with patients (88%) and financial rewards (72%).

    Authors were skeptical that malpractice concerns are truly a driver of use of low-value care, citing research that estimates "defensive medicine" adds roughly 3% to overall health care spending. Similarly, the argument that patient demand drives the use of low-value care is also not supported by research, according to the study's authors.

    The relatively slow decline in the use of unnecessary care since Choosing Wisely's debut points to a need to develop a "roadmap" for the next 5 years, 1 that will lead to a greater impact on care, say authors of a separate analysis and commentary that also appeared in Health Affairs. They stress the need for more robust efforts at almost all levels, from stronger recommendations from societies to the use of more rigorous study designs to evaluate barriers and outcomes.

    Authors cite 4 major areas that they believe need to be strengthened if the Choosing Wisely campaign wants to make a real difference in usage of low-value care:

    Strong methods for developing recommendations. Authors assert that early on, societies tended to select tests and treatments that were fairly safe bets among their members—low-value, to be sure, but also not necessarily widely practiced. Recommendations now need to move into areas that have wider prevalence and potential impact, they write.

    Innovative intervention methods. More thinking needs to go into why providers and patients are not opting out of low-value services, including looking into behavioral science frameworks that shed light on decision-making, and investigating ways to pursue cultural change among clinicians and patients.

    Meaningful evaluation techniques. Rigorous research should be applied to studying the barriers to and facilitators of success, authors write, including measurement of clinically meaningful outcomes.

    Collaborative dissemination. Authors believe that states, communities, patients, payers, health systems, and academic partners need to be brought together in a more coordinated way to "test and disseminate successful approaches."

    "Clearly, [Choosing Wisely] has been changing the conversation and is beginning to influence culture, thus setting the foundation for the next 10 years," authors write, citing "a convergence of activities" for realizing the campaign's potential already exists, including support from organizations, increased use of accountable care organizations and value-based payment models, and the pressure patients face through higher health insurance deductibles.

    "Choosing Wisely has created a principal pathway through which patients and their doctors can discuss when health care services may not be needed," authors write. "As we have outlined, several important steps still remain to fulfill the promise of Choosing Wisely. It is now time to take those steps."

    To get a better sense of how the Choosing Wisely campaign intersects with APTA's efforts to help PTs and PTAs understand their role in reducing fraud, abuse, and waste, visit the association's online Center for Integrity in Practice.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Review: Sport Specialization at an Early Age Can Increase Injury Risk

    Parents and coaches need to be educated on the risks and signs of overuse injuries common in children who specialize in a single sport at a young age, say authors of a recent research review published in theAmerican Journal of Sports Medicine. Surgery, they concur, should not be the first-line treatment for such injuries.

    An increasing number of children are focusing on 1 sport early, often because parents and coaches are enticed by the possibility of scholarships and professional participation, “increasing emphasis on sports accomplishment,” and perceived value of elite competition, authors note. But the evidence, say authors, suggests that children who wait until age 12 or older to specialize in 1 sport or begin intense training reach higher levels of athletic achievement than those who specialize at a younger age.

    In general, say authors, young athletes’ “underdeveloped musculature” and still-growing bones make them prone to overuse injuries such as rotator cuff tendinitis, shoulder instability, humeral epiphysiolysis, knee and elbow ligament injuries, hip impingement, and stress fractures, among others. The strain to a developing body also may increase their risk of injury as adults.

    The authors write that more research needs to be done to determine early specialization risks and injury patterns for specific sports, and to identify long-term consequences. In the meantime, they urge, it is important to inform parents and coaches about general injury risk and signs of overuse injuries in children. In addition, say authors, while “operative treatment is occasionally indicated for these injuries [it] should not be taken lightly or considered the first treatment option for most overuse injuries.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Available through the APTA Learning Center: "Repetitive Stress Injury in Youth Athletes," an online course that explores the most recent evidence related to differential diagnosis and treatment of common repetitive stress injuries in this population.

    Study: Direct Access to Physical Therapy Safe, Effective, and Cheaper Than Referral-Based Care

    In brief:

    • Researchers analyzed claims and outcomes data for 447 patients receiving physical therapy for back or neck pain either via direct access or medical referral
    • Patients in both groups received the same guideline-based care using the same outcome measures
    • Improvement in pain and disability was similar, but direct access patients with neck or back pain incurred $1,543 lower average costs than those who chose referral from a physician, with no adverse events
    • Authors suggest physical therapy direct access as 1 way to decrease cost of care in this population

    While opponents of direct access to physical therapy often cite patient safety as a concern, a new study comparing direct access and traditional access to care identified similar outcomes, no adverse events, and lower cost of care. Patients who obtained physical therapy via direct access had significantly lower medical costs—an average of $1,543 less per patient than those who chose referral from a physician. The study was e-published ahead of print in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free).

    Using a clinical registry, researchers compared 2 years' worth of claims data and patient outcomes for 447 patients who received physical therapy for back or neck pain in a “physical therapy-led spine management program” via medical referral versus patients who accessed physical therapist care without a referral. Outcome measures used for the study were the numeric pain rating scale, Oswestry low back pain index or neck disability index (as appropriate), the patient health questionnaire for anxiety and depression (PHQ-4), and the EQ-5D, a standardized overall health status measurement instrument.

    The 276 patients who chose direct access had “significantly fewer” physical therapy sessions (mean = 0.9) and days in care (mean = 10.5). The average cost per direct access patient was $260 less for physical therapy, $169 less for radiology, and $53 less in “other costs” such as medications compared with individuals who accessed physical therapy after physician referral. Total cost savings for the entire direct access group equaled $400,000.

    “These findings are pragmatic and reflect the impact of patient choice to access care for neck and back pain in a real clinical environment,” say authors. “Our results suggest who sees a patient with neck and back pain first influences downstream costs over the next year.”

    This is significant, according to the researchers, because “spine-oriented conditions” cost $85 billion every year, not including costs of workplace productivity. And these costs continue to rise—the average cost per patient has increased 49% between 1997 and 2006.

    Authors note that the increase in costs has not led to improved outcomes, hypothesizing that 1 possible reason is the delay in care due to the process of medical referral. They believe direct access to physical therapy would lead to lower costs and outcomes similar to traditional medical referral avenues.

    Researchers merged clinical data from the ATI Patient Outcomes Registry with claims data from Blue Cross Blue Shield of South Carolina. All participants were adult employees or employee dependents of the Greenville Health System in South Carolina. The program included access to 8 physical therapy clinics in 3 counties. During the program, BCBS actively encouraged patients to seek physical therapy care first, rather than seek physician care first for low back or neck pain. BCBS plan benefits were the same for both groups.

    All patients received the same type of care based on clinical practice guidelines with progression criteria and were evaluated using the same outcome measures for pain, disability, psychosocial factors, and overall health. In a few cases, direct access patients were referred to a physician for consultation.

    “When patients chose to see a physical therapist first, there were no identified incidents of missed diagnosis or delays in care as a result of physical therapists’ clinical decision making," authors write. "This suggests that physical therapists utilizing a standardized, evidence based screening questionnaire can adequately determine appropriateness of physical therapist intervention. This is an important finding, as patient safety is often noted as a counter argument to direct access to physical therapy.”

    Authors of the study include APTA members Thomas R. Denninger, PT, DPT, Chad E. Cook, PT, PhD, and Charles A. Thigpen, PT, PhD, ATC.

    The study did have some limitations: The majority of the patients chose traditional referral. Patients in that group were younger, more likely to have acute onset of symptoms, and more likely to have widespread pain. The study also was potentially biased by “unmeasured factors” influencing patients’ choice of first provider, lack of prior health utilization data, and exclusion of patients who did not complete physical therapy.

    However, authors say the results “suggest that the availability of the choice to pursue direct access to physical therapy for back and neck pain is safe and provides similar outcomes with cost savings comparing to traditional medical referral.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: For Individuals With Knee OA, 3 Tests Can Predict Ability to Walk 6k Steps a Day

    Getting individuals with knee osteoarthritis (OA) to walk regularly is a crucial component in reducing knee pain, improving physical function, and staving off comorbidities such as cardiovascular disease. But how can a clinician know if a patient is capable of meeting minimum walking recommendations? Authors of a recent study believe it may come down to performance on 3 simple tests.

    In a study of 1,925 participants with or at risk for knee OA, researchers sought to link performance on the 5 times sit-to-stand test, the 20-meter walk test, and the 400-meter walk test to walking patterns outside the clinic. Participants ranged in age from 56 to 74 years, with an average age of 65. The study was e-published ahead of print in Arthritis Care and Research (abstract only available for free).

    Participants were given accelerometers and instructed to wear the devices during waking hours for 7 consecutive days. Participants' accelerometer data were later reviewed and compared with their performance on the 3 tests. Researchers divided participants into 2 groups—those who averaged 6,000 or more steps a day and those who averaged fewer than 6,000 steps. Here's what they found:

    • The overall steps-per-day average for all participants was 6,166 steps a day, but there was wide individual variation—by nearly 3,000 steps above or below the average.
    • Just over half (54%) of participants walked 6,000 or more steps a day.
    • Average performance on the tests were 10.5 seconds on the 5 times sit-to-stand test, 1.33 meters per second for the 20-meter walk test, and 306 seconds on the 400-meter walk test.
    • Each additional 1 second it took for a participant to complete the 5 times sit-to-stand test was associated with walking 130 fewer steps a day.
    • Walking 0.1 meter slower during the 20-meter walk test was associated with walking 342 fewer steps a day.
    • Each additional 10 seconds it took for a participant to complete the 400-meter walk test was associated with walking 125 fewer steps a day.

    The bottom line, according to researchers: taking longer than 12 seconds to complete the sit-to-stand test, walking slower than 1.22 meters per second during the 20-meter walk test, or taking longer than 5.22 minutes to walk 400 meters are reliable indicators that an individual with knee OA may not have sufficient physical function to reach the 6,000 steps-per-day walking goal.

    That, authors believe, is where the role of the physical therapist could make a big difference.

    "One possible implication of our study is [that] referral to rehabilitation, such as physical therapy, may be of benefit to those with or at risk of knee OA not meeting 1 or more of these physical function thresholds," authors write. "[Common] interventions that are employed by physical therapists are effective to improve physical function in people with knee OA."

    Authors of the study include APTA members Hiral Master, PT, MPH; Louise Thoma, PT, DPT; Meredith Christiansen, PT, DPT; Emily Polakowski, MS, SPT; Laura Schmitt, PT, DPT; and Daniel White, PT, ScD, MSc.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    From PTJ: PTs, PTAs, Students Report High Rates of Inappropriate Sexual Behavior by Patients

    Inappropriate sexual conduct happens everywhere, and physical therapy settings aren't immune to the problem, according to a new article e-published ahead of print in Physical Therapy (PTJ) that looks at instances in which patients are the perpetrators of the conduct. The article is based on a survey of 892 physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy students which found that 84% had experienced inappropriate patient sexual behavior (IPSB) at some point during their careers or training, and that 47% experienced IPSB within the past year. (Editor's Note: Articles e-published ahead of print are not the final version. The final version of this article will be published in the November issue of PTJ.)

    The study, which authors describe as the largest of its kind to focus on IPSB among PTs, PTAs, and students, found that there has been little progress on the issue since a similar 1997 study of PTs only, in which prevalence of IPSB over the length of a career averaged 81% to 86%. The high rates "warrant practitioner and student education, as well as workplace policy and support," authors write.

    Authors define IPSB as instances in which a patient engages in any of a range of behaviors, "from leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault." For the purposes of the current study, IPSB was categorized into 3 groups: mild (such as being leered at or being given a romantic gift), moderate (including sexually suggestive gestures or being propositioned for sexual activity) and severe, which includes indecent exposure, physical touch, harassment outside the workplace, and forced sexual activity.

    Mild IPSB at some point during their careers was reported among 77% of respondents, with "patient made a sexually flattering or suggestive remark" experienced by 68.8% of those who encountered that level of IPSB. "Patient stared at you or your body parts in a way that made you feel uncomfortable" was experienced by just over half of the respondents (55.5%) who experienced mild IPSB. More than 1 in 3 (34.6%) reported patients asking for dates.

    Among the 58% of respondents who reported moderate IPSB, 52% reported instances in which a patient "made [an] overtly sexual remark or joke, asked you questions or commented on your sex life, or shared a sexual fantasy about you." Close to 31% of the respondents reported a patient making sexually suggestive gestures, and 11.2% said that they were propositioned for sex by their patients.

    Severe forms of IPSB were reported by 37.2% of respondents, with 20.3% of that group saying that a patient had purposefully touched or grabbed them in "private areas" or in "a clearly sexual manner." Among this group, 7.7% reported instances in which patients followed, watched, or harassed a respondent, while 0.9% reported experiencing threats of forced sexual activity or an attempt at forced sexual activity, and 0.3% reported being forced to submit to sexual activity.

    Some of the risk factors authors identified for IPSB among physical therapy clinicians include fewer years of direct patient contact, routinely working with patients with cognitive impairment (PWCI), female practitioner gender, and male patient gender. Of those risk factors, clinical experience was the most predictive risk factor, followed by managing patients with PWCI.

    The study found that women were more than twice as likely as men to have experienced IPSB, and clinicians who treated mostly male patients had a 400% greater chance of exposure to IPSB. Additionally, being new to the profession also put respondents at higher risk: 58% of physical therapy students experienced IPSB, compared with 42% of physical therapy professionals.

    Still, authors point out, these risk factors only account for up to 15% of the total variance, meaning that the possibility of a PT, PTA, or student experiencing IPSB during any given year is a very real one for nearly all areas of the profession.

    In a related PTJ podcast interview with Editor in Chief Alan Jette, PT, PhD, FAPTA, to be released in November, Jill S. Boissonnault, PT, PhD, and Ziádee Cambier, PT, DPT, 2 of the study's coauthors, discussed the characteristics of IPSB and management strategies to mitigate or address the issue.

    Physical, sexual, psychological, and racial abuse are all serious issues for health care providers, but, Cambier notes, “it makes sense to separate them out for more in-depth research” because there are “real differences” in risk factors and responses to the particular type of abuse.

    While workplace training can “help people prepare” for IPSB, says Cambier in the podcast, it does not prevent the events from happening. Establishing clearly stated workplace policies and supports may help to prevent or address IPSB, including options and procedures for staff such as:

    • When employees can have a second staff member in the room
    • When and how to transfer patients or terminate care
    • How to issue warning letters
    • How to use behavioral contracts

    Most important, Boissonnault states in the podcast, is training supervisors to offer support. The study includes responses to open-ended questions that show varying levels of attention to IPSB among supervisors, from 1 respondent who reported feeling "very supported by my clinical instructor and other staff" to others who felt that when they reported IPSB, they were not taken seriously by supervisors, not helped, or even punished for reporting the inappropriate behavior.

    Some respondents even reported instances in which the supervisor tacitly or actively participated in IPSB, including 1 male clinical instructor who did not intervene when a patient commented on the respondent's physical appearance, and actually joined another patient in giving the respondent dating advice.

    "He definitely didn't have enough training on the topic," the respondent wrote. "When I discussed my experiences with 2 female classmates, I found that every 1 of us had been harassed on our summer internships."

    APTA has taken a strong position on sexual harassment, and provides a webpage to help members recognize harassment and understand their rights.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Just Taking a Walk Can Extend Your Life, Say Researchers

    Experts have long encouraged moderate or vigorous walking to improve overall health. However, new research published in the American Journal of Preventive Medicine shows that even some walking is better than none for reducing all-cause mortality in older adults.

    Few studies have explored the potential association between walking and mortality rates in the aging adult population. Researchers attempted to focus on this relationship by analyzing data from participants in the American Cancer Society’s Cancer Prevention Study Nutrition Cohort. The present study compared baseline 1999 physical activity survey data from 62,178 men (mean age, 70.7) and 77,077 women (mean age, 68.9) with death rates and causes from 1999 through 2012.

    The survey asked participants about a variety of types of physical activity, including pace and frequency of walking. Authors report that 5.8% of men and 6.6% of women had no physical activity at baseline. These "inactive" individuals were compared with individuals assigned to 3 groups for whom walking was their sole form of physical activity: an "insufficiently active" group (walking fewer than 2-3 hours a week), a "minimum up to twice [the standards]" group (2-6 hours per week); and an "exceeding recommendations" group (over 6 hours per week).

    Researchers found that even a small amount of walking had an impact on health, with the all-cause mortality rate for inactive individuals 26% greater than for the "insufficiently active" group. And things got better the more people walked: Compared with the insufficiently active group, participants who walked 2-6 hours per week were 20% less likely to have died by the end of the study, and those who walked more than 6 hours per week were 22% less likely.

    Walking as the only form of physical activity, even at fewer than 2 hours per week, also was significantly associated with lower rates of death from respiratory disease, cardiovascular disease, or cancer compared with inactivity. Interestingly, authors note that these effects were similar when comparing by participant sex, baseline age, BMI, prevalent disease status, and leisure-time sitting.

    "Engaging in any walking or other [moderate-to-vigorous physical activity], even if not meeting the minimum recommended levels, is associated with lower mortality compared with inactivity," authors write. Walking is an "ideal activity" for most people, they say, because it is "simple, free, and does not require any training."

    Authors also cite some disturbing facts, asserting that physical inactivity accounts for 6%–10% of the world’s noncommunicable diseases and 11% of United States (US) health care expenditures. In addition, they write, the percentage of US adults over age 65 is expected to reach 20% by 2030.

    Getting people to walk more may take more than sparking interest and motivation—it may also require stronger efforts to create environments that walking easy, or merely possible. According to 1 recent assessment, that part of the equation is missing in much of the country: a National Physical Activity Plan Alliance "report card" on walking and walkability says that the US is falling short when it comes to the pedestrian-friendliness of its communities. APTA is an alliance member.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Researchers Find No Evidence for Popular Treatment for UI, POP

    There are solid evidence-based treatments for pelvic floor dysfunctions such as urinary incontinence (UI) and pelvic organ prolapse (POP), but 1 treatment popular in Europe, South America, and Canada isn’t among them. In fact, researchers write, the treatment—called abdominal Hypopressive technique (AHT)—is at best an approach still “in development,” with no significant data to back it up.

    In an article published in the British Journal of Sports Medicine (BJSM) (abstract only available for free), researchers described their attempts to track down studies on AHT, a group of breathing and posture exercises created in the 1980s. The exercise involves diaphragm inspiration followed by total air expiration and gradual contraction of the transversus abdominis (TrA) and intercostal muscles. Proponents of AHT believe the decreased abdominal pressure created through the exercise sparks a reflex response of muscles in the abdominal wall and pelvic floor, which in turns reduces UI and POP.

    But according to authors of the BJSM article, there’s a problem: no published evidence exists that supports the effectiveness of AHT. Searches on multiple research databases including PubMed and the Physiotherapy Evidence Database (PEDro) turned up only 2 studies that involved AHT—an experimental study that added AHT to a regiment of pelvic floor musical training (PFMT), and a randomized controlled trial involving the addition of AHT to PFMT among 58 women with stage II POP. Both studies found no effect from the addition of AHT.

    “At this stage, AHT is based on a theory with 20 years of clinical practice,” authors write. “We conclude that at present, there is no scientific evidence to recommend its use to patients.”

    Carrie Pagliano, PT, DPT, vice president of the APTA Section on Women ‘s Health, says while it’s true that the evidence isn’t there for AHT as a standalone or first-line treatment, clinicians shouldn’t be quick to dismiss some of the principles that underlie AHT.

    “There is some anecdotal, case-by-case support for this technique, and clinicians that use it in practice do identify Hypopressives as a small component of treatment,” Pagliano said. “Despite the small number of studies with little support for AHT, this shouldn’t discount the use of Hypopressives in conjunction with a thorough evaluation of the patient and a sound critical hypothesis.”

    While not as prevalent in the US, AHT is described by authors of the BJSM study as a treatment that has “worldwide huge interest [among] the public and clinical community.” The approach is marketed through a website that offers provider training on the technique, and is now taught by more than 1500 coaches in 14 countries, according to the BJSM article.

    In contrast to AHT, there is an approach that does in fact have high-level evidence for effectiveness, according to the reseachers: PFMT. Still, they write, “despite the strong evidence for PFMT for [UI and POP], several other exercise regimens have been proposed and advocated.”

    The problem, authors point out, is that for AHT, what’s being advocated hasn’t yet been associated with a strong foundation in research.

    “This particular treatment currently illustrates the phenomenon that not all recommended treatments are evidence based,” authors write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Foundation Funding Opportunities Available for 2018

    The Foundation for Physical Therapy (Foundation) is now accepting applications for 2 major funding programs.

    Eligibility and application information for the postprofessional 2018 Promotion of Doctoral Studies (PODS) Scholarship and the New Investigator Fellowship Training Initiative (NIFTI) (a $100,000 award over a 2-year period) is posted on the Foundation website. The deadline to apply is January 10, 2018, by 12:00 pm, ET.

    Applicants are encouraged to start the submission process early to allow for potential questions to be answered. Award recipients will be notified in June.

    Contact Jordan Rochon for more information, or call 800/875-1378, ext 3167.

    Important tip: thoroughly read through all instructions and funding mechanism deadlines before beginning your application. Want to stay on top of what's available? Sign up for the F4PT Alert and be first to know about Foundation funding opportunities.

    Study: CMS Should Pay Closer Attention to Chronic Wounds

    In its push toward outcomes-based models, the US Centers for Medicare and Medicaid Services (CMS) needs to take a closer look at wound care, say authors of a new study that estimates nearly 15% of all Medicare beneficiaries experience chronic nonhealing wounds at an annual cost of nearly $32 billion. And the researchers believe those numbers are on the conservative side.

    The study, recently published in Value in Health, analyzed data from Medicare’s 5% Limited Data Set during 2014 for details on claims in which wounds were the primary or secondary diagnosis. Researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, chronic ulcer, pressure ulcer, skin disorders, skin infection, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infection. Here’s what they found:

    • In 2014, approximately 14.5% of Medicare beneficiaries were diagnosed with at least 1 type of wound or wound infection—that’s about 8.2 million patients.
    • Surgical wound infections were the largest category, at 4% of beneficiaries, followed by diabetic wound infections (3.4%) and nonhealing surgical wounds (3%). Pressure ulcers were associated with 1.8% of beneficiaries; venous ulcers were present in 0.9% of Medicare patients.
    • Although Medicare’s episode-of-care payment system makes it hard to tease out exactly how much is spent on care associated with each of various conditions a patient may have experienced, authors were able to generate a 3-tier set of estimates based on whether the wound was a primary or secondary diagnosis. Overall costs were estimated at $28.1 billion annually under the most conservative model and up to $96.8 billion under a model that assumed the wound “was always the underlying cause of the service.” Mid-range cost estimate was $31.7 billion.
    • In terms of wound type, the highest costs were associated with surgical wounds ($11.7 billion, $13.1 billion, and $38.3 billion in the 3-tier model), followed by diabetic foot ulcers ($6.2 billion, $6.9 billion, and $18.7 billion).
    • Mean Medicare spending per wound was $3,415, $3,859, or $11,781 depending on the estimate models, with arterial ulcers and pressure ulcers registering the highest rates of spending per wound.
    • Spending on wound care for hospital outpatients was nearly twice as high as inpatient spending, with estimate models at $9.9 billion, $11.3 billion, and $35.8 billion.

    Authors believe that that data point to the need for CMS to question assumptions that have played into how it establishes episode-based measures that do not encompass wound care and are rooted in inpatient models.

    “The construction of these episode groups reveals 2 important misconceptions,” authors write. “The first is that chronic nonhealing wounds represent a less significant burden [than] other conditions, and the second is that the primary driver of cost is the hospital inpatient stay. Our data dispute both assertions. Not only does chronic wound care represent a large portion of the Medicare budget, but our data suggest there has been a major shift of costs from hospital inpatient to hospital outpatient settings.”

    Authors acknowledge that more analysis is needed to arrive at clearer estimates of costs associated with wounds, but they believe the study’s results could be the basis for the development of “more appropriate quality measures and reimbursement models, which are needed for better health outcomes and smarter spending for this growing population.”

    The study was funded by the Alliance of Wound Care Stakeholders. APTA is a member of the alliance.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Rates of Cancer Associated With Overweight and Obesity Register Significant Increases from 2005 to 2015, Says CDC

    America's obesity and overweight problem is also a cancer problem. According to the US Centers for Disease Control and Prevention (CDC), the US has witnessed a 7% increase in overweight- and obesity-related cancers (other than colorectal cancer) over 10 years, with some types of overweight- and obesity-related cancer rates increasing from 26% to 40%.

    The findings appear in an October 3 CDC report on a study of data from the United States Cancer Statistics (USCS) data set between 2005 and 2014. Researchers tracked incidence rates for 13 types of cancer associated with overweight and obesity: cancers of the esophagus, breast, endometrium, gallbladder, gastric cardia, kidney, liver, ovary, pancreas, thyroid, meningioma, plasma cells (myeloma), and colon/rectum. Researchers looked at overall rates as well as rates by age, sex, and race/ethnicity. Here's what they found:

    • Overall, the overweight/obesity-related (OOR) cancer rate declined by 2% between 2005 and 2014, but that doesn't tell the whole story. Researchers believe that the overall decrease was largely driven by a 23% decline in colorectal cancers, which have a high rate to begin with. Authors think that more widespread detection and removal of precancerous polyps are responsible for the drop in that cancer type.
    • When colorectal cancer is excluded from the data, OOR cancer rates show a 7% increase between 2005 and 2014, with thyroid cancer rates increasing by 40% and liver cancer rates increasing by 29%.
    • Besides the decline in rates for colorectal cancer, a few other cancers showed declines during the study period, including ovarian cancer (16% drop), and meningioma (29% drop); however, these declines weren't enough to offset the overall increase.
    • OOR cancers accounted for 40% of all cancers diagnosed in 2014.
    • OOR cancers accounted for 55% of cancers diagnosed in women and 24% of cancers diagnosed in men in 2014.
    • OOR cancer rates were higher among non-Hispanic blacks and non-Hispanic whites compared with other groups.

    Authors believe that growing rates of obesity and overweight in the US—now estimated at about 1 in 3 Americans—threatens to overwhelm efforts to reduce overall cancer rates, and that more needs to be done to promote healthy diet and increased physical activity.

    "Without intensified nationwide efforts to prevent and treat overweight and obesity, the high prevalence of excess weight might impede further declines in overall cancer incidence," authors write. "These efforts include investing in addressing both social and behavioral determinants of health."

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