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  • Study: Knee OA Treatment That Doesn't Follow Guidelines Comes at a Price

    In brief:

    • Current orthopedic surgeon guidelines recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee OA, and against use of injections and opioids other than tramadol.
    • Analysis of claims utilization data found that the top 3 interventions were corticosteroid injections (46.0%), hyaluronic acid injections (18.0%), and opioids other than tramadol (15.5%), none of which are recommended in the guidelines.
    • Physical therapy was prescribed for only 13.6% patients.
    • Adhering to AAOS treatment guidelines for knee OA could decrease cost of care by 45%.

    If health care providers treated patients with knee osteoarthritis (OA) according to established guidelines that include physical therapy, researchers say costs of treatment could drop by as much as 45%. Yet too many physicians are prescribing interventions that are not supported by evidence and may even carry extra risk.

    An award-winning study published in The Journal of Arthroplasty (abstract only available for free) queried the Humana claims database to determine the prevalence of 8 nonsurgical treatment modalities—hyaluronic acid (HA) injections, corticosteroid (CS) injections, physical therapy, knee brace, wedge insole, opioids, NSAIDs, and tramadol—used to treat 86,081 patients with knee OA. The patients were receiving conservative treatment in the year prior to total knee arthroplasty (TKA).

    Of all 8 modalities, only physical therapy, NSAIDs, and tramadol are strongly recommended by the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for nonsurgical management of knee OA. However, authors found the 3 most frequent interventions to be CS injections (46.0%), HA injections (18.0%), and opioids (15.5%). Physical therapy was utilized by only 13.6% of patients.

    More than half of the total cost of knee OA treatment was for noninpatient care, with 29.2% accounted for by HA injections, which AAOS classifies as “Cannot recommend – strong.” The per-patient cost for physical therapy was half that of HA injections. Researchers found that the AAOS-recommended interventions represented only 12.2% of the cost of noninpatient care: physical therapy at 10.9%, NSAIDs at 1.2%, and tramadol at 0.1%.

    The study shines a bright light on the “high prevalence of low-value interventions in the management of knee OA symptoms in the year prior to TKA,” say authors, who also express concern about risk of infection associated with injections. Preoperative use of opioids, they note, has a higher risk for complications and “a more painful recovery” after TKA.

    While experts acknowledge they have no data on the interventions’ effectiveness, “given that all patients in this study underwent TKA within a year or less … it seems likely that the treatments were not overly successful in alleviating symptoms.”

    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 The Atlantic: Unsupported Treatments Such as Meniscus Surgeries 'Distressingly Ordinary'

    A recent article in The Atlantic explores the idea that it's "distressingly ordinary" for patients to receive treatments whose effectiveness is not supported by evidence and uses the prevalence of meniscal surgery as a prime example.

    In "When Evidence Says No, but Doctors Say Yes," author David Epstein looks at how treatments can become disconnected from scientific support and yet continue to be used, driving up health care costs with no comparable improvement in patient outcomes.

    "Sometimes doctors simply haven't kept up with the outcomes," Epstein writes. "Other times doctors know the state of play perfectly well but continue to deliver these treatments because it's profitable—or even because they're popular and patients demand them. Some procedures are implemented based on studies that did not prove whether they really worked in the first place. Others were initially supported by evidence but then were contradicted by better evidence, and yet these procedures have remained the standards of care for years, or decades."

    Among the examples cited by Epstein: the use of arterial stents and the frequency of arthroscopic partial meniscectomies (APMs), even though for the latter "a burgeoning body of evidence says that it does not work for the most common varieties of knee pain."

    The article refers to studies that compare APM with physical therapy and found APM to be ineffective, and another that used sham surgery to compare outcomes with actual APM. "The sham surgery performed just as well as the real surgery," Epstein writes. "Except that, in the long run, the real surgery may increase the risk of knee osteoarthritis. Also, it's expensive, and, while APM is exceedingly safe, surgery plus physical therapy has a greater risk of side effects than just physical therapy."

    Part of the disconnect may be attributable to cultural changes that have tended to posit stronger belief in the curative powers of medicine than in public health or lifestyle changes—changes that can have more dramatic and long-lasting effects, according to the article. Epstein goes on to show how faulty research can feed into that belief system by making inaccurate claims about effectiveness and downplaying potential harms.

    "There's this cognitive dissonance, or almost professional depression," emergency physician Graham Walker tells The Atlantic. "You think, 'Oh my gosh, I'm a doctor, I'm going to give all these drugs because they help people.' But I've almost become more fatalistic, especially in emergency medicine. If we really wanted to make a big impact on a large number of people, we'd be doing a lot more diet and exercise and lifestyle stuff. That was by far the hardest thing for me to conceptually appreciate before I really started looking at studies critically."

    Cardiac Bundling Program Launch Still on Track After Executive Order

    Despite shifts in regulatory policy introduced by the Trump administration earlier this month, representatives from the US Department of Health and Human Services (HHS) say that the new mandatory bundling program for cardiac care—and some expansions in the existing bundling program for knee and hip replacements—will roll out as scheduled on July 1.

    Questions about implementation arose after President Donald Trump signed an executive order mandating a freeze on the implementation of all new rules for the first 60 days of the new administration. On February 15, HHS posted a notice in the Federal Register delaying some portions of the new bundling rule—but only those with a February 18 start date. The new start date for those provisions is March 21.

    According to an article in Modern Healthcare, "what will be delayed are minor changes, such as small adjustments on quality scores, and a new track … that meets the criteria to be an advanced alternative payment model under MACRA." The article cites an "HHS spokesman" as stating that "there are no plans to further change the launch of the models."

    In other words, it's still full-steam ahead for the July 1 launch date of the cardiac bundling model for Medicare beneficiaries, which will be required in 98 randomly selected metropolitan areas. The cardiac model will be applied to care associated with bypass surgery and heart attacks, and includes provisions that will incentivize the use of cardiac rehabilitation. The 2017 rule also includes an expansion of the Comprehensive Care for Joint Replacement (CJR) model beyond hip and knee arthroplasty, to include patients undergoing care for hip and femur fractures.

    Both models are based on the same approach: CMS establishes a lump payment target for a total episode of care, from admission to a set number of days postdischarge, and compares what hospitals spend in total on care with what Medicare thinks they should be spending. If the total spending is less than the Medicare target, the hospitals may be eligible to receive additional payment from Medicare—but if they spend more than the Medicare target, they could be required to pay back some portion of the difference.

    Prior to 2016, CMS offered only voluntary bundling programs to hospitals. Last year's CJR model was the first time participation was required—albeit limited to 67 metropolitan areas. The cardiac bundling model will be a required system for 98 markets (which overlap with the 67 already participating in the CJR).

    APTA's education efforts on bundling began well before the April 1, 2016, startup of CJR, and include 2 webinars (1 on the basics of the CJR program and 1 that includes insights from PTs participating in bundled care programs), an article in PT in Motion magazine, and a webpage that contains background information as well as links to evidence-based clinical information and community programs.

    From PT in Motion: The Role of PTs and PTAs in Healthy Aging

    Unlike R-rated movie admission, voting, and senior discounts at restaurants, the aging process isn't something that happens after you reach a magic-number birthday. It begins the moment you do.

    Or as Mindy Renfro, PT, PhD, puts it: "Children, 20 year olds, 50 year olds—everyone's aging. There's no way around it." The key, of course, is for individuals to move through the aging process in good health, which includes staying as active and mobile as possible to meet the physical challenges that can arise in later years. And according to a recent article in PT in Motion magazine, that's where physical therapists (PTs) and physical therapist assistants (PTAs) can play a crucial role.

    "Preparing for Old(er) Age" in the February issue of PT in Motion explores the reasons PTs and PTAs are the ideal health care providers to help the public understand how the aging process works, and the steps to stay healthy throughout life.

    According to the PTs interviewed for the story—including 2016 McMillan lecturer Carole Lewis, PT, DPT, PhD—1 of the biggest impediments to healthy aging is society's attitude about what it means to age. "We have a lot of misconceptions and prejudices about the potential of people who are older," Lewis says in the article.

    Mike Studer, PT, MHS, echoes Lewis's sentiment.

    "A lot of myths need to be debunked about what normal aging really is," Studer is quoted as saying. "And we as physical therapists—the 'movement experts'—should be out there leading the way."

    "Preparing for Old(er) Age" is featured in the February issue of PT in Motion magazine and is now available to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    Federal Advocacy Forum Coming Just in Time; Registration Open Through February 24

    Talk about timing: APTA's 2017 Federal Advocacy Forum, set for March 26-28, will bring physical therapists (PTs) and physical therapist assistants (PTAs) together in Washington, DC, just as bills close to the heart of the physical therapy profession emerge on Capitol Hill—including a repeal of the Medicare therapy cap, and better Medicare coverage for lymphedema supplies.

    And there's still time to get in on the action, but hurry, because the registration deadline is February 24.

    As in previous years, the Forum will allow attendees to get the very latest on regulatory and legislative issues affecting the physical therapy profession, to hear from decision-makers on Capitol Hill, and to get tips on how to effectively communicate with elected officials. Then, participants will be offered the opportunity to apply what they've learned by making in-person visits to Senate and House offices.

    The Forum takes place not long after 2 important bills were introduced in Congress: 1 proposal that would permanently repeal the therapy cap on Medicare beneficiaries receiving PT services, and another piece of legislation that would extend Medicare coverage to supplies used in the treatment of lymphedema. Both bills are consistent with APTA's most recent public policy priorities.

    Other activities at the Forum include an evening reception, awards presentations, and breakout sessions on state and federal advocacy, regulatory affairs, and student action. Guest speakers include Brad Fitch, president and chief executive officer of the Congressional Management Foundation, a nonprofit organization that works with legislators and their staff on management issues and techniques.

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    Physical Therapy Outcomes Registry Open for Business, Ready to Make History

    After several years of careful development, APTA has launched what it predicts will be a new chapter in the history of the physical therapy profession: the Physical Therapy Outcomes Registry (Registry). The project aims to build an extensive nationwide repository of patient and practice data that APTA Chief Executive Officer Justin Moore, PT, DPT, describes as "a bridge from our proud past in physical therapy to fully realizing our potential in the future."

    The Registry collects and aggregates electronic health record data from participating physical therapist (PT) practices, allowing PTs to make improved, data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of PT services. It's the most extensive resource of its kind designed specifically for use in the physical therapy profession.

    Speaking at the Registry's February 15 launch event held at the APTA 2017 Combined Sections Meeting, APTA President Sharon Dunn, PT, PhD, described the platform as "a resource that will elevate the care we provide our patients, that will better visualize our value, and that will help define our future, both as individual therapists and as a profession."

    "Ultimately, that means making a difference in people's lives," Dunn added.

    In a video dispatch on the launch, Jay Irrgang, PT, PhD, FAPTA, who heads up the scientific advisory panel that oversaw the development of the database, described the Registry as a singular source of data "from the profession, for the profession," adding that information from the Registry has the potential to impact not only practice, but quality improvement initiatives, payment, and research.

    The extent of those impacts? To a large degree, that's up to the profession itself, Moore told the audience at the launch event.

    "The Physical Therapy Outcomes Registry has the potential to become one of the most significant developments in the history of our profession, but only if we, as a profession, make use of it," Moore said. "The Registry is a bridge to our full potential. It's up to us now to walk across it."

    Visit the Registry website  to find out how it works, and learn how you can use the Registry to transform your practice—and the profession.




    Analysis of Hospital System's LE Joint Replacement Bundling Programs Reveals Significant Drop in Expenditures

    In brief:

    • Analysis of Medicare payments related to 3,942 LE joint replacements in a 5-hospital network participating in voluntary bundling programs between 2008 and 2015.
    • During study period, average expenditures on replacements without complications dropped by 20.8%; expenditures on replacements with complications dropped by 13.8%.
    • Treatment population, severity of illness, and outcomes remained stable during study period; volume rose steadily.
    • Just over half (50.2%) of the savings were related to reduced in-hospital costs—predominantly due to a 30% reduction in the cost of implants. The remaining 48.8% of savings were related to a decreased use of IRFs and SNFs.
    • Use of home health care (including physical therapy in that setting) increased by 9% during study period.

    It may be too soon to judge the cost-effectiveness of Center for Medicare and Medicaid Services' (CMS) mandatory hip and knee replacement bundling programs, but if the experience of 1 hospital system that participated in earlier voluntary programs is any indication, facilities have reason to expect overall Medicare expenditures to drop, say authors of a new study. Their analysis of nearly 4,000 patients who participated in bundling programs between 2008 and 2015 revealed an average 20.8% reduction in expenditures for joint replacements without complications, with the bulk of those savings due to reduced implant prices and the decreased use of institutional postacute care.

    The study, published in JAMA Internal Medicine (abstract only available for free), tracked Medicare claims related to lower extremity joint replacement among patients in the Baptist Health System (BHS), a 5-hospital network in San Antonio, Texas. During the study period, from 2008 to 2015, BHS participated in 2 voluntary bundling programs offered by CMS—the Acute Care Episode (ACE) demonstration, and later, the major joint replacement of the lower extremity (MJRLE) bundle offered through the Bundled Payment for Care Improvement (BCPI) program. A total of 3,942 patients (average age 72.4) participated in the programs.

    Researchers found that between 2008 and 2015, average Medicare episode payments for joint replacements without complications decreased from $26,785 to $21,208—a 20.8% drop during a time period in which nationwide payments rose by 5%. Among the 204 cases with complications, expenditures were reduced by 13.8% on average, from $38,537 to $33,216. Authors of the study say that patient age, proportion of male patients, and severity of illness did not change significantly during that time; however, volume did rise steadily, from 192 to 246 episodes per quarter.

    Authors cite 2 major factors contributing to the savings: first, BHS was able to find less expensive implants that brought the price down by nearly 30% during the study period, (a change that accounted for 80.5% of all in-hospital savings). Second, BHS reduced spending on inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) by 54% and 24.3%, respectively. In the end, the savings associated with internal hospital cost reductions represented 51.2% of overall savings, and decreased use of IRFs and SNFs represented the remaining 48.8%.

    According to the authors, the overall BHS results may be related to the amount of experience the system has with bundling, which allowed it to build "data infrastructure and an orthopedic working group to track hospital and [postacute care] variation." Another important factor: something authors call "organizational and market characteristics" that included the "availability of home-based services such as physical therapy allowing BHS to safely reduce institutional [postacute care]." During the study period, per-episode spending on home health care rose by 9%.

    The BHS move away from institutional postacute care has not escaped notice: in 2015, National Public Radio featured the BHS bundling model, reporting that "the loss to the nursing homes and other post-discharge providers was [BHS'] gain."

    Authors of the study acknowledge the limitations associated with a focus on only 1 hospital system, but assert that their study "provides important data for hospitals implementing joint replacement bundles," particularly under the CMS Comprehensive Care for Joint Replacement (CJR) model now required in 67 metropolitan areas.

    In that sense, authors say, the BHS study could be a catalyst for large-scale changes.

    "If such approaches are successfully implemented on a broad scale with similar results, the magnitude of savings that could accrue to Medicare—and possibly private payers—would be substantial," authors write. "In turn, the success of CJR participants could accelerate the shift toward bundled payments for more conditions and procedures."

    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.

    The Good Stuff: Members and the Profession in Local News, February 2017

    "The Good Stuff" is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Cristin Beazley, PT, describes the need for baseline concussion testing among youth athletes, and shares an innovative program to do just that in partnership between Sheltering Arms Hospital and FC Richmond, Virginia. (Richmond Times-Dispatch)

    Sheila Klausner, PT, MS, offers tips on how to become a runner. (Apopka, Florida Voice)

    Viral video: Hunter Christ, PT, uses zydeco dancing to get his patient moving. (KATC3, Denham Springs, Louisiana)

    William Carey University (MS) PT students help with cleanup after a devastating tornado. (WDAM7, Moselle, Mississippi)

    Robyn Wilhelm PT, DPT, discusses the role physical therapy can play in treating pelvic floor dysfunction. (Shape magazine)

    PT students at Central Michigan University joined with med students to explore ways to work together to improve treatment services. (Mt. Pleasant, Michigan Morning Sun)

    PTJ Editor in Chief Alan Jette, PT, PhD, FAPTA, discusses the future of the journal. (Oxford University Press blog)

    Sarah Morrison, PT, MBA, MHA, takes over as CEO of The Shepherd Center. (Atlanta Journal-Constitution)

    California State University-Long Beach PT students donate adaptive tricycles. (Long Beach, California Post)

    Marilyn Moffat, PT, DPT, PhD, FAPTA, explains the ways exercise can help individuals with Parkinson disease. (New York Times)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Revised Physician Guidelines Shift to Non-Drug Approaches as First-Line Treatment for LBP

    In brief:

    • In a revision of clinical guidelines, the American College of Physicians is recommending nonpharmacologic approaches over the use of medications as first-line treatment for acute, subacute, and chronic LBP.
    • Changes are based in part on new evidence showing that acetaminophen and antidepressants were no better than placebos.
    • Guidelines recommend that physicians advise patients that pain is likely to diminish through exercise and maintenance of as many daily activities as possible.

    The latest advice on low back pain (LBP) from the American College of Physicians (ACP) makes it clear: patients with acute LBP will generally improve over time regardless of treatment, and that when treatments are necessary, nondrug approaches including exercise are preferred for all but the most stubbornly chronic manifestations of the condition. The new guidelines represent a shift from ACP's previous position, which called for the use of medication as part of first-line treatment.

    The guidelines, released on February 13, include 3 recommendations—1 each for acute (fewer than 4 weeks) or subacture (4 to 12 weeks) LBP, chronic LBP (more than 12 weeks), and chronic LBP that persists after the use of nonpharmacologic therapy. Researchers analyzed studies on the effectiveness of both pharmacologic and nonpharmacologic treatments among the 3 types of LBP. Drug-based treatments studied ran the gamut from acetaminophen to opioids, including antidepressant medications. Nonpharmocologic treatments reviewed included spinal manipulation, multidisciplinary rehabilitation, massage, "exercise and related therapies, and various physical modalities," among other approaches.

    In the end, what researchers found had less to do with breakthrough understandings of the effectiveness of exercise and maintaining daily activities—benefits of which were reestablished through a systematic review conducted as part of guideline development—and more to do with a weakening of evidence supporting the use of medications.

    "The [review that served as the basis for the previous guidelines published in 2007] concluded that acetaminophen was effective for acute low back pain," authors write. "However, [the 2017] update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo," with the same results surfacing when it came to the use of antidepressants. On the other hand, they add, "many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update."

    At the acute and subacute levels, the new guidelines strongly recommend that physicians advise patients that the pain is likely to improve over time, and discuss the use of "superficial heat, massage, acupuncture, or spinal manipulation." At the chronic level, the guidelines strongly recommend "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (supported by moderate-quality evidence), tai chi, yoga, motor control exercise," and other approaches that include low-level laser therapy and spinal manipulation (supported by low-quality evidence). In all cases, they write, "it is important that physical therapies be administered by providers with appropriate training."

    For patients with chronic LBP that persists after nonpharmacologic approaches have been tried, the guidelines make a "weak" recommendation for considering nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, with tramadol or duloxetine as a second-line therapy. "Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and related benefits with the patients," authors add.

    The updated guidelines generated wide media coverage, including stories from CBS News, NBC News, and the New York Times, which characterized the recommendations as "bucking what many doctors do."

    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.

    Lymphedema Treatment Legislation Returns to Congress

    The possibility of Medicare paying for lymphedema treatment supplies, a longtime target of APTA advocacy efforts, is back on the table at the US House of Representatives with the reintroduction of a bill that would expand coverage.

    Last week, Reps Dave Reichert (R-WA), Earl Blumenauer (D-OR), Leonard Lance (R-NJ), and Jan Schakowsky (D-IL) introduced the Lymphedema Treatment Act (HR 930), legislation that would expand the range of compression supplies covered by Medicare for lymphedema treatment. A companion bill is expected to be filed in the Senate in the coming weeks.

    “Individuals suffering from lymphedema should have equal access to treatment," said Rep Reichert in a press release announcing the introduction. “Closing the Medicare coverage gap for compression garments is a common-sense way to give patients real hope to fight back and live with the best possible quality of life.”

    Similar legislation was introduced in 2015 but never made it to a full vote in either the House or Senate, even though the bill had 261 cosponsors in the House. During the lead-up to that push, APTA representatives participated in a congressional hearing to educate lawmakers and staff on the bill.

    APTA staff will monitor the legislation’s progress and update members with news and advocacy opportunities.