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  • Rehab Research Bill Passes Major Hurdle in Senate

    APTA's efforts to support improvements in rehabilitation research just received a major boost by way of a US Senate Committee, which has completed the "markup" phase of a bill that would bolster research efforts at the National Institutes of Health (NIH).

    Next stop: the Senate floor.

    Titled the "Enhancing the Stature and Visibility of Medical Rehabilitation Research at NIH Act," (S. 800), the bill passed through markup by the Senate Committee on Health, Education, Labor, and Pensions (HELP) with only minor changes. The Disability Rehabilitation and Research Coalition (DRRC) worked with NIH and the office of Sen Mark Kirk (R-IL), the bill's sponsor, to develop the necessary compromises. APTA is on the steering committee of DRRC, which is composed of over 40 organizations committed to promoting rehabilitation research.

    If signed into law, the bill would help better coordinate rehabilitation research across all institutes at NIH in several ways, including statutorily defining medical rehabilitation research to ensure continuity in the use of the word, and standardizing reporting mechanisms to enhance the coordination of research.

    The bill is based in part on recommendations from an NIH blue ribbon panel that was co-chaired by Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and Alan M. Jette, PT, PhD. The panel's recommendations, issued in 2013, were supported by APTA, with then-APTA President Paul A. Rockar Jr, PT, DPT, MS, characterizing the findings as ones that reflect APTA's "core principles," and are "critical to meeting the NIH's mission and impacting society in a positive manner."

    The bill will join a package of Senate legislation that serves as a companion of the 21st Century Cures legislation (H.R. 6) on the House side that passed last year.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities.

    Jimmo Message Hasn't Sunk In; CMS Needs to Do More

    When theJimmo v Sebelius settlement was announced in 2013, patient advocates applauded what they saw as a landmark change for individuals who need care to maintain their medical conditions or slow their declining health. However, 3 years later, many providers and payment adjudicators are still making coverage decisions as if they're living in a pre-Jimmo world—mostly because the US Centers for Medicare and Medicaid Services (CMS) hasn't done enough to bring them up to speed, according to an advocacy group supported by APTA.

    Recently, APTA provided a supporting declaration to the Center for Medicare Advocacy's (CMA) efforts to get CMS to do a better job of making it clear that the "Improvement Standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy, and that skilled maintenance care can qualify for payment.

    "There are still many providers and contractors who do not know about, understand, or trust the change in the improvement policy," CMA wrote in a December 2015 letter to APTA and other stakeholders. "We believe this is largely due to the fact that CMS' Education Campaign was insufficient to make up for the rigor with which Medicare enforced the Improvement Standard—for decades." According to CMA, CMS conducted only 1 briefing for providers and adjudicators, in early December of 2013. Since that time, CMS "has refused to do more," CMA writes.

    APTA agreed with CMA's take on the situation and submitted a declaration of support, writing that the information provided by CMS is "introductory in nature and [has] not been sufficient in educating our members."

    "Approximately 2 years after the CMS National Education Campaign, APTA is still receiving inquiries from physical therapists regarding the coverage of skilled maintenance therapy under Medicare," APTA writes. "We have found that many providers have not received any information regarding the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit." The association suggests posting answers to frequently asked questions, sharing information briefs on what to do in case of denials, hosting national calls, and sponsoring regional town halls.

    Patients and physical therapists do have recourse: CMA has created a "self-help packet" for appealing denials of outpatient therapy that may have been made based on a pre-Jimmo understanding of payment policy. The webpage featuring the packet also contains background information on Medicare coverage and the "improvement myth," therapy cap exceptions, and appeals processes.

    APTA engaged in an extensive effort to educate its members on the Jimmo settlement, and maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    Botox Approved for Lower Limb Spasticity

    Six years after gaining FDA approval for the treatment of upper limb spasticity, onabotulinumtoxinA—commonly known as Botox—has now been OK'ed for the same use in lower limbs.

    According to Medscape (free sign-in required) the FDA approval was based on a clinical trial of more than 400 individuals who were experiencing lower limb spasticity poststroke. Participants treated with Botox showed statistically significant improvements at weeks 4 and 6 in muscle tone and clinical patient benefit.

    The trials were focused on the ankle and toes, and didn’t confirm use in other areas of the lower extremities.

    In 2010, FDA approved the use of Botox for upper limb spasticity, but effectiveness was only confirmed for the elbow, wrist, and fingers. Five years later, effectiveness was confirmed for use in 2 thumb muscles.

    Zika Outbreak a 'Public Health Emergency,' Could be Linked to Guillain-Barré, Other Disorders

    The Zika outbreak has been elevated to a "public health emergency of international concern" by the World Health Organization (WHO) while health officials scramble to understand the disease, including its possible relationship to Guillain-Barré Syndrome (GBS) and other disorders that affect the nervous system.

    As of January 30, 26 countries had reported locally transmitted Zika infections across Central America, South America, the Caribbean, and the Pacific Islands. The list of countries treating these infections continues to grow. Travel-related cases have been identified in the continental United States. Puerto Rico, American Samoa, and the US Virgin Islands already are experiencing ongoing transmission of the virus.

    The new status from WHO may help affected countries better respond to the virus through stepped up research, surveillance, care, and follow-up.

    The virus largely has been transmitted via mosquito bites, but a US Centers for Disease Control and Prevention (CDC) report notes that infections have occurred through mother-to-fetus transmission, sexual transmission, blood transfusion, and lab exposure. This week, the first human-to-human transmission of the virus within US borders was reported in Texas, where a woman contracted the disease through sexual contact with her husband.

    Signs of Zika infection include fever, skin rash, conjunctivitis, muscle and joint pain, malaise, and headache, but health officials are also concerned about the infection's possible relationship to disorders of the nervous system. In addition to a rise in microcephaly recorded in Brazil since October 2015, both Brazil and El Salvador have observed a dramatic increase in cases of GBS coinciding with the 2015 Zika outbreak.

    In a January 18 statement, the Pan American Health Organization (PAHO) recommended that “countries in the Americas prepare their healthcare facilities to respond to a potential increase in demand for specialized care for neurological syndromes.”

    WHO does not recommend a travel ban to infected countries, and while health officials anticipate clusters of outbreaks in the United States due to infected travelers, CDC says that widespread transmission “appears to be unlikely.” The CDC has issued a set of travel tips for anyone visiting areas affected by the Zika outbreak.

    The CDC asks providers to report any suspected cases to their state health department to enable laboratory diagnostic testing and avoid further transmission.

    White House Proposes $1.1 Billion to Reduce Opioid Abuse

    In a proposal aimed in part at building on an initiative that includes APTA, President Barack Obama has designated $1.1 billion in new funding over 2 years to intensify the fight against the country's opioid use and heroin abuse epidemic.

    According to a White House fact sheet, Obama's proposal takes a "2-pronged approach" to address the drug problem: $1 billion in new mandatory funding for expanding treatment for individuals with an opioid use disorder, and $500 million to increase prescription drug overdose prevention strategies, including more funding for medication-assisted treatment. Some of the funds will be directed specifically to rural areas of the country, which have seen disproportionately high levels of abuse and overdose.

    The proposal, which requires congressional approval, further intensifies the administration's focus on the opioid abuse epidemic. That focus received national attention in October 2015, when Obama announced the creation of a public- private partnership to combat opioid abuse and heroin use. APTA is participating in the initiative along with 39 other health care provider groups that include the American Medical Association, the American Academy of Family Physicians, and the American Nurses Association.

    APTA has long advocated for the role of the physical therapist (PT) in pain management, using its MoveForwardPT.com website to educate the public, and featuring new approaches to pain treatment being used by PTs in a 2014 feature story in PT in Motion magazine. More recently, the August 2015 issue of Physical Therapy (PTJ), APTA's peer-reviewed journal, included a discussion of how to interpret the burgeoning effectiveness evidence from recent clinical trials and systematic reviews on pain treatment.

    APTA Adds Physical Therapy Perspective to Senate Work Group Report on Chronic Health Conditions

    The challenges of providing care to individuals with chronic health conditions are now the focus of a bipartisan working group in the US Senate, and APTA is helping to shape the group's policy proposals.

    In December 2015, the Senate Finance Committee's Bipartisan Chronic Care Working Group issued a 30-page "policy options document," the product of a 6-month investigation of possible ways to improve care delivered to Medicare beneficiaries with chronic health conditions. The information-gathering process included over 80 stakeholder meetings and 530 recommendations, with the final document including 24 policy proposals ranging from the changes to the Medicare Advantage (MA) program to expanded education and research initiatives.

    According to the work group, the policy changes listed in the document are aimed at increasing care coordination, streamlining Medicare payment systems "to incentivize the appropriate level of care," and establishing a chronic care system that "facilitates the delivery of high quality care, improves care transitions, produces stronger patient outcomes, increases program efficiency, and contributes to an overall effort that will reduce the growth in Medicare spending."

    On the whole, APTA's comments to the proposals were supportive, with the association focusing on 12 proposals that would most directly affect physical therapy. Among them:

    Expansion of the Independence at Home demonstration project into a "permanent, nationwide program." APTA supported the idea, but advocated for a careful approach.

    Continued access to MA special needs plans. APTA asserted that "all plans have access to physical therapy services."

    Provisions that would allow MA plans to vary benefit structures to meet the needs of chronically ill enrollees. APTA supported this idea, but called for care in the definition of "non clinical" professionals.

    Telehealth provisions that would expand opportunities for use in MA, accountable care organizations (ACOs), and for beneficiaries poststroke (3 separate policy proposals). APTA supported all 3 proposals, particularly in relation to physical therapy, writing that "telehealth will not replace traditional client care, but it will give [physical therapists] and [physical therapist assistants] the flexibility to provide services in a greater capacity."

    Ensuring accurate payment for individuals who are chronically ill. APTA wrote that it was "generally supportive" of the proposal, but suggested that to truly achieve a more effective payment system, additional regulatory changes need to happen—including a full repeal of the Medicare therapy cap.

    The association also commented on proposals to increase care coordination among ACOs, the development of quality measures for chronic conditions, and a suggestion to increase transparency at the CMS Center for Medicare and Medicaid Innovation (CMMI), a center that should create more grant funding opportunities "aimed at providers such as physical therapists," according to APTA.

    APTA highlights the role of the physical therapist and physical therapist assistant in the treatment of chronic conditions through its prevention, wellness, and disease management webpage. In addition, the 2015 House of Delegates adopted the position Health Priorities for Populations and Individuals (RC 11-15) "to guide [APTA's] work in the areas of prevention, wellness, fitness, health promotion, and management of disease and disability." The priorities include active living, injury prevention, and secondary prevention in chronic disease and disability management. The topic was also the subject of a popular presentation at the 2015 NEXT Conference and Exposition.

    Also available from the APTA Learning Center: "Disease Management Models for Physical Therapists: Focus on Diabetes and Cardiovascular Disease."

    CMS Looks at Cultural Components of Hospital Readmission Rates

    It's established fact that minorities and other vulnerable populations face a higher risk of hospital readmissions for conditions such as chronic heart failure or procedures such as total knee or hip arthroplasty. But that could change if hospitals and other health care providers started to comprehensively address the matrix of cultural, economic, and comorbidity issues faced by racially and ethnically diverse patients, according to a new publication from the US Centers for Medicare and Medicaid Services (CMS).

    "While not all readmissions are entirely preventable, it is widely understood that a portion of unplanned readmissions could be avoided by addressing a series of barriers patients face prior to, during, and after admission and discharge," write authors of a recently release CMS guideline. The publication, titled "Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries," lays out key issues related to the higher readmission rates, and accompanies those issues with a set of ambitious strategies for reducing those rates.

    The issues that contribute to higher readmission rates among racially and ethnically diverse patients, as identified by CMS, include lower rates of follow-up after discharge, fewer linkages to primary care providers, limited English proficiency in certain cases, degree of health literacy, cultural beliefs or customs that may influence health behaviors, socioeconomic barriers to resources, higher rates of anxiety and depression, and the effect of comorbidities.

    The strategies suggested by CMS for addressing these disparities are wide-ranging, and depend in large part on increased levels of interdisciplinary collaboration, greater attention to patient education, and stronger connections with communities and resources outside the health care facility.

    According to the guide, any effort to close the readmission gap must include strong patient data collection efforts to better understand the particular barriers each individual faces; readmission reduction strategies that begin even before admission; and the creation of true multidisciplinary, culturally competent teams to help coordinate care and educate the patient. Additionally, the CMS guide encourages the creation of better partnerships throughout the community "to ensure that the next care provider is aware of the patient's status and care information, and to direct at-risk patients to needed care following hospitalizations."

    "CMS has an important opportunity and a critical role in preventing hospital readmissions while promoting health equity among diverse Medicare beneficiaries," said Cara James, director of CMS’s Office of Minority Health in a CMS news release. "This guide encourages action-oriented steps and solutions in achieving health equity, addresses reducing readmissions and focuses on our initiative of achieving better care, smarter spending, and healthier people throughout our health care system."

    The guide also includes 3 case studies that CMS believes demonstrate efforts to reduce the readmission gap: a "re-engineered" discharge process; a system that incorporates telehealth into home health; and a "health connections" program that identified area "hot spots" of "super utilizers" and then delivered education and other programs to that population.

    APTA highlights cultural competence as a crucial part of evidence-based practice on its Cultural Competence in Physical Therapy webpage, and offers additional online resources on the ways racial and ethnic disparities affect health care.racial and ethnic disparities affect health care.

    Learn about how physical therapy can affect readmissions: check out "The Value of Physical Therapy in Reducing Avoidable Hospital Readmissions," offered through the APTA Learning Center, and “There's No Place Like Home: Reducing Hospital Readmission Rates,” a feature article in the November 2015 PT in Motion magazine.

    CMS Announces Addition of Patient Opinions to Home Health Compare Website

    The US Centers for Medicare and Medicaid Services (CMS) has added patient perspectives to yet another of its star rating systems—this time, for home health agencies.

    The newly added ratings summarize patient responses to how often the home health team gave care "in a professional way"; how well the team communicated with patients; whether the team discussed medicines, pain, and home safety with patients; how patients rate "the overall care" from the agency; and whether patients would recommend the agency to friends and family. According to CMS, about 6,000 of the 11,000 agencies listed on the Home Health Compare site now include patient care experience ratings.

    According to a CMS news release, the home health addition continues a Department of Health and Human Services effort "to build a health care system that delivers better care, spends health care dollars wisely, and results in healthier people." In addition to the home health site, CMS offers consumer-focused comparison information for nursing homes, physicians, dialysis facilities, and hospitals.

    NYT Says Don't Stop Believin' (in Exercise for LBP)

    PT in Motion News recently covered a study and a Cochrane systematic review touting the positive effects of exercise for treating and preventing recurrence of low back pain (LBP). The New York Times (NYT) picked up on this message in its Well blog article, "To Prevent Back Pain, Orthotics Are Out, Exercise Is In."

    NYT columnist Gretchen Reynolds writes about the systematic review published in JAMA Internal Medicine (abstract only available for free) that analyzed effectiveness of interventions for preventing recurrence of low back pain. For those who experience LBP (described in the NYT article as "80% of those … in the Western world'), exercise is the key to preventing its return—not patient education, not back belts, not insoles.

    The article quotes APTA member Chris Maher, PT, PhD, FCAP, one of the authors of the review, as saying "of all the options currently available to prevent back pain, exercise is really the only one with any evidence that it works."

    Maher is a professor at The University of Sydney and research fellow at The George Institute for Global Health in Sydney, Australia, as well as an Editorial Board member of Physical Therapy, APTA's research journal.

    Some exercise programs examined in the review were standalone, and others combined exercise with education. Reynolds explains that, regardless of the type of exercise program, the participants were less likely to have experienced a subsequent episode of LBP after participating in the programs. The only caveat is that the effect tapers off after 1 year, according to existing high-quality research.

    Maher told NYT that the jury is still out on whether continuing exercise has the same effect in the long term, or which types of exercise program may be more beneficial than others.

    The results echo those of the recent Cochrane systematic review on knee osteoarthritis (OA) covered by PT in Motion News on January 14. Like the LBP review, OA reviewers also found that exercise relieved pain up to 2 months after completing an exercise program, after which point the effects were minimal.

    APTA offers a wealth of resources on low back pain. Offerings range from consumer-focused information including a PT's guide to low back pain, a podcast, and a video. The PTNow evidence-based practice resource includes a variety of guidelines on low back pain, including one published by the APTA Orthopaedic Section.

    Systematic Review: Physical Therapy in Hospice and Palliative Settings Supported by Limited Research

    A review of recent research on the role of physical therapy in hospice and palliative care supports the idea that physical therapy can go a long way toward improving patients' physical, social, and emotional well-being. The problem, according to authors, is that the research itself has a long way to go.

    In a systematic review published in the American Journal of Hospice & Palliative Medicine (abstract only available for free), authors reviewed 13 articles—mainly qualitative—that looked at the use of physical therapy among patients diagnosed with a critical or terminal illness. Authors focused on 5 major components addressed in the various studies—age of participants, types of physical therapy interventions used, assessment tools used, efficacy of treatment, and patient-reported satisfaction and quality of life. Authors of the study include Ahmed Radwan, PT, DPT, PhD.

    Age. Participants ranged in age from 17 to 95. Most subjects were 40-70 years old.

    Interventions. The most frequently discussed interventions were strengthening/therapeutic exercises, patient and family/caregiver education, balance and falls training, and transfer training.

    Assessment tools and outcome measures. Though a variety of outcome measures were used, the most common tools used in the studies were ones that rated patients' pain levels—mostly numeric scales; however, no single tool or measure was used in more than 1 study.

    Efficacy of treatment. "Throughout all of the 13 reviewed articles, it was reported that physical therapy resulted in improvements in a variety of aspects of patients' function and symptoms," authors write. Not surprisingly, most of the improvements were related to pain, although some studies noted improvements in mobility, activities of daily living, endurance, mood, fatigue, and lymphedema.

    Patient satisfaction. Among the studies reviewed, only 5 directly addressed satisfaction or quality of life. All found that these factors had improved.

    While the findings are encouraging, authors of the review also include a long list of limitations to their analysis, most having to do with the current dearth of information on the role of physical therapy in hospice and palliative care.

    Primary among the limitations is what authors believe is a general lack of quantitative research on the topic. When it comes to the reviewed studies themselves, authors cited limitations that include a lack of specificity around the types of treatment provided; multidisciplinary care approaches that, though "realistic," made it difficult to precisely identify the impact of physical therapy; a lack of discussion of treatment costs; high dropout rates; and the fact that every study used a different outcome measure.

    Despite those problems, authors believe that their review sheds some light on how physical therapy is used in hospice and palliative care, and the ways in which it can improve quality of life for patients and caregivers.

    "It is apparent that there is benefit in utilizing physical therapy in end-of-life and palliative care settings," authors write. "This study confirms that physical therapists serve a vital role in [these] settings and should be active members of the multidisciplinary team providing care for this critical patient population."

    APTA advocates for the use of physical therapy in hospice and palliative care, and offers a webpage devoted to the topic. Resources include guides, podcasts, and links to information from Medicare and Medicaid. In addition, PTNow's resources include a health care guideline on palliative care.

    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.