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  • Study: Many Gaps Still Exist in Insurer Coverage of Nondrug Treatments for LBP

    According to authors of a new study, physical therapy and occupational therapy to treat low back pain (LBP) frequently may be included in public and private insurer plans, but there's a lack of consistency in factors such as copays, referral requirements, prior authorization, and treatment limits. Coupled with a general lack of attention to many other nonpharmacological approaches to LBP, the inconsistencies create coverage gaps at a time when increased emphasis is being placed on nonopioid pain treatment, they write.

    The study, published in JAMA Network Open, looked at 2017 data from 15 commercial, 15 Medicaid, and 15 Medicare Advantage (MA) health plans in 16 states selected to provide a cross section of relative wealth, geographic location, and other factors. In addition to the insurers studied—a sample that authors claim represents insurers of more than half of the nation's populace—researchers also interviewed 43 "senior medical and pharmacy health plan executives" to get their take on the use of, and barriers to, nonpharmacological treatments for LBP.

    Researchers were interested in the degree to which insurers were covering nonpharmacological treatments for LBP and, if so, what restrictions they were placing on that use. It's an area in need of study, they say, given the current opioid crisis, the link between later opioid abuse and initial prescriptions of opioids to treat pain, and recommendations from the US Centers for Disease Control and Prevention (CDC) and others pushing for nonopioid approaches as first-line treatment for chronic noncancer pain.

    The study focused on 5 nonpharmacological therapies for LBP across all plans: physical therapy, occupational therapy, chiropractic care, acupuncture, and therapeutic massage. Additionally, because the information was readily available through Medicaid, researchers added 6 more approaches to their review of Medicaid plans: transcutaneous electrical nerve stimulation (TENS), psychological interventions, steroid injections, facet injections, laminectomy, and discectomy. Here's what they found:

    Physical therapy and occupational therapy fared well in terms of medical necessity.
    Among both commercial insurers and MA, physical therapy and occupational therapy were almost always deemed a "medical necessity" and thus subject to coverage. Of the commercial insurer coverage policies reviewed, all included physical therapy, and all but 1 included occupational therapy.

    But exactly how that physical therapy is covered? That's another matter.
    Researchers found that when it comes to utilization management issues, not all plans are equal. Among the 15 commercial insurers studied, researchers found 1 instance of prior authorization requirements, 10 instances of limits put on visits to a physical therapist (PT), and 1 instance of a referral requirement. The prior authorization (PA) situation in MA is worse (a fact that APTA is working with other groups to change), with 5 of the 15 plans studied requiring PA, and 1 requiring a referral.

    Copays can vary, too—sometimes by a lot.
    In the MA plans studied, patient copays for physical therapy for LBP ranged from $32.50 to $40 per session; the range was $15 to $50 per session among the commercial payers.

    Coverage for other nonpharmacological treatments for LBP is spotty.
    Of the commercial plans studied, only a few conferred "medical necessity" status on acupuncture (3 providers), TENS (3 providers), steroid injections (3 providers), and facet injections (3 providers). The MA system consdiered TENS, steroid injections, and facet injections medically necessary.

    Medicaid reflected the same general coverage patterns.
    As in the commercial and MA study group, the Medicaid plans included in the research largely covered physical therapy and occupational therapy (14 of 15, with the remaining plan being "unclear or not found"). All other treatments were in the single digits, with the exception of TENS (10 plans covered) and chiropractic care (12 plans covered).

    Are health plan execs on board with making it easier to access nonpharmacological pain treatments? Not exactly.
    In their interviews with health plan executives, authors of the study found that "overall, informants indicated a low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies." Researchers noted that when the interviewees did mention "innovative strategies to combat the opioid epidemic," those strategies tended to center around improved formulary management of opioids, substance abuse treatment, and identification of opioid over-users and over-prescribers—"less so on innovations aimed at optimizing coverage and access to nonpharmacologic therapies for chronic pain," they write.

    "The findings of this study support what we find on the ground with our members—namely, that while we have made progress in areas such as basic coverage and direct access, there's still much more work to be done to increase patient access to physical therapy and other nonopioid treatments," said Carmen Elliott, MS, APTA vice president of payment and practice management. "That's why we continue to engage with commercial payers, utilization management providers, and insurer interest groups to help them find a way to apply the evidence of physical therapy's effectiveness to their own policies."

    Authors of the study echo that sentiment, writing that "despite a growing evidence base supporting the effectiveness and cost-effectiveness of many of the nonpharmacological treatments examined in our study, our findings depict inconsistent and often absent coverage for many of these treatments."

    These inconsistencies present a challenge for patients, particularly those who are pursuing a multidisciplinary approach to treatment, they add.

    "Treatment-based approaches can require a co-payment for each visit, in addition to costs associated with travel and missed work," authors write. "These issues are multiplied if a patient is taking a multipronged approach that incorporates multiple therapies for chronic pain. In addition, the wide variation in utilization management criteria…underscores the uncertainty that may exist around what constitutes an appropriate duration and intensity of treatment (eg, physical therapy) for chronic noncancer pain."

    Authors of the study believe the way out of this dilemma may depend on establishing and promoting the evidence base for nonpharmacological pain treatment and—most important—for these treatments to be widely used by providers.

    "Utilization management requirements were highly variable, which speaks to a need for evidence-based guidance regarding optimal use of these therapies, and standardized, comprehensive training for practitioners to effectively implement the evidence base into their practice," they 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.

    From PTJ: Unwarranted Variation in Pelvic Floor Muscle Function Terminology an Obstacle to Advances in Treatment

    Researchers use a wide variety of terms and definitions in published studies on pelvic floor muscle function (PFMF), according to authors of a new study in the October issue of PTJ (Physical Therapy). They say that it's this lack of standardized terminology, combined with too much focus on how to measure versus what to measure, that may be hindering “effective communication, data gathering, and advances in the evidence-based approach to women” with urinary incontinence (UI). [Editor's note: APTA members may access the full article for free through the "sign in via society site" link on the PTJ website.]

    The study examined terms related to PFMF, as well as their "conceptual" and "operational" definitions, used in 64 cross-sectional studies in women with and without UI. Authors of the study were particularly interested in how definitions of terms (or the lack of definitions) impacted both the individual studies as well as the degree to which the studies could be compared with each other.

    Authors began by clarifying what they meant by "conceptual" and "operational" definitions used in the studies they reviewed. For the PTJ study's authors, a conceptual definition involves a description of what needs to be measured—for example, a conceptual definition of the term strength is capacity of a muscle to generate force. An operational definition could be a procedure, such as vaginal manometry, as well as an explanation of how it was performed.

    Authors identified 196 terms used in the various studies and grouped them into 61 categories—for example, "strength" was used as an umbrella term for 11 other terms such as "pelvic floor strength." The authors then looked at how well the studies managed terms and definitions. Here's what they found:

    • Only 29.7% of the studies included operational definitions of terms.
    • A single study might use different terms to refer to the same muscle function.
    • While "strength" was the most commonly researched muscle function, the term was conceptually defined in only 5 studies—in 3 different ways.
    • The operational definitions of "strength" included both dynamometry and manometry; however, several different scales were used, making it impossible to compare results.

    “Concepts are the building blocks for all thinking,” write authors, who warn against “operationism”—focusing on how to measure variables as opposed to “what is relevant to be measured.”

    “Once the concept being measured becomes synonymous to the measurement outcomes, even small changes in method produce a new concept,” researchers say. This leads to an increasing number of terms and definitions that make it difficult to gather and analyze data or generalize results. It also restricts a study’s results to its “particular methodology,” authors write.

    The study results, say authors, “pose an urgent need to build and adopt a standardized terminology based on a sound theoretical framework encompassing the different disciplines, related areas, researchers and policy makers in order to increase understand¬ing of PFMF in women with UI and hopefully to provide higher quality of health 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.

    New White Paper Presses for Consistent Mobility Assessments, More Outcome Measures for Hospitalized Older Adults

    The impact that loss of mobility can have on hospitalized older adults can reach far beyond the hospital stay, yet there is little consistency in the ways hospitals assess and promote movement, and almost no acknowledgement of mobility as an outcome measure. That needs to change, and soon, say authors of a new white paper advocating for a shift in "a hospital culture that does not value or prioritize mobility." APTA was among the organizations that participated in a peer review of the document, with member James Tompkins, PT, DPT, conducting the review.

    The white paper, produced by the American Geriatric Society's (AGS) Quality and Performance Measurement Committee, describes the current state of mobility assessment in acute care settings as spotty at best, with a few hospitals conducting regular, validated mobility reviews with patients, and many others using inconsistent assessments or relying too much on hospital physical therapy departments to keep up with tests and measures that could be conducted by nurses. The assessment gaps, coupled with what researchers describe as a "focus on fall prevention at all costs," result in dramatic and potentially long-lasting losses in mobility in a population already at risk.

    The lack of thorough and consistent assessments isn't necessarily surprising, given the general lack of attention paid to mobility as an outcome measure for acute care, according to authors of the white paper. "Nursing staff may be assessing mobility routinely and repeatedly, but they are not doing so in the standard or validated manner necessary for mobility quality measurement or intervention," authors write, adding that entities including the Joint Commission and the US Centers for Medicare and Medicaid Services (CMS) largely ignore mobility as an outcome measure.

    To help fuel the needed changes, the white paper offers 7 recommendations:

    • Promote mobility assessment in acute care through "incentives for the use of standard, validated, mobility assessments" by CMS and other regulators
    • Advocate for more research funding for translational research in mobility assessment and intervention programs
    • Develop a consensus on standard methods to assess mobility "appropriate for acute care settings and clinically meaningful for providers and patients"
    • Minimize the burden of mobility measurement through, among other efforts, "optimizing workflow and documentation and minimizing redundancy by specifying the roles of various health care professionals such as nurses and physical therapists"
    • Evaluate the feasibility of a mobility quality measure for use by CMS
    • Reframe the current regulatory focus on falls in acute care to focus on safe mobility "in the face of little evidence of the effectiveness of strategies to prevent falls in acute care"
    • Develop resources for acute care providers available from AGS and other entities

    One bright spot, according to the white paper authors, is that several standardized mobility assessments could fit the bill. Authors identified 6 assessments as especially promising, with most able to be administered by a nurse: the Activity Measure for Post-Acute Care 6-Clicks; the Banner Mobility Assessment Tool; the de Morton Mobility Index; the Hierarchical Assessment of Balance and Mobility; the Johns Hopkins Highest Level of Mobility assessment; the Minimum Data Set 3.0 version 1.14, Section G; and the Minimum Data Set 3.0 version 1.14, Section GG. [Editor's note: many of these assessments are available in APTA's PTNow online resource center.]

    The end result, according to white paper authors: "We anticipate that routine mobility assessment will lead to a new paradigm in which stabilization of or improvement in mobility will be a universal indicator of high-quality hospital care."

    Researchers Say Mobility Is Key Quality-of-Life Issue for Individuals With SCI

    While individuals who have experienced a traumatic spinal cord injury (TSCI) can face a wide range of challenges affecting their health-related quality of life (HRQoL), a new study is helping to clarify that 1 particular functional ability stands out as the most important factor: independent mobility.

    Researchers analyzed data from 195 patients who had sustained a TSCI between 2010 and 2016 and participated in a series of assessments conducted between 6 and 12 months after the injury. Those assessments included the Spinal Cord Independence Measure Version 3 (SCIM-III), a detailed assessment of functional abilities, as well as the SF-36v2 assessment of HRQ0L, a 36-question survey covering 8 domains that produces both a physical component score (PCS) and a mental component score (MCS). Authors say their study is the first to establish correlations between these assessments, allowing the researchers to more specifically pinpoint which factors most affect HRQoL.

    The study population included individuals 17 years and older who sustained a TSCI between C1 and L1 that required surgery. More than half of the study population—65%—experienced tetraplegia (also referred to as quadriplegia) as a result of the injury; the remaining 35% experienced paraplegia. Participants were excluded if a penetrating trauma was the cause of the TSCI or if they did not complete the assessments between 6 and 12 months after the injury. Results were e-published ahead of print in the American Journal of Physical Medicine & Rehabilitation.

    Here's what the researchers found:

    • Overall, the strongest correlation was between mobility in the abilities assessment and PCS in the HRQoL assessment. Researchers also noted a small-but-significant correlation between respiration/sphincter management and PCS.
    • The tetraplegic group showed the strongest correlations between mobility and PCS, particularly for mobility outdoors, mobility indoors, mobility for moderate distances, and stair management.
    • In the paraplegic group, "moderate significant" correlations were also found for lower body bathing.
    • Researchers were unable to establish a strong correlation between the functional abilities assessment and the mental component score on the HRQoL assessment.

    Authors of the study believe their findings line up with previous research into HRQoL among individuals who sustained TSCI, but they note that theirs is the first to examine which specific functional abilities were most important to this population.

    "In our study for both tetraplegic and paraplegic patients, mobility on even surfaces was more strongly correlated with PCS than items related to transfers," authors write, adding that "our study suggests that higher mobility is better correlated to quality of life than higher arm/hand function for both tetraplegic and paraplegic subjects."

    Authors also note that the lack of correlation between function and the MCS on the HRQoL assessment may seem "counter-intuitive," but they suggest that the findings point to the possibility that "mental health after a TSCI strongly depends on other factors that were not considered in the current study," including depression, hope, purpose, and feelings of self-worth.

    "The current study showed that it is of paramount importance to analyze tetraplegic and paraplegic patients distinctly when evaluating impact of function on [quality of life], considering the magnitude of difference between the strength and correlation of SCIM sub-scores," authors write. "Different priorities for patients lead to distinct goals in the rehabilitation effort."

    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: Some Changes in Care Occurred After Jimmo Settlement

    The 2013 Jimmo v Sebelius settlement was supposed to bust the "improvement standard" myth under Medicare Part B, but has the agreement actually made a difference in care? Authors of a new study say yes—but there's more work to be done.

    Authors focused on 2 datasets from Medical Expenditure Panel Surveys—one from 2011–2012, and another from 2014–2015, for a representative sample of 1,183 patients receiving physical therapy and/or occupational therapy. The time periods selected were chosen to provide a before-and-after snapshot of care relative to a 2013 court settlement requiring the US Centers for Medicare and Medicaid Services (CMS) to clearly debunk the idea that Medicare coverage can be extended only if that care will actually improve the patient's condition. The fallacy, known as the "improvement standard," was widely used as the basis for denials of claims for individuals with chronic conditions in need of skilled maintenance therapy.

    Researchers assessed the impact of the Jimmo settlement by looking at changes to the number of physical therapy and/or occupational therapy visits per year, per patient, focusing specifically on the number of individuals who had 12 or more therapy visits during a 12-month timespan. Authors also examined variables including race, body mass index, and geographic region. APTA member Justine Dee, PT, MS, coauthored the study.

    The results, e-published ahead of print in The Archives of Physical Medicine and Rehabilitation (abstract only available for free) show that the treatment landscape did in fact change, with the post-Jimmo patients 1.41 times more likely to have 12 or more visits than those receiving care prior to the agreement. There were no significant demographic or other differences between the groups except for age, which was lower in the postsettlement group.

    Other findings from the study:

    • Overall, the median number of therapy visits pre-Jimmo was 7; that number rose to 8 in the postsettlement group.
    • The total estimated number of Medicare recipients receiving physical therapy or occupational therapy rose between the 2 time periods studied, from 6.3 million in 2011 and 2012 to 9.3 million in 2014 and 2015.
    • Prior to Jimmo, nonwhite patients were slightly more likely than white patients to receive extended therapy, with adjusted probability for nonwhite patients estimated at 0.39 compared with a 0.21 probability for whites. After Jimmo, those probabilities reversed, with a 0.30 probability for whites, and a 0.23 probability for nonwhites. Authors describe the reasons for the change as "obscure" but write that the difference did seem to diminish over the time period studied.

    "We can estimate that, at a minimum, the Jimmo settlement will increase utilization by about 12 million visits per year," authors write. "Given typical reimbursements of $80 per therapy visit, costs will increase by approximately $960 million/year. However, if outpatient therapies can help minimize functional decline, avoidable hospitalizations, and nursing home admissions, the Jimmo settlement may result in lower total costs."

    Other stakeholders, including APTA, have reason to believe that utilization numbers may continue to rise, given CMS' weak efforts at getting the word out about Jimmo to its contractors between 2013 and summer of 2017. Last year, the agency was ordered to step up its communications around Jimmo by a federal judge who found that CMS wasn't living up to its end of the settlement agreement.

    "It's likely that numbers are higher now that CMS is doing a better job of education," said Kara Gainer, director of regulatory affairs for APTA. "But now isn't the time for CMS to let up; if anything, CMS needs to be doing even more on Jimmo, particularly in relation to payment changes in the home health and skilled nursing facility settings, where maintenance therapy can play a major role." APTA offers multiple resources related to the Jimmo settlement and the broader concept of skilled maintenance at a webpage devoted to the topic.

    Authors acknowledge that other national health care policy changes also may affect the numbers they observed, but they echo Gainer's perspective that CMS shouldn't take its eye off the ball when it comes to education around Jimmo.

    "Although we do see a change in utilization, the [Center for Medicare Advocacy, one of the groups that brought the Jimmo case to court] and other organizations continue to report that many [Medicare Administrative Contractors] are still requiring that patients demonstrate improvement as a condition of continued coverage. Education and support of the Jimmo settlement guidelines need to continue to ensure that patients are not being inappropriately denied their Medicare benefits."

    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: Functional Limitation Reporting Isn't Delivering the Data Goods

    Since the beginnings of Medicare's Functional Limitation Reporting (FLR) program, APTA has maintained that the system was overly burdensome and unlikely to provide meaningful information. Now a new APTA-funded study fleshes out the case against FLR's usefulness, finding that the codes simply have not been submitted in ways that are consistent with regulations. The holes in data make it difficult to rely on FLR as a source for tracking improvement and outcomes—a deficiency pointed out by APTA to the US Centers for Medicare and Medicaid Services (CMS), and a factor in a CMS decision to propose dropping the FLR altogether.

    The study, e-published ahead of print in PTJ (Physical Therapy), used a 5% random sample of Medicare part B fee-for-service claims for outpatient physical therapy provided in 2014, the first year nonparticipation in the FLR system was tied to claim rejection. Authors tracked FLR and Severity Modifier (SM) coding used throughout episodes of care, analyzing not only the completeness of the reporting, but the projection and documentation of patient improvement from physical therapist (PT) initial examination (IE) to discharge. A total of 114,558 unique patients were included in the study.

    The good news for FLR, if there was any to be had, was that PTs had a high level of submitting complete FLR information at IE, with more than 90% of claims including both a current FLR status code and a projected goal status code. The bad news was that complete reporting fell off dramatically after that, with fewer than 17% of claims required during interim reporting periods—at least once every 10 treatment days—including current and projected status coding. Reporting rates were as low as 9.7% for interim reports of current status.

    Similarly, discharge claims also showed a significant drop in reporting, with an average completion rate of 36.8% for FLR discharge status.

    When it came to planned and documented improvement in functional status as reflected in changes to the SM code, most of reports did identify goals for positive change. For the FLR code sets related to specific functional limitations, at least 85% included estimates of planned improvement; the percentage was slightly lower—78.7%—for the code sets related to "other" PT/occupational therapist (OT) care categories, but that didn’t surprise researchers. The actual level of improvement ratings varied, but, overall, the most frequently used SM for projected goal status was "CI," indicating an improvement to 1%-20% impaired or restricted.

    The study arrives at a time when CMS has proposed the elimination of FLR as part of its move to include physical therapists (PTs) among the providers participating in the Quality Payment Program, a major shift toward value-based payment included in the proposed 2019 physician fee schedule. CMS is accepting comments on the proposed rule through midnight on September 10—APTA will submit comments and encourages members to do the same using a letter template the association created to simplify the process. APTA's analysis of FLR reporting was cited as a factor that led to CMS' decision to drop the program. [Editor's note: for more information on the proposed fee schedule, visit APTA's Fee Schedule webpage, and scroll down to the "APTA Summaries and Fact Sheets" header for a 3-part explanation of the proposal]

    Other highlights from the study:

    • Mobility was the most commonly used FLR code, present on 63.4% of all the PT evaluation claims; "carrying, moving, and handing objects" was next at 16%, followed by "changing body positions" comprising 11.7% of claims.
    • Overall, facility-based claims tended to have lower estimates of planned improvement compared with noninstitutional settings, the most significant being improvement ratings for mobility (80.3% for facilities versus 91.2% for noninstitutional) and self-care (83.7% for facilities, 91.9% for noninstitutional).
    • Most of the FLR codes reported at discharge showed improvement by way of changed SMs, with an average improvement of 1 to 2 steps in the graduated SM code set out in 20% improvement increments. Fewer than 2.5% of all FLR codes reflected worse function, and fewer than 15% reflected no improvement.

    Researchers theorize that the lower reporting rates at discharge may be related to the lack of specific Medicare discharge codes for physical therapy, and that patient drop-out also may come into play, "limiting the ability of the physical therapist to document the FLR codes at the time of discharge."

    The low rates of interim reporting, however, is another matter, according to authors, and a big problem for the FLR system.

    "The reason for the very low completion rate for the interim reporting periods is unknown, and to our knowledge this is the first study to report on this," they write, speculating that the "time burden" involved in completing reports at least once every 10 days of treatment could be a factor.

    "We know that the collection of functional data is core to physical therapist practice, so the question becomes why the FLR system has such significant data gaps," said Heather Smith, PT, MPH, APTA program director for quality who coauthored the study with APTA member Meghan Warren, PT, PhD. "Our study indicates that the real issue is the mechanism through which these data are collected—FLR adds burden and complexity without producing much in the way of useful data."

    While authors acknowledge their study's limits—which include the discharge issue, the potential for inaccurate coding, and an inability to generalize findings to apply to Medicare Advantage beneficiaries—they say the bottom line is clear: the FLR system is not producing the data it was intended to produce—at least not when it comes to physical therapy.

    "The Medicare FLR program, in policy, supports evidence-based practice…however, the current data collection process has significant issues that limit the use and application of the data," authors write. "The ultimate solution to these issues may be the collection of functional data through the use of standardized functional outcome measures that allow for benchmarking by patient condition, at the national and local level, and by setting of physical therapist care." They add that data could be strengthened through sources other than claims, including registries such as APTA's Physical Therapy Outcomes Registry.

    "Without feedback on data completeness and change in function over the episode of care, the collection of these data has limited use," authors write. "Therefore, feedback to providers on performance is a crucial component of making these data meaningful to physical therapists and their patients."

    Study: PTs in Emergency Departments Reduce Likelihood of ED Revisits for Falls

    Talk about hammering home a point: just after publication of one study that says putting physical therapists (PTs) in hospital emergency departments (EDs) leads to better overall results comes another, unrelated research effort that pinpoints an example: namely, the effect PTs in the ED has on lowering the odds for an ED revisit for patients whose initial visit was fall-related. According to authors of the new study, consultation by a PT in the ED reduced the odds of a fall-related revisit within 30 days by 35% and within 60 days by 32%, compared with patients treated in EDs with no PT consultation.

    The study, published in Journal of the American Geriatrics Society, is based on Medicare claims data for individuals 65 and older who visited an ED for treatment related to a ground-level fall between 2012 and 2013. Researchers divided the claims data into 2 groups: individuals who received PT services during the ED visit (N=17,975) and a control group that didn't (N=542,302). Then, they tracked the rates of ED revisits for fall-related injury within 30 and 60 days of the initial visit. The data they examined also included injury severity (initial visit) as expressed in the New Injury Severity Score (NISS) as well as the presence of various comorbidities as identified in Medicare's Comorbidity Conditions Warehouse (CCW).

    While all-cause revisits were only slightly higher for the non-PT group at 30 days (21.7% for the non-PT group compared with 20.4% for the PT group) and just about the same at 60 days (about 30% for both), researchers found more striking differences when it came to revisits related to a fall. At 30 days, 1.7% of the PT group had revisited the ED for a fall, compared with 2.6% of the non-PT group; at 60 days, the rate was 2.6% for the PT group, compared with 3.6% of the non-PT group.

    There were some differences between the PT and non-PT groups. Individuals in the PT group tended to be slightly older than the non-PT group (average age of 82.4 compared with 80.6), and NISS ratings tended to be lower (less severe injury) among the PT group. Researchers explored the possibility that the lower NISS figures may have played a role in the revisit data, but when they compared individuals with an NISS of 0 (no injury noted) from both groups, they found revisit rates similar to the groups as a whole.

    Other factors, however, were related to greater chances of an ED revisit. Being male, Medicaid-eligible, and having a comorbidity raised the odds of a revisit; age, however, did not. Of the comorbidities most strongly linked to increased odds of revisit, Alzheimer's disease was associated with the strongest impact.

    Authors acknowledge that a PT consult in the ED may not always be appropriate, either due to the severity of injuries sustained or the intensity and prevalence of comorbidities such as dementia. Still, they argue, the consultation rates fall far short of where they should be, given the data they uncovered.

    "Our results suggest that EDs could play an important role in reducing fall-related ED revisits by linking individuals who have fallen with appropriate follow-up care, yet data suggest the likelihood of receiving a PT referral from the ED after a visit for a fall is rare," authors write. "Only 3.2% of older adults presenting for a fall-related ED visit received PT services during that visit, according to claims data."

    Further, authors point out, their study only tracked whether the individual received PT services during the initial ED visit—it didn't include data on whether the patients participated in any rehabilitation or falls prevention interventions after the visit, possibly "the most likely pathway through which reduction in future falls would be achieved."

    APTA is a strong supporter of the importance of PTs in the ED. A House of Delegates position promotes physical therapy as a professional service in the emergency care environment, and the association offers a webpage on the topic that includes an online toolkit, a video, and links to resources from the US Department of Health and Human Services.

    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: Listen to the CPGs—Cardiac Rehab Works

    The clinical practice guidelines are right: Ambulatory cardiac rehabilitation (CR) should be routine for patients with cardiovascular events such as myocardial infarction, say authors of a study in the European Heart Journal (abstract only available for free). However, despite evidence of its effectiveness—including a nearly 50% drop all-cause mortality for patient who receive CR—CR “remains significantly underused,” they write.

    Authors compared the long-term outcomes of an early discharge CR program for patients with ST-elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, planned percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) versus no CR at all. At one hospital, all 839 patients received early CR; at a second, none of the 441 patients received CR, as it was not available. The hospitals were in the same geographic area.

    The CR program included evaluations, cycle-ergometer tests, and echocardiograms for all patients. Patients with STEMI or CABG received 5 weeks of exercise bicycle training followed by 6 weeks of gym training, supervised by a nurse and a physical therapist. The program was tailored to each patient’s needs.

    After a 5-year follow-up period, researchers analyzed the data to account for confounding demographic variables and found:

    • All-cause mortality in the CR group was lower (10%) compared to the non-CR group (19%).
    • Cardiovascular mortality was 2% for the CR group and 7% for the non-CR group.
    • Hospitalization for cardiovascular causes was lower for the CR group (11% for the CR group, 25% for the non-CR group).
    • Combined hospitalization for cardiovascular causes and cardiovascular mortality was 13% for the CR group, compared with 29% for the non-CR group.

    Authors think that the CR method used for their study "can be adopted without the use of expensive resources and can be applied in any ambulatory CR center," thus making it easier for CR to become more widespread.

    And it's that the lack of widespread use of CR that's the problem, they note.

    "Despite these evidences supporting the benefits of CR programs, this service is greatly underutilized, especially by women, elderly, and diabetic patients," authors write. "Referral and participation range is between 30% and 50% in Europe and it is around 25% in [the United States]."

    Study: Widespread Fall-Risk Screening Efforts, Followed by Appropriate Interventions, Could Produce 'Striking' Results

    If health care providers delivered consistent, widespread screening for fall risk, would it make a difference in health outcomes? Authors of a new study think so, asserting that assessments, followed by connecting patients to interventions that address their specific risk areas, could result in a "striking" reduction in falls and associated medical costs—as many 45,000 fewer falls in a single risk area, with a resultant $442 million drop in expenses.

    The study, published in the American Journal of Preventive Medicine, paired a review of meta-analyses on various fall interventions with data on the percentage of older adults with various risk factors for falls. Researchers established an "effectiveness" score for each intervention's ability to reduce falls over 1 year, determined the percentage of adults potentially eligible for each intervention, and then assigned a 10% compliance rate to estimate both the overall number of falls that could be prevented with each intervention and the number medically treated falls prevented. Last, they estimated the direct medical costs that could be averted through each intervention.

    The risk factors and related interventions studied were: poor balance associated with neurologic gait disorders or mobility problems addressed through tai chi or the Otago Exercise Program managed by a physical therapist (PT); taking a medication possibly linked to falls addressed through a medication review; vitamin D insufficiency addressed through vitamin supplementation; cataracts addressed through expedited first-eye cataract surgery; poor depth perception due to multifocal eyewear addressed through single-vision distance lenses for outdoor activities; and home hazards addressed through home modifications delivered by an occupational therapist. Here's what they found:

    • The fall risk affecting the largest number of adults aged 65 and over was home hazards, with an estimated 38 million individuals demonstrating a risk factor for falls. The intervention—home modifications delivered by an occupational therapist—was estimated to result in the prevention of nearly 400,000 falls, resulting in $442,000 in medical cost reductions.
    • Visual impairments, either from cataract or poor depth perception related to eyewear, was a risk factor estimated to affect 27.3 million older adults, with the related interventions (cataract surgery and single-vision distance lenses) preventing an estimated 500,641 falls combined.
    • The Otago program managed by a PT potentially could be used on a subset of 11.5 million older adults with neurologic gait disorders and 13.1 million older adults with mobility problems, resulting in a reduction of a little more than 62,000 falls and $229 million in averted medical costs.
    • Even a basic medication review and modification program could produce results if applied consistently, according to the study, with an estimated reduction of 114,000 falls leading to a medical cost reduction of $418 million.

    When all the numbers were crunched, researchers foundhe results convincing. "The potential for reducing falls and averting the associated direct medical costs was striking," authors write, adding that the falls reduction and savings estimates are likely on the conservative side, since they looked at risks factors separately rather than approaching the issue from the more realistic perspective of individuals having 2 or more risk factors for falls.

    Authors acknowledged that in addition to the its focus on individual risk factors, the study also was limited through its application of a 10% participation rate that may or may not be accurate across all interventions, and did not consider the costs associated with implementing the various interventions. However, authors pointed out, an earlier study of the Otago program and a tai chi program known as "Moving Better for Balance" showed that both programs were cost-effective.

    "Healthcare providers are well positioned to implement evidence-based clinical interventions, such as those described in this analysis," authors write, through a combination of easy-to-conduct in-office screenings for medications and vitamin D intake, referral to specialists, and community- and home-based interventions. "When put into practice, clinical fall prevention efforts…could prevent falls and help America's older adult population live safe, healthy, and independent lives."

    APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has also published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

    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: Emergency Department PTs Are Just What the Doctor Ordered

    More hospitals should incorporate physical therapists (PTs) into their emergency department (ED) workflow, say authors of a review in the American Journal of Emergency Medicine (abstract only available for free). Hospitals that have done so already, they write, have seen “positive impacts in clinical care and patient and physician satisfaction” due to PT expertise, “extended bedside care,” and patient education.

    Researchers examined the typical ED PT practice patterns and clinical outcomes, intangible impacts of ED PT services, and considerations for building an ED PT program. Study coauthors include APTA members Kyle J. Strickland, PT, and Michael T. Lebec, PT, PhD.

    According to the authors, ED PTs are most often consulted for patients with acute musculoskeletal issues, not only to provide patient education and develop a plan of care for these conditions, but to help physicians make a more specific diagnosis to begin with. “Nearly half of all medical schools do not require curriculum in musculoskeletal medicine,” authors write, adding that emergency medicine training is geared toward identifying and managing life-threatening conditions.

    According to preliminary reports, hospitals with ED PT programs have noticed increased patient and provider satisfaction, decreased wait times, and decreased admission rates for patients with orthopedic symptoms.

    Physical therapists also may be consulted for patients with suspected peripheral vertigo after a physician has excluded more serious causes. Due to the protracted assessment time for such patients, PT involvement and expertise takes some of the burden off physicians who cannot devote uninterrupted time.

    Emergency department PTs are increasingly being called to assist with gait training and patient disposition planning. The ED physicians who have access to PTs cite PT evaluation of patient mobility and safety as “a significant added value,” authors write.

    Authors hypothesize that the inclusion of ED physical therapist services also may increase workplace satisfaction, improve patient flow, decrease opioid usage, reduce unnecessary diagnostic imaging, decrease downstream health care utilization, and prevent unnecessary hospitalization.

    Hospitals wishing to create such a program can learn from the experiences of existing programs, authors suggest. Important steps in implementation “include engaging with key stakeholders in physical therapy and emergency medicine, estimating initial clinical volume and staffing needs, and targeting appropriate personnel for the unique practice environment of the ED,” they write.

    "This review is consistent with a position that APTA has supported for several years—that PTs have an important role to play in the ED," said Anita Bemis-Dougherty PT, DPT, MAS, APTA's vice president of practice. "In 2008, the association's House of Delegates adopted a position promoting physical therapy as a professional service in the emergency care environment, but that official statement reflected beliefs that were widely shared in the profession for some time." The official House motion can be found here. In addition, APTA offers a webpage on the topic that includes an online toolkit, a video, and links to resources from the US Department of Health and Human Services.

    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.