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  • HHS: 29% of Rehab Hospital Patients Experience Adverse Events, Temporary Harm During Stays

    Close to 1 in 3 Medicare beneficiaries in independently-run rehabilitation hospitals experience adverse or temporary harm events during their stay—and nearly half of those events are preventable, according to a new report from the Department of Health and Human Services (HHS) inspector general.

    The report, part of a series that also analyzed adverse events in acute care hospitals (ACHs) and skilled nursing facilities (SNFs), involved reviews of a "representative sample" of 417 Medicare beneficiaries who were discharged from independently-run (as opposed to hospital-based) rehab hospitals in March 2012. Nurse screeners identified cases that indicated adverse events, and a panel of physicians evaluated the events to rate severity, as well as to assess the possibility that the event could have been prevented. Here's what they found:

    Overall, the rehab hospitals' rates were in line with ACHs and SNFs.
    Earlier HHS studies found harm rates of 27% for ACHs and 33% for SNFs. The 29% harm rate for the rehabilitation hospitals isn't much different.

    46% of the events were "clearly" or "likely" preventable, 51% weren't, and the remaining 3% were unclear.
    The 46% rate was further broken down according to whether the event was "likely" preventable (38% of all cases) or "clearly" preventable (8% of all cases). The 51% of "not preventable" events were described as ones in which "harm could not have been avoided given the complexity of the patient's condition or care required." Authors of the report write that when it came to the preventable events, "reviewers frequently cited as factors the provision of appropriate treatment in a substandard way and failure to adequately monitor a patient's progress" as elements leading to the event.

    Out of 158 events, 112 were classified as "temporary harm events," with the rest described as more serious "adverse events" that resulted in longer stays, transfers to ACHs, permanent harm, interventions to sustain the patient's life, or death.
    Authors estimate that temporary harm events make up about 18% of all events. Less than 1% of patients experience an event that leads to death, while 1.7% experience a "cascade event"—a series of multiple harm events related to a single cause.

    Falls were associated with 4% of all events.
    Of the 158 adverse events studied, 6 were related to falls. Pressure ulcers were cited in 8%, venous thromboembolism, deep vein thrombosis, or pulmonary embolism in 2%, and edema/volume overload in 1%.

    Nearly 1 in 4 Medicare patients who experienced an event were transferred to an ACH.
    That ratio includes both patients admitted as inpatients and patients who had outpatient emergency department visits only. Authors estimate that those ACH admissions and visits cost Medicare about $92 million annually.

    As for what to do about lowering the rates of harm, authors recommend that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) include rehabilitation hospitals among its targets for education and training. Additionally, the report calls for AHRQ and CMS to collaborate on the creation of a list of potential events that would "go beyond conventional postacute care issues (eg, falls, pressure ulcers) and include a comprehensive range of possible patient harm, emphasizing the unique case mix in rehab hospitals and the rehabilitation needs of affected patients." According to the report, CMS and AHRQ have agreed with the recommendations.

    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.

    $12.5 Million PCORI Grant Will Fund Research on Team Approach to Pain Management

    A recently announced $21 million grants program includes a $12.5 million award for a project that will investigate the effectiveness of interdisciplinary teams that include a physical therapist (PT) in creating "integrative" pain management options to avoid reliance on opioids.

    The grants program, sponsored by the Patient-Centered Outcomes Research Institute (PCORI), will support research related to the management of chronic pain, with a goal of reducing opioid use. The largest award was provided to a University of Minnesota project that will evaluate 2 approaches in the treatment of veterans with chronic pain: one approach that pairs a pharmacist and supervising physician to determine a medication plan and create a telemedicine-based care program, and a second approach that establishes a team including a physician, psychologist, and PT to create a plan "that encourages integrative pain management options, such as exercise, in addition to medication," according to a PCORI news release.

    The second grant award, for $8.5 million, will go to a University of Wisconsin-based research team investigating the effectiveness of mindfulness meditation and cognitive behavioral therapy in the treatment and management of low back pain.

    This is not the first time PCORI has acknowledged the role of PTs in improving patient outcomes. Early in 2015, the group—an independent, nonprofit organization authorized by Congress in 2010—announced nearly $28 million in support for 2 research projects led by PTs.

    Study: African Americans With OA 34% Less Likely to Have Office-Based Therapy

    Authors of a new study on disparities have found that, after controlling for socioeconomic variables, African Americans with osteoarthritis (OA) are 34% less likely to have an office-based physical therapy or occupational therapy visit than other racial and ethnic groups studied. The reasons behind the disparity, however, are not easy to pin down.

    The study, published in the Journal of Racial and Ethnic Health Disparities (abstract only available for free), analyzed 2008-2010 data from the Medical Expenditure Panel Survey-Household Survey, which is a set of surveys of US households, employers that offer insurance plans, and medical providers. In the end, researchers used 20,735 observations involving Americans 17 and over who reported having OA. Authors tracked respondents' answers to whether they had an office-based therapy visit, comparing them with overall numbers of office-based therapy visits for any reason, and analyzing responses in terms of race/ethnicity and socioeconomic variables.

    The bottom line: overall, Hispanic Americans with OA are 26.5% less likely than white or Asian Americans to have a therapy visit, while odds for a visit among African Americans with OA are 44.8% less. When researchers adjusted for socioeconomic variables, the reduced odds for Hispanic Americans disappeared but remained for African Americans, with a rate of 34% less likely than the other groups studied.

    Researchers cite 4 possible reasons for the disparity: lack of availability of therapists, inconvenient locations for therapy offices, hours of office operation that may make scheduling an appointment difficult, and "cultural factors," revealed in other studies, that authors say point to "lower levels of trust in the health care system" among African Americans.

    Authors write that while the reforms of the Affordable Care Act may have increased utilization of office-based therapy services among some populations, more will need to be done to get African Americans into therapy offices in greater numbers.

    "For African Americans, it is doubtful that increased affordability for therapy services alone will erase the existing disparity," authors write. "Improved patient education and awareness of the benefits of outpatient physical therapy and occupational therapy may be necessary."

    Among other findings in the study:

    • Approximately 55.7 million US adults have self-reported OA.
    • Overall, 8% of the US adult population with self-reported OA attends an office-based therapy visit each year—about 8.3 million people. That's just over half of all American adults who report an office-based visit for physical therapy or occupational therapy for any reason, including OA.
    • Nationally, about 3% of the US population will use office-based therapy services each year.
    • Income, insurance status, and education level all helped to decrease access disparity (and essentially eliminate it among Hispanic Americans)—but that effect was much less for African Americans.

    Authors acknowledge study limitations, including a scope confined to office-based visits (versus home-health or inpatient care), and no investigation into the primary reason(s) for a reported visit. Additionally, they acknowledge that the lower incidence of joint replacement surgery among African Americans "may explain a disparity in access of office-based therapy services."

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.

    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: Could Occupation Affect Leisure-Time Physical Activity Rates?

    Here's the good news: employed adults seem to be meeting national health guidelines for leisure time aerobic and muscle-strengthening activities ahead of a 2020 deadline. Here's the bad news: that's an across-the-board average. When you look at the numbers in terms of employment setting and demographics, the picture is less uniformly rosy. Authors of the study that revealed the differences believe the findings point to "barriers" to leisure time physical activity that affect some more than others.

    A recently released Department of Health and Human Services (HHS) analysis took a look at adults across the US who reported meeting federal guidelines for both aerobic and muscle-strengthening activities, divided both by demographics and occupational settings—managerial, professional, teaching or social service, services, sales, and production and related occupations. The federal guidelines call for 150 minutes per week of moderate physical activity, or 75 minutes per week of vigorous activity, accompanied by muscle-strengthening activities 2 or more days per week. The HHS Healthy People Initiative has established a goal of 20% of all Americans meeting these guidelines by 2020.

    The HHS study includes responses from 118,507 adults who reported being employed as part of their responses to a National Health Interview Survey conducted between 2008 and 2014. Here's some of what was revealed:

    Guideline attainment among employed adults is ahead of the federal goal, but not across the board.
    While the total average of 24.3% is better than the 2020 goal, some occupational categories fared better than others. Respondents in the "professional" group—business specialists, computer-related workers, health care workers, etc—had the highest average, at 31.4%. Individuals in production and related occupations—maintenance workers, farming-related occupations, construction, repair, etc—had the lowest, at 17.5%. The production group also had the highest percentage of members who did not meet either the aerobic or muscle guidelines with a 51.4% rate.

    Authors of the study pointed out that the data were related to leisure-time physical activity only and did not incorporate physical activity that may be associated with a particular job. Still, they write, the findings seem to indicate "that a person's occupation—specifically, the type of work performed on the job—may constitute a barrier to meeting federal guidelines … through [leisure time physical activity]."

    Men fared better than women across all occupation categories.
    When analyzed by sex, men reported meeting all guidelines with more frequency than women, in ranges that varied from 37.7% to 25.1% in teaching and social services, to 18.5% to 11.4% in production.

    Non-Hispanic whites had slightly better rates than Hispanics or non-Hispanic blacks—except in 1 category.
    Though the differences weren't generally huge, non-Hispanic whites were slightly more likely than Hispanics and non-Hispanic blacks to meet the guidelines, with the biggest differences being reported in the sales occupation category, where non-Hispanic whites reported a 27.4% rate, compared with 18.9% among Hispanics and 20.9% among non-Hispanic blacks. That general pattern did not extend to the production category, where non-Hispanic blacks reported the highest levels of compliance, at 20.7%, compared with 19% among non-Hispanic whites and only 12.9% among Hispanics.

    Education seems to make a difference.
    Across all occupational categories, the likelihood of meeting the activity guidelines increased with highest educational level obtained—as high as 38% of individuals with a bachelor's degree or higher in the managerial category.

    Individuals who put in the hours at work also put in the hours of leisure time physical activity.
    In all categories except production, respondents who said they worked 50 hours or more a week were more likely to meet activity guidelines. In the production category, hours worked didn't seem to produce many differences, from a 16.1% rate for respondents who worked 1-19 hours per week to a 17.6% rate among those who reported 50 hours or more of work, with other categories falling between the 2.

    Encouraging healthy, active lifestyles is central to the physical therapy profession's ability to transform society. Keep up with the latest resources at APTA's Prevention, Wellness, and Disease Management webpage. Also check out opportunities to make a difference through the National Physical Activity Plan (NPAP), a recently revised roadmap for community-level change developed by the NPAP Alliance, a group that includes APTA member Dianne Jewell, PT, DPT, PhD.

    From PTJ: Preliminary Study Makes the Case for PT Participation in Discharge Team Rounds

    Want to reduce 30-day hospital readmission rates? Get a physical therapist (PT) involved in making rounds with the discharge team, according to authors of a new preliminary study. The findings come as health care systems aggressively seek to address unplanned readmissions rates to avoid Medicare payment adjustments.

    The study, published online in unedited draft form by Physical Therapy(PTJ), APTA's science journal, tracked 398 neurology, neurosurgery, and general surgery patients at a level 1 trauma center, assigning them to 1 of 2 discharge teams: 1 with a PT and 1 without. Researchers then followed the patients for 5 months.

    Their finding: hospitals with interdisciplinary discharge teams that did not include a PT had a 30-day readmission rate 3.8 times higher than facilities that included PTs on the team. The PT participation group included 250 patients; the PT-absent group included 148.

    Within the PT participation group, each week the PT evaluated, treated, and completed forms documenting current functional status and discharge recommendations, and attended interdisciplinary rounds in person. For patients in the PT-absent group, the PT treating the patient had no formal contact with the interdisciplinary team, and the clinical case manager identified physical therapy discharge recommendations from the PT’s evaluation and progress notes.

    In addition to assessing adherence to follow-up care, researchers also followed the match between PT discharge recommendations and actual discharge disposition. Overall, patients' actual discharge dispositions matched the PTs’ recommendations 73% of the time in the PT participation group.

    The authors’ analysis concluded that the “only significant predictive factors” increasing the likelihood of readmission were having no PT participation in rounds (278% increase), and the patient being discharged to home (147% increase) as opposed to “other inpatient facilities.”

    PT participation in rounds may have “reinforced the importance of follow-up services leading to better compliance with the follow-up care in the PT participation group,” authors write – even though both groups received PT care.

    Authors note that the study's findings are preliminary and "only offer a starting point for additional research" into the role of PTs in discharge planning teams. They assert, however, that there's reason to believe that PTs could make the kind of difference they observed.

    "Accurate identification of a patient's functional capacity, appropriate [durable medical equipment], rehabilitation needs, and safety for return-to-home is unique to the physical therapy discipline," they write. "As a result, physical therapy recommendations could have a significant impact on patient satisfaction and net effect of reduced health care costs."

    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.

    Decreasing Rest Time Before Starting Physical Therapy Could Hasten Return-to-Play for Adolescent Athletes With Acute Spondylolysis

    A new study says that when it comes to physical therapist (PT) of adolescent athletes with acute spondylolysis, the sooner the better (within reason). According to researchers studying the medical charts of 196 adolescent athletes, patients whose physical therapy began fewer than 10 weeks after the injury were able to return to play almost 25 days sooner, on average, than those whose physicians required a wait of 10 weeks or more.

    Researchers wanted to go beyond the commonly accepted protocol for the conservative management of the condition—rest from physical activity for up to 3 months, comprehensive physical therapy, and full return-to-play in 5-7 months—to find out if that initial rest phase could be shortened to speed up return-to-play, and what the risks might be. As it turns out, the study indicates that answers are "yes" and "none." Results were published in the Clinical Journal of Sports Medicine (abstract only available for free).

    Authors of the study analyzed chart information from adolescent athletes diagnosed (via single-photon emission computerized tomography/SPECT or MRI) with acute spondylolysis over a 4.5 year period at the sports medicine department of Nationwide Children's Hospital in Columbus, Ohio. Patients were grouped according to their physician, with charts analyzed according to whether the patient began physical therapy after less than 10 weeks (the "aggressive" group) or more than 10 weeks (the "conservative" group) of rest. Average age of the participants was 14.3.

    Physical therapy for all patients was provided by 21 PTs at 5 separate clinics. All patients received a 45- 60-minute session twice a week for 6 weeks, with interventions that included flexibility exercises, body mechanics, and strengthening of the core and upper and lower extremities. Exercises were individualized to meet patient needs.

    In the end, 132 patients were referred to the conservative group, with the remaining 64 in the aggressive group. Researchers found that the group with the shorter wait time returned to play much sooner than their longer-wait counterparts—by an average of 25 days, dropping the entire recovery time from the commonly accepted 5-7 months to as few as 3-5 months.

    "For athletes, a time difference of this magnitude is without a doubt clinically significant and would be a highly desirable outcome," authors write. "The return to activity … with the aggressive group is consistent with the time frame found necessary for a greater chance of an excellent outcome."

    Another benefit of the more aggressive approach, according to researchers, is that it helps the athlete avoid the related effects of long periods of rest—weight gain, atrophied muscles, and increased anxiety about being able to return to sport.

    As for safety, researchers found no increased risk of adverse reactions between the aggressive and conservative approaches, a finding that authors write "may be of special interest to clinicians whose practice may be to delay [physical therapy] for fear of exacerbating the spondylolytic stress injury."

    According to authors, adolescent athletes report low back pain at rates as high as 50%. Of those, an estimated 47% are found to have spondylolysis.

    Authors acknowledged several research limitations "inherent in any nonrandomized study," as well another potential confounder: a difference in the bracing devices used in each group. Still, they argue, the study's findings are significant and point to the need for more research on longer-term follow-up, as well as the development of randomized studies.

    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: Primary Prevention Key to Decreasing Disparity in Black-White Stroke Mortality Rate

    Reducing the stark disparity in stroke mortality between black and white Americans requires a focus on risk prevention in primary care and public health, say authors of a new study. But, they add, those efforts need to "go further upstream" by examining the reasons for the higher prevalence of stroke risk factors among black Americans, including consideration of what authors call "nontraditional risk factors."

    While overall stroke mortality and risk factors such as hypertension have declined over the years for both groups, black Americans at age 45 are more than 3 times as likely as their white peers to die of the disease. Although this difference has existed for decades, it wasn’t clear, based on evidence, where and how to target interventions accordingly.

    The big question, according to authors, has to do with whether black Americans are having more strokes than white Americans, or whether strokes are more often fatal for black Americans. The answer could help health care providers, including physical therapists, understand the best way to approach this public health issue.

    Enter the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a longitudinal cohort study of 30,239 black and white individuals aged 45 years and older. Between 2003 and 2007, 12,212 black and 17,470 white participants were assessed for risk factors via phone interview and in-home visits. Researchers followed up with the participants every 6 months for risk surveillance, and also documented any health risks or events from medical record data. Results were published in the journal Stroke (abstract only available for free).

    Among participants, aged 45–54, the black-to-white ratio of stroke mortality—the percentage of people who die from stroke among that population—is approximately 3:1, but by age 75 the rate is roughly equal. The ratio of stroke incidence showed a similar pattern. However, researchers found that the "fatality" of stroke—that is, the percentage of people who die from stroke among the population of people who experience a stroke—is not significantly different between blacks and whites. In other words, a black American who has a stroke isn't more likely to die from the stroke than a white American, but black Americans are more likely than whites to experience a stroke in the first place—at least until late in life when rates even out.

    According to the researchers, the findings mean that primary prevention, not secondary prevention, should be the main focus in efforts to reduce the disparity.

    Stroke risk factors such as diabetes, they say, account for 40% of this disparity in stroke incidence, and the remaining 60% could be related to: "awareness, treatment, and control of risk factors," such as hypertension, which may have a "more potent effect" in black individuals; nontraditional risk factors, such as depressive symptoms or higher rate of environmental exposures; or measurement error and confounding.

    Authors also acknowledge that there are "substantial black-white differences in care after stroke" but note that in this study, at least, there was no difference in case fatality after stroke.

    Researchers hope this study will lead to better-targeted research and patient care in the future. They write, "We are at the early phase of processes to understand these alternative pathways that potentially contribute to the black-white disparity in stroke incidence, and we need to redouble our efforts to the investigation of these pathways."

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.

    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.

    Last Chance to Register for Online Access to Major Health Policy Research Gathering

    Time is almost out to register for online attendance at a first-of-its-kind gathering of some of the profession's top physical therapy health policy and services researchers.

    The Center on Health Services Training and Research (CoHSTAR) is offering a 2-day Summer Institute on Health Services Research June 28-29 at Boston University. Specifically targeted toward training physical therapists in health policy and health services, the institute is CoHSTAR’s first national conference since its inception in 2015. In-person attendance has reached capacity, but CoHSTAR is offering live online access to the conference on June 29. Registration deadline is June 28.

    Events during the institute will include presentations on integrated health care systems, pragmatic trials, health care industry collaboration, and hospital and academic collaboration, as well as discussions of ongoing CoHSTAR research projects. Presenters include Kristin Archer, PhD, DPT, Katherine Berg, PT, PhD, Gerard Brennan, PT, PhD, Tony Delitto, PT, PhD, Pamela Duncan, PT, PhD, Kelley Fitzgerald, PT, PhD, Michael Friedman, PT, MBA, Julie Fritz, PT, PhD, James Irrgang, PT, PhD, Alan Jette, PT, PhD, Diane Jette, PT, DSc, Michael Johnson, PT, PhD, Vincent Mor, PhD, Ken Ottenbacher, PhD, Linda Resnik, PT, PhD, and Mary Stilphen, PT, DPT.

    CoHSTAR was created through a $2.5 million grant awarded by the Foundation for Physical Therapy, a grant that received $1 million in support from APTA. In addition to the summer institute, CoHSTAR sponsors visiting scientists, offers fellowships, and provides other training sessions.

    PTJ Continues to Grow in Research 'Impact'

    The influence of Physical Therapy (PTJ), APTA's scientific journal, continues to grow: according to Journal Citation Reports (JCR), the frequency with which PTJ is cited in other journals—its so-called "impact factor"—made PTJ #5 among rehabilitation journals and #10 among orthopedic journals in 2015.

    A rating used by many researchers to decide where to publish their work, PTJ’s impact factor rose to 2.799 last year, a 10.8% increase over 2014. The journal now ranks second for total cites.

    The JCR rating isn't the only indicator that PTJ 's prominence is growing. Another rating, called the Eigenfactor score, ranks PTJ third among rehabilitation journals even after excluding self-citation (references from one article in a journal to another article in the same journal). The Eigenfactor score also places PTJ third among rehabilitation journals when it comes to "article influence," a measure of the average influence of a journal's articles over the first 5 years after publication.

    "This improvement is thanks to the hard work of former Editor-in-Chief Rebecca Craik, her editorial team, our reviewers, and the outstanding authors who have published their work in PTJ," said current PTJ Editor-in-Chief Alan Jette, PT, PhD. "PTJ will continue to strive to be the preeminent international journal in physical therapy and rehabilitation by publishing the very best articles that advance clinical practice, inform policy, and engender a powerful and sustained impact on the health of individuals and communities."

    Subscription to PTJ is free to APTA members, who can receive print versions, read articles at the journal's website, and download recordings from the journal's podcast series.

    USBJI Young Investigators Program Accepting Applications for 2016 Program

    Physical therapist investigators have an opportunity to receive guidance in getting their research funded and "other survival skills required for pursuing an academic career" through a program that connects them with experienced researcher-mentors.

    The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada announced that they are now accepting applications for the Young Investigator Initiative, a career development and grant mentoring program. Investigators chosen to participate in the program will attend 2 workshops 12-18 months apart and work with faculty between workshops to develop grant applications.

    This grant mentoring workshop series is open to promising junior faculty, senior fellows, or postdoctoral researchers nominated by their department or division chairs. It also is open to senior fellows or residents who are doing research and have a faculty appointment in place or confirmed and have a commitment to protected time for research. Basic and clinical investigators, with or without training awards (including K awards), are invited to apply.

    Application requirements and more details can be found at the USBJI website. Deadline is July 15, 2016, to participate in the next workshop, November 4-6.

    APTA is a founding member of USBJI.