CSM Preview: Genomics and Precision Physical Therapy With Richard K. Shields and Eric D. Green
In his 2017 McMillan Lecture, "Turning Over the Hourglass," Richard K. Shields, PT, PhD, FAPTA, predicted that, as we learn more about the effects of exercise on genetic pathways that influence health, "precision physical therapy will emerge side by side with precision medicine." Genomic analysis, he said, is "laying the groundwork for physical therapists to dose movement in ways that we never considered possible."
Shields and colleague Eric D. Green, MD, PhD, will dive deeper into this topic at the upcoming APTA Combined Sections Meeting in January 2019. In "Personalized Physical Therapy: The Time Is Now," sponsored by APTA's Frontiers in Rehabilitation, Science, and Technology (FiRST) Council, the speakers will explore the implications of genomics for exercise science and performance and how knowledge of a gene's function could alter a patient's medical management and clinical outcomes.
The session will be moderated by FiRST Council co-chair Steven L. Wolf, PT, PhD, FAPTA, and was organized by Catherine Curtis, PT, EdD.
#PTTransforms spoke with Shields (RS) and Curtis (CC) to get some quick takes.
First, what is the FiRST Council?
CC: APTA's Board of Directors established the Frontiers in Rehabilitation Science and Technology (FiRST) Council to help prepare its members for innovative medical technologies and approaches to clinical care, such as sensing technologies and robotics, regenerative medicine, precision medicine, telehealth, and imaging. Any APTA member in good standing can join the FiRST Council. Non-PT or PTA individuals who are in related disciplines, such as bioengineering or genetics, are eligible to be "Council Partners."
What was the genesis for this session?
CC: Completion of the first reference sequence of the human genome in 2003 gave rise to a sea change in the biological and medical sciences. Francis Collins, director of the National Institutes of Health (NIH) and former director of the National Human Genome Research Institute (NHGRI), has said that virtually every human ailment, except some cases of trauma, is considered to have some genetic basis. Medicine is becoming more personalized, with a shift toward early risk identification and diagnosis, and targeted therapy. Physical therapists need to be aware of the effects of genetic variants on health and disease and be prepared to devise individualized lifestyle interventions for both prevention and wellness.
How close are we to understanding how to use a patient's genetic information to tailor their physical therapy treatment?
RS: Physical therapists and their patients already are armed with new knowledge about genomics and how a patient's genetic makeup may influence personal health and health care treatments. Many patients will bring their own genotype to the clinic, whether acquired through a medical center screening program or a private vendor. Research is providing clinicians with increasing information about the effects of genotypes on health conditions. For example, we know that the homozygous ACTN3 577X genotype has been consistently associated with delayed onset muscle soreness and muscle damage after eccentric exercise. Clearly, dosing eccentric exercise may vary based on whether an individual has this known allele.
While we must be careful not to overstate, we must be cognizant of the power of regular, repetitive movement (exercise) on the epigenome—the system that can promote healthy genes and repress damaged genes. Physical therapists must understand the power of their own prescriptions from a fundamental science perspective.
CC: While genetic testing for rare disorders is available, regular testing for common disease variants is not routinely performed in clinical practice. There are issues with screening accuracy and sensitivity, and even if variants are identified, their clinical significance is still unclear. As we learn more, testing for common disease variants will likely become more routine, and genetic information will be increasingly available in clinical settings. These are some of the topics Eric D. Green will cover in his presentation, as well as how the NIH All of Us Research Program seeks to extend precision medicine to all diseases by building a national research cohort of 1 million or more US participants. By taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine.
What are some opportunities and challenges regarding application of genomic research in practice?
RS: The key challenge is that public opinion may race ahead of scientific evidence. A great number of studies have found evidence for higher prevalence of certain genotypes in various populations. The public may infer causality where none exists, so physical therapists must be able to accurately interpret genomic information.
Physical therapists will have many opportunities to speak truthfully about the meaning of the genomics movement and continue to advance knowledge about the power of regular movement-based treatments. Accordingly, they should participate in educational programming that helps jump-start their knowledge of genomics and epigenetics.
CC: The Genomic Era is upon us, with advances relevant to health and wellness now emerging. The translation to clinical physical therapist practice is still very new, and the initial challenge for the profession is that all therapists must expand their knowledge in this area beginning with basic concepts and an awareness of the potential impact on the health and wellness of individuals. With this background, the opportunity for more and more research on direct application to practice will emerge.
What other physical therapy–related genomic research is on the horizon?
CC: Physical therapists—including members of the FiRST Council genomics group—are increasingly engaged in genetics-related research relevant to clinical practice. Steve Cramer, MD, and Steve Wolf, PT, PhD, FAPTA, are studying how brain-derived neurotrophic factor (BDNF) Val66Met genotype is associated with greater brain atrophy after stroke. Cameron Mang, PhD, MSc, and Laura Boyd, PT, PhD, are exploring how genetic influences underlying acute aerobic exercise affect motor learning. Allon Goldberg, PT, PhD, is researching how angiotensin I-converting enzyme gene (ACE) polymorphism affects grip-strength correlations with balance and walking speed in older adults. And Laura Case, PT, DPT, and colleagues are examining phenotypic traits of infants with Pompe disease identified by newborn screening.
RS: There are many studies examining the relationship between genetic markers and functional outcomes in people with Parkinson disease, total hip/knee replacement, stroke, spinal cord injury, and diabetes. We are looking at the relationship between muscle exercise and tagging certain genes known to be strong signatures of metabolic health. The outcomes of all of these types of studies will help chart the course for using genetic biomarkers to guide us as we determine who will benefit from our prescribed movement-based interventions.
What should people take away from this session?
RS: Be ready. Get your minds around the fact that genomics is and will continue to be a part of our profession. Start incorporating the needed content into curricula, but don't panic and don't "jump the gun" by promoting false information that sets the health care world back. There is still a long way to go before the evidence is sufficient to drive care. Stay calm and become a par excellence consumer of genomic and epigenetic literature so that you add value to the overall movement of precision health among the health care team.
For more in-depth discussion, listen to this recent podcast interview between PTJ Editor-in-Chief Alan Jette, PT, PhD, MPH, FAPTA, and Richard Shields.
To attend this exciting CSM session, register now at www.apta.org/CSM/. CSM advance registration discounts end December 5.
Easing Administrative Burden: APTA Makes It Easy to Make Your Voice Heard
Everyone hates unnecessary paperwork and red tape—it cuts into your time with patients, adds to a clinician's workload, and often can delay care. The Centers for Medicare & Medicaid Services (CMS) seems to have gotten the message, going so far as to propose a rule on reducing administrative burden. And you have an opportunity to weigh in on the issue: CMS is asking for public comment on regulatory burdens as it considers ways to streamline processes in future rules. Comments are due by November 19.
Carol Zehnacker, PT, DPT, has worked in a multitude of practice settings, including acute care, skilled nursing facilities, home health, and private practice. Zehnacker says, "There has been an explosion of regulations and administrative burdens that hamper our ability to provide quality care, and can lead to provider burnout."
"We all went into this profession with a desire to help others," says Theresa Marko, PT, DPT, MS. "The health care system sometimes inhibits progress due to unnecessary regulations. How do we fix any of this? How can one person make a difference? APTA has a team of people working to improve the system in which we operate. If we can rally together with one collective voice to let the powers that be know how we feel, wouldn't that be great? For this proposed rule, APTA has created an easy-to-use template you can download, edit with personalized comments, and send in to CMS."
Both Zehnacker and Marko are submitting comments using APTA's template, which provides therapists with some specific content areas they can customize by providing their personal stories and highlighting other regulations that are overly burdensome on physical therapists. The content areas in the template letter include the following:
Streamline the Medicare credentialing process.
Institute a permanent moratorium on the direct supervision requirement for outpatient physical therapy services in critical-access hospitals.
Eliminate or modify the outpatient therapy plan of care 30-day initial certification and 90-day recertification requirements.
Eliminate prior authorization for Medicare Advantage patients or require same-day authorizations.
Better ensure accurate beneficiary eligibility data.
In her comments to CMS, Zehnacker, a private practice owner who has a contract with a home health agency, described the "unnecessary requirement" of notifying the physician when the plan of care changes, such as a missed visit or a treatment or service as required by the plan of care. "This is time consuming for both the therapist and the staff at the physician's office. The physician has already ordered physical therapy in the home health setting. In reality, it is the physical therapist who develops the physical therapy plan of care and awaits the physician's sign-off."
You don't have to go to Capitol Hill to make your voice heard. Rather, you can use your voice, through written comments, to educate and influence executive and independent agencies, the bodies that create or publicize regulations by the authority of Congress.
"When regulatory agencies propose to take action on a certain subject that is of interest to you, it's important to take that opportunity to use your voice," says Kara Gainer, APTA's director of regulatory affairs. "It's the individuals who often provide the most compelling comments, offering the agency a different perspective that is both personal and closely connected to the issue at hand."
Although comments submitted by APTA, representing the physical therapy profession, are incredibly influential, "when CMS is making important decisions that will affect our everyday operations in our professions, they will take into consideration all the comments submitted by providers," says Marko. "Personalizing APTA's template and uploading it to the CMS website is easy—I was able to do it in about 15 minutes! As a private practice orthopedic PT I have experienced much unnecessary burden throughout my career. The template is an easy way for all of us to impact the system in which we operate and produce a positive outcome."
Visit APTA's website to download the template and submit your comments. (Scroll down to "CMS Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction.")
Understanding Trauma and Chronic Toxic Stress in Your Pediatric Patients
By Jessica Barreca, PT, DPT
In our profession, the word "trauma" typically leads us to think of a catastrophic injury, emergency medical care, and comprehensive rehabilitation services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), however, trauma also includes "events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening, which result in adverse effects on the individual's functioning and well-being."
ACEs Are More Prevalent Than You Might Think
The first study to examine trauma's long-term health effects was the CDC-Kaiser Permanente Adverse Childhood Experiences Study, which collected confidential surveys of over 17,000 Kaiser Permanente patients. Respondents were asked about their exposure to adverse childhood experiences (ACEs)— neglect, abuse, and "household dysfunction" such as domestic violence—and their current health status, risk behaviors, and disease. The study found that over 50% of participants had experienced at least 1 ACE and 25% had experienced 2 or more.
In 2013, the Philadelphia Urban ACE study (.pdf) surveyed a more racially diverse sample of adults and expanded survey questions to include topics such as community violence, racism, and neighborhood safety. More than 80% of those surveyed had experienced at least 1 ACE and nearly 40% had experienced 4 or more. Children of all ages and backgrounds experience ACEs, but poverty is a risk factor (.pdf).
To achieve optimal health outcomes for children who have or are experiencing trauma, physical therapists (PTs) and physical therapist assistants (PTAs) should practice SAMHSA's "Four Rs" (.pdf):
- Realize trauma's impact
- Recognize signs and symptoms
- Respond by integrating knowledge of trauma-informed care
- Resist retraumatizing patients
Realizing the Impact of Trauma and Toxic Stress
The brain is most plastic and develops most rapidly during early childhood. The influences of the environment and an infant's relationships with adults can significantly impact neural development. Stress plays a large role in all of our lives and is in fact essential to the development of a healthy stress response system, but the presence of a positive, caring adult is what helps a child avoid toxic stress, defined as "strong, frequent, or prolonged activation of the body's stress response systems in the absence of the buffering protection of a supportive, adult relationship."
According to the National Scientific Council on the Developing Child, our bodies respond to stress in different ways. A positive stress response may occur, for example, on a child's first day of kindergarten: The child's heart rate will increase and there will be a minimal rise in stress hormones. Under more challenging circumstances, such as the death of a caregiver or a natural disaster, a child experiences an elevated stress response system for a temporary period of time. In both of these scenarios, children learn to manage stress and regulate their stress response by receiving support from an adult who creates a nurturing environment and models effective coping strategies.
However, when a child is exposed to prolonged, significant, and/or cumulative trauma ranging from abuse, neglect, witnessing violence in their community, or living in poverty—without ongoing support from a caring adult—a toxic stress response occurs.
Research shows that trauma and toxic stress experienced in childhood negatively impacts the physical, mental, social, and emotional development of children, from developmental delays to learning and behavior problems. In the long term, ACEs are linked to risky health and lifestyle behaviors, chronic diseases, and even premature death.
Even when children experience significant trauma, there is still the capacity to develop resilience.
Recognize Signs and Symptoms of Trauma in a Pediatric Patient
The National Child Traumatic Stress Network provides a comprehensive list of signs and symptoms of trauma for individuals from infancy through early adulthood.
Infants and toddlers often don't have the ability to verbally express the events, experiences, and feelings of trauma. Be aware of sudden changes in a young child's behavior—all behavior is communication. Young children who have experienced trauma may exhibit increased separation anxiety, excessive clinginess, crying and/or whining, increased fear and anxiety, regression in global developmental progress, or failure to achieve developmental milestones.
Elementary school students ages 6–12 who have experienced trauma may exhibit a variety of different behaviors, such as increased anxiety, fear, and distress, as well as withdrawal and avoidance. These kids may also demonstrate decreased ability to focus, overreaction to auditory stimuli (a door slamming shut or fire alarm), a change in academic performance, poor impulse control, and challenges with authority figures or constructive criticism. Increased physical complaints (stomachaches and headaches) may be observed as well.
Respond by Integrating Trauma-Informed Principles Into Your Care
SAMHSA's trauma-informed principles can be incorporated into any type of health care setting or organization, and all patients and families, with or without a lived experience of trauma, can benefit from PTs adopting a trauma-informed approach. By adopting these principles, we shift our own internal dialogue from "What is wrong with you?" to "What happened to you?" and view our patients through a trauma-aware lens.
Often a family will miss multiple therapy appointments and will be labeled as a "no-show." By taking a trauma-informed approach, the PT recognizes the multitude of social, economic, and contextual factors that may contribute to missed therapy appointments. Instead of discharging the patient, the PT incorporates trauma-informed principles and meets with administrators, office staff, other team members, and the family to identify pertinent issues and create a solution that allows the child to regularly attend physical therapy. As a next step, the office administrator invites families, office staff, and the therapy team to review policies regarding the clinic's attendance policy. Through this process, policies are amended in a culturally sensitive and collaborative manner with all involved stakeholders to ultimately promote a more inclusive environment for children and their families.
Resist Retraumatizing Patients Inadvertently
PTs working with children and families can take concrete steps to build a culture of emotional and physical safety in their clinical, school, or hospital settings. When the health care team uses trauma-informed principles in partnership with a family-centered approach, it creates a safe environment with reduced potential for retraumatizing children and families. Often individuals who have experienced maltreatment as children are distrustful of authority figures, including health care professionals. By ensuring that families and children have a voice in their plan of care, we can work toward empowering patients through choice.
Jessica Barreca is a physical therapist with over 17 years of experience working with children in a variety of settings including outpatient, early intervention and school systems. She is the community site coordinator in the Center for Interprofessional Education & Research and adjunct instructor of physical therapy at Saint Louis University. Jessica is an ambassador for Alive and Well STL and is passionate about spreading knowledge and awareness regarding the widespread prevalence and impact of childhood trauma on families and children in our communities.
Interested in learning more about this topic? The 2019 APTA Combined Sections Meeting will be holding several presentations related to trauma, including: Sexual Assault and Communities of Color: PT Roles, Pain Science With Vulnerable Populations: Transforming the Human Experience, and A Trauma-Informed Pathway to Caring for Patients and Providers. Register now at www.apta.org/CSM/.
Jessica Barreca will be presenting Using a Trauma Sensitive Lens to Promote Shared Decision Making in Pediatric Practice at the Academy of Pediatric Physical Therapy Annual Conference in November, 2018.
CSM Preview: All You Ever Wanted to Know About MIPS
By Kara Gainer, JD
Value. Quality. Outcomes. Costs. The United States is moving away from the traditional fee-for-service reimbursement structure, one in which providers are rewarded solely for the volume of services provided, to one that holds providers accountable for patient outcomes and costs.
Beginning January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), which offers incentive payments to help eligible clinicians focus on care quality and making patients healthier, will include many physical therapists who participate in Medicare Part B.
While we estimate only about 5% of Medicare-enrolled physical therapists in private practice will be mandated to participate or face a penalty, almost all physical therapists in private practice will be eligible. Considering that there are no more scheduled payment updates to the Medicare physician fee schedule after 2019, QPP participation is something you should seriously think about if you're one of those eligible PTs.
At APTA's Combined Sections Meeting in January, we will answer your most pressing questions about QPP:
- What do these acronyms mean?!
- How does it work?
- If I am not required to participate, what is the benefit to me if I do?
- What is the difference between the Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Model (APM)?
- How can I maximize my incentive payment?
Nothing is simple when it comes to Medicare, and QPP is no different. The devil is in the details—and there are a lot of them.
APTA Director of Quality Heather Smith, PT, MPH, and I will be diving into the nitty gritty of what physical therapists need to know if they want to successfully participate in QPP, whether through MIPS or Advanced APMs.
You may be asking yourself: "Do I really need to attend this session?" Well, here is what one California PT who attended a similar session on Medicare payment said:
So, if you're ready to get out of your comfort zone and transform your practice, join us on Friday, January 25, in downtown Washington, DC, for "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models," where you will learn more about QPP and how you can participate in Medicare payment models that reward value over volume, achieving better patient outcomes.
CSM advance registration discounts end December 5.
Kara Gainer, JD, is APTA's director of regulatory affairs. You can connect with Kara on Twitter at @karagainer.
When Health Decisions Aren’t a Matter of Choice: Addressing Social Determinants of Health
Physical therapists (PTs) and physical therapist assistants (PTAs) focus on both restoring movement in those with decreased function and promoting healthy behaviors to prevent health problems such as obesity or high blood pressure. But in doing so, they also must consider how social determinants of health—economics, education, neighborhood, and other factors—influence the lifestyle choices patients and clients make.
Zachary D. Rethorn, PT, DPT, a home health PT, board-certified orthopaedic clinical specialist, doctoral student in health promotion and wellness, and adjunct professor at the University of Tennessee at Chattanooga, has been giving these ideas careful thought and incorporating them into his practice. In 2018, he co-presented on the topic of social determinants of health at APTA's NEXT Conference and Exposition, and earlier this year he published a blog post that further explored the topic. In the post, he writes:
. . .the narrative in our country is one in which personal responsibility is emphasized so much that we can forget we live in communities and systems which influence the choices we make. Say you have a prized rose bush (like I do). If it doesn't bloom this year am I going to uproot it, chuck it out, and get a new one? Of course not! When a flower doesn't bloom you fix the environment in which it grows. Not the flower.
#PTTransforms interviewed Rethorn to learn how PTs and PTAs can incorporate these concepts at the point of care.
In your blog post, you write about the 5 areas of social determinants of health: economic stability, education, social and community context, health and health care, and neighborhood and built environment. Most of these areas pertain to things that neither the patient nor the provider can change, for the most part. You can't change the fact that your neighborhood isn't safe for you to get more physical activity, for example. How can a clinician use this information? Should we be screening for social needs?
ZR: The first question we have to ask ourselves is are we a profession which delivers health services? Or are we a profession that promotes the health of our neighborhoods, communities, cities, and states? If we believe that our role is to advocate for and improve the health of those we serve, then a good place to start is by considering the social and environmental context in which our patients live.
Screening for social needs can be very different from our typical medical or health screening tools. I want to caution readers that screening must be linked to the ability to provide appropriate referrals and treatment. Screening without the capacity to assist is ineffective and potentially unethical.
To mitigate negative unintended consequences of screening, here are 5 tips:
- Be patient-/family-centered in screening.
- Integrate screening with referral and linkage to community-based resources.
- Perform screening within the context of a comprehensive system that supports early detection.
- Acknowledge and build on strengths of patients, families, and communities.
- Engage the entire practice population, rather than targeted subgroups.
How can a clinician evaluate this information and use it to help with shared decision making to improve the patient's health?
ZR: There are a number of evidence-based toolkits that clinicians and health systems can use to screen for social needs, including HealthLeads, PRAPARE, HealthBegins, and the Accountable Health Communities Screening Tool. These tools all provide a starting point with recommended core domains such as food insecurity, housing instability, utility needs, and financial resource strain. Based on a community's needs, additional domains such as child care and social isolation may be added.
Whatever tool you choose to use:
- Make it short and simple—no more than 12 questions, written at a fifth-grade reading level, translated into appropriate languages.
- Choose clinically validated questions designed to open a conversation.
- Integrate the tool into clinical workflows.
- Elicit patient feedback to prioritize screening items.
- Pilot before scaling.
Once a clinician has gathered information about an individual's social context, it is essential to open a conversation with that individual regarding what he or she wants and believes will be most helpful. This is place where the clinician can provide advice and not only refer the individual to other services, but also facilitate access to those services in a sensitive, culturally acceptable, and caring way.
What modifications can a PT make to account for, say, a neighborhood where a patient feels unsafe? Or lack of access to fresh fruits and vegetables?
ZR: The first step to take if individuals are saying that a neighborhood is dangerous or there is no access to fresh fruits and vegetables is to understand what local resources are available. Often, there are resources available that the person may not be aware of.
For the first few years of my practice, I worked in a neighborhood where many of my patients felt unsafe going outside. But as I got to know the neighborhood better, I realized there were opportunities for physical activity outside but perhaps in ways different from what I first envisioned. Instead of coaching individuals to take walks by themselves, I started walking groups. Suddenly, this became a feasible way for many of the older adults I worked with to feel safe and be more social in their neighborhood.
If a creative solution is truly unavailable, this is where advocacy comes into play. My clinic was located in a food desert, where the closest grocery store with fresh produce was 2 miles—but 3 bus changes and 50 minutes—away. As I heard more and more that lack of access to healthy food was a perceived need in my population, I took this to a local farming nonprofit that agreed to begin hosting a mobile market in the neighborhood 2 afternoons per week.
These examples are not extraordinary. They come from carefully listening to the individuals I serve and reimagining my role as a PT from one who simply delivers interventions to one who is invested in and cares about the health of my patients. Caring about the health of my patients necessarily means that I care about the social and environmental context they live in, because the context is what shapes their health behaviors and choices.
When working with a patient, how do you balance empowering the individual to make healthy choices with the knowledge that some things you just cannot control?
ZR: When I work with a patient, I am considering health influences at multiple levels. At purely an individual level, I am examining their health behaviors such as physical activity, diet, stress, and sleep. During my history taking, I will ask about these factors and coach the patient to change their health behaviors based on their desires and resources.
At a wider level, I am cataloguing the individual and systemic barriers that individuals are relating to me. Perhaps a number of individuals are telling me that the sidewalks in their neighborhood are in disrepair. At this point, I can gather more information from a neighborhood association, search for data related to sidewalks in the city, or go to a city councilor to bring up the need related to sidewalk repair.
The goal is to find pain points where social and economic factors present barriers to individuals' ability to engage in health behaviors. From there I can use clinical experience and research evidence to advocate for social change which will improve the health of the population I serve.
Is there a danger of implicit bias here? How can clinicians avoid making assumptions about the relationship between a patient's health and these 5 areas? Or do social determinants of health help us respect the personal, economic, and cultural circumstances our patients face?
ZR: Current data suggest that, first, implicit bias is a real phenomenon. We all hold underlying attitudes and stereotypes toward members of other groups. But not only is it real, health care providers exhibit the same amount as the general population. This bias is shown in positive attitudes toward Whites and negative attitudes toward people of color. Further, this implicit bias may impact the clinical decision making of health care providers toward their patients.
Addressing implicit bias must be a conscious decision. One way to avoid making assumptions is to commit to screening for social determinants of health across your entire patient population and not just for select subgroups. If you target only demographic variables such as age, education, residence, underrepresented minority status—it may reinforce stereotypes and prejudicial presumptions and could stigmatize the screening process.
Another strategy is to improve your understanding of health disparities and bias in health care. Once I understood the daily challenges that my population faced, I became more empathetic and better equipped to facilitate positive changes in the community.
Do you see social determinants of health taking a larger role in health research in the future? How so?
ZR: Research on the social determinants of health is already robust. The influence that the social and environmental context plays on individuals' and populations' health is clear. The question is: Do we have the social will to take what we already know and implement it? Are we willing to address health where it starts, not just where it ends? Can we make the healthy choice the easy choice in culturally sensitive and appropriate ways from neighborhood to neighborhood and city to city?
Primary Care and the Physical Therapist: Lessons From the Military
By Jason Silvernail, PT, DPT, DSc
If you keep up with the news, you may have seen headlines like these: "Doctor shortage may reach 120,000 by 2030," "How can we remedy the shortage of health care providers?" and "US faces looming shortage of primary care physicians."
Given the importance of primary care, this isn't good news. To address this shortage, medical schools have increased enrollment, hoping to graduate more primary care physicians. But there are other ways to meet the demand for primary care than just producing more medical doctors, as the US military can teach us.
Several times in its history, the US military has experienced critical shortages of physicians. As a result, after the Vietnam War the military had to develop models of health care that can be an example for a civilian practice environment facing the same problem. Surely if these approaches—validated through reviews of military medicine by organizations such as The Joint Commission and the National Committee for Quality Assurance—are successful for our men and women in the military, they should be considered seriously as options to improve the supply of civilian primary care providers!
Primary health care teams in military medicine are constructed with a basic set of capabilities in mind and can include physicians, nurse practitioners, physician assistants, physical therapists (PTs), and behavioral health care providers such as psychologists and social workers. This "capabilities model" allows these licensed independent providers to work at their full level of training, share responsibilities, and help get the right patient to the right provider in a timely manner to provide effective care.
The military's health care teams often rely on what's known as "capabilities-based assessment": it determines what functions (capabilities) need to be present for success and then identifies resources to provide those functions. Instead of relying on old models and assumptions of how things have always been done, teams develop new solutions that are matched to the details of the problem.
There may be barriers to translating such a model to civilian care, such as high copays and Medicare not recognizing PTs as primary care practitioners, but such barriers are based on health policy, not on medical necessity or appropriateness. After all, PTs aren't seeking to replace primary care physicians but to provide primary health care within the scope of their training and expertise—care that is low-cost, low-risk, and proven effective for many common medical conditions that bring patients to primary care providers.
Primary care providers in team settings need to be able to evaluate and manage a wide variety of injuries, illnesses, and disorders—and no one profession can do it all. An ideal primary care team will be able to triage and direct the patient to the right team member. For example, the patient with the acute sports injury to the physical therapist, the cough and fever to the nurse practitioner, and the acute anxiety reaction to the psychologist.
PTs in the US military are right now stationed all over the country and around the world working in primary care teams managing acute sports injuries, dizziness and balance problems, pelvic pain, nerve injuries, wound care, and of other illnesses, injuries, and disorders well suited to their expertise. Easy access to PTs allows military members and their families to get rapid access to low-cost, low-risk, high-quality care. Using a team-based model in primary care helps foster trust and teamwork as different providers learn to share the overall workload while matching patients to the right provider.
No single provider can do it all—that's why you need a team. PTs are ready now to take on this team role, if we are willing to confront the policy obstacles that stand between Americans and the quality care provided by doctors of physical therapy as part of primary health care teams.
Jason Silvernail is a career Army officer and works in hospital leadership in the Washington DC area. Statements appearing here are Dr Silvernail's personal opinions and commentary and do not reflect the official policy or position of the United States Army, the Department of Defense, or the US Government.
Editor's note: Are you practicing as a primary care PT or working in primary care? APTA wants to hear from you! Contact Hadiya Green Guerrero at email@example.com or Jeannie Bryan Coe at firstname.lastname@example.org for your personal survey link.
What Is the PROMISe of Global Outcome Measures? 3 Things You Need to Know
By Jeff Houck, PT, PhD
As health care providers, we often indirectly gauge patient outcomes by quantifying process measures such as number of visits per episode, cost per visit, and compliance with standardized guidelines. These variables can answer important questions: Are we wasting resources? Do we have unwarranted variation in care within our facility? Are treatments consistent with published clinical practice guidelines? But process measures do not place the patient's voice at the center of their care.
Patient-reported outcome measures (PROMs) are pivotal to assessing and achieving high-quality care. Patient-reported outcomes represent the only direct input of health status from the patient, unfiltered by a provider. Patient advocates and agencies such as the Centers for Medicare and Medicaid Services (CMS) see patient-reported outcomes as a key avenue to give patients a voice in their health care.
Global (as opposed to condition- or disease-specific) outcome measures, such as the Patient Reported Outcome Measurement Information System (PROMIS) scales, use the newest approaches to outcomes assessment (computer-adaptive testing and item-response theory) to capture a patient's overall health and compare it with the national average. Measures such as PROMIS allow physical therapists to hear their patients' voices relative to overall health during rehabilitation and to champion wellness programs.
Physical therapists were leaders in adopting condition- and disease-specific outcome measures, so it's natural for us to do the same with global outcome measures.
1. Global measures change the assessment paradigm from disease-specific effects to holistic health assessment that includes the patient's perspective.
Global measures offer distinct advantages over condition- or disease-specific measures. In contrast to such measures, which target a diagnosis, global measures target a health domain independent of diagnosis. The goal is to capture a patient's overall health status. PROMIS, for example, includes over 300 different health domains assessing symptoms and physical, mental, and social health traits. The scales are designed to accurately measure health domains such as pain interference, physical function, fatigue, self-efficacy, or social isolation across a population.
The main benefit of global measures is that they combine different health domains to obtain an accurate picture of a patient's perceived overall (physical, mental, and social) health. For wellness and for patients with comorbidities—which are the majority of patients—global measures help clinicians determine when treating a local problem may have strong effects on overall health and, vice versa, when costly interventions that remedy a local problem have no influence on overall health.
Let's consider a fictional patient, Mary, who had a total knee replacement due to knee osteoarthritis.
Because of Mary's previous longstanding chronic knee pain, she had gained weight and now fatigues easily. Many patients do not increase physical activity after knee joint replacement and are therefore unable to correct these primary health concerns.
A condition-specific measure such as the Knee Injury and Osteoarthritis Outcomes Score (KOOS) would assess Mary's opinions about her pain, ADL function, sports, recreation, and quality of life specific to her knee. In contrast, the PROMIS physical function and pain interference scales would measure Mary's overall physical function and pain.
Fear of doing too much after the surgery and low endurance are not routinely detected using condition-specific assessments such as the KOOS, while the efficiency of PROMIS computer-adaptive scales (1-minute per health domain) allows for additional health domains to be assessed that are important to the patient or provider without burdening the patient.
In Mary's case, the PROMIS physical function and pain interference scales detected deficits similar to the KOOS. However, the addition of the fatigue and self-efficacy scales also detected Mary's low energy and low confidence in her ability to manage her health, which her physical therapist addressed.
By following her plan of care, Mary has lost weight and improved her cardiovascular fitness, in addition to experiencing improvement in physical function and pain interference.
2. Condition- and disease-specific measures are still valuable for some populations, but global measures often perform just as well.
An important issue for the switch to value-based care is documenting change. In statistical terms, a measure needs to be valid and responsive to be effective clinically. There may be some very specific problems, such as carpal tunnel syndrome, where global measures are not as responsive and may require the continuation of disease-specific measures in some specialty practice areas. However, for most conditions, from anterior cruciate ligament reconstruction to geriatric assessment, the PROMIS scales are performing as well or better than disease-specific scales.
(See the PROMIS Health Organization's website for published papers on validity and responsiveness of PROMIS scales.)
3. Global measures present opportunities for PTs to expand their role in the broader health care ecosystem.
Global assessments are agnostic to disease, so scales can be applied successfully across diagnoses and shared easily across multiple types of providers. Everyone speaks the same language! This frees up time for physical therapists and focuses outcomes on a common goal of improved overall patient health. For example, patients with abnormally low physical function may be flagged for physical therapist services such as fall prevention or presurgical screening.
Global measures also support the philosophy of value-based care, which is one reason that APTA's Physical Therapy Outcomes Registry—also rooted in the pursuit of value-based care—has integrated measures like PROMIS. They allow the Registry to develop quality measures that demonstrate value to the patient and multiple types of clinicians, as well as across episodes and provider types.
Wide-scale integration of global measures in electronic medical records has been implemented at major medical systems such as the University of Utah and University of Rochester. PROMIS also is available as an iPad app for users with less technical support or in a private practice setting who want to use computer-adaptive tests rather than long or short forms.
This places highly accurate, state-of-the-art assessment of over 300 health domains at the fingertips of clinicians working in both small practices and large-scale health systems. Patients and providers can easily understand and apply the scores to their clinical decision making. The health care ecosystem is ready to respond to new health care challenges based not on process outcomes but on the voice of patients who are seeking improved overall health.
Jeff Houck is director of research in the physical therapy program at George Fox University.