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  • Can't-Miss Special Edition of PTJ Focuses on Intersection of Pediatric Physical Therapy and Developmental Science

    The June edition of PTJ (Physical Therapy) is something special: an entire issue devoted to the ways pediatric physical therapy and developmental science are informing each other—all to the benefit of children and their families.

    The issue shouldn't be missed, say Alyssa Fiss, PT, PhD, and Anjana Bhat, PT, PhD, both of whom are board-certified pediatric clinical specialists. PT in Motion News asked Fiss, a physical therapy professor at Mercer College, and Bhat, who teaches at the University of Delaware, to share their personal highlight of the issue. Here's what they had to say:

    Alyssa Fiss: "Michele Lobo and colleagues' ‘Wearables for Pediatric Rehabilitation: How to Optimally Design and Use Products to Meet the Needs of Users’ was a favorite of mine among many very strong articles. This article provides an excellent overview of the broad spectrum of wearable clothing and devices that support pediatric rehabilitation. Specific examples of wearables, with benefits and considerations for each, provide for interesting, thought-provoking reading about the variety of options available for children. When I read it, I was inspired to think of ways to creatively and intentionally use or design wearables to support children in active engagement and participation in daily life."

    Anjana Bhat: "I think 'Feasiblity and Effectiveness of Intervention With the Playskin Lift Exoskeletal Garment for Infants at Risk' by Iryna Babik and colleagues is one of the standouts of the issue. This is a beautifully written paper describing changes in reaching and cognitive performance over a 4-month period as well as a 1-month follow-up in infants born preterm or with birth injury, or both. This paper is unique in its use of a Playskin Lift garment to improve reaching and object exploration skills of young infants. Clinicians who work with challenging and highly diverse populations will gain a lot from this paper, including some new ideas on how to broaden their therapeutic toolbox. Parents should also be encouraged to explore what Babik and her coauthors have to say."

    But wait, there's more: in addition to the articles highlighted above, the special issue includes perspectives and original research on topics ranging from the ways motor skills development is connected to social skill development, to neonatal abstinence syndrome, as well as a case study on the use of electrical stimulation in gait training of adolescents with cerebral palsy. In all, 17 articles are included in the special issue.

    "Pediatric physical therapy and developmental science share a fundamental concern—the optimization of developmental outcome," write special issue coeditors Jill Heathcock, PT, PhD, and psychologist Jeffrey Lockman, PhD. "We believe this issue contains 'something for everyone'—practical information for clinicians in the trenches and intriguing trends in research for investigators."

    Attending the 2019 APTA NEXT Conference and Exposition? Stop by the PTJ booth in the APTA pavilion to find out more about the special issue and all of the other resources available at the journal's website.

    Study: Burnout Comes at a (Literal) Cost to Organizations

    A recent PT in Motion magazine story that looked at burnout among physical therapists (PTs) and physical therapist assistants (PTAs) highlighted the ways the condition can impact the lives of individual providers, and characterized burnout as an "area of concern" for the profession. Now a study of physicians adds another dimension to the concern: burnout also comes with a hefty price tag.

    Authors of the study were well aware of the relationship between burnout and negative clinical outcomes, decreased patient satisfaction, and medical errors. What they wanted to uncover was burnout's economic impact—particularly in terms of the ways turnover and reductions in clinical hours reduced revenue for facilities. Their estimate: about $4.6 billion annually, or $7,600 per employed physician.

    The $4.6 billion cost figure was an average. Depending on the models they used, researchers estimated burnout-attributable costs ranging from $2.2 billion to $6.7 billion annually. Likewise, the individual physician cost ranged from $3,700 to $11,000 depending on the analysis used. Estimated turnover costs tended to represent the lion's share of the expenses, exceeding the costs of reduced productivity.

    To get this snapshot, researchers used results from physician surveys and other studies on physician turnover, and combined those with studies related to the value of hours worked and the cost of physician replacement including expenses related to search, hiring, and onboarding. Results were published in the Annals of Internal Medicine (abstract only available for free).

    APTA's focus on burnout—particularly on the ways undue administrative burden contributes to it—has led to several gains for the profession, including the elimination of functional limitation reporting under Medicare, an end to the functional independence measure in inpatient rehabilitation facilities (effective October 1 of this year), and reduction in the number of required assessments in skilled nursing facilities (also effective October 1). Other contributing factors, such as student debt burden, are also being addressed by the association, which offers an online financial solutions center to boost financial literacy and offer options for loan refinancing.

    Authors of the Annals study agree that "burnout is a problem that extends beyond physicians" to other health care providers, and they urge further research to uncover the costs involved, hinting that among some policymakers, an analysis of the bottom line may be key to helping them sit up and take notice of the problem.

    "Traditionally, the case for ameliorating physician burnout has been made primarily on ethical grounds," authors write. "Our results suggest that a strong financial basis exists for organizations to invest in remediating physician burnout."

    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 Reveals Racial Disparities in Postdischarge Rehab After Traumatic Injury

    The road to recovery after a moderate-to-severe traumatic injury can be daunting for anyone, but a new study suggests that individuals who are African American may face an even more challenging path. Researchers found that in groups matched for age, injury type, and injury severity, African Americans were on average 36% less likely to use rehabilitation services and 40% less likely to have outpatient visits postdischarge.

    The presence of the apparent difference echoes APTA's characterization of racial and ethnic disparities as existing "across a range of illnesses and health care services."

    The study's conclusions are based on an analysis of 2.5 years' worth of patient-reported data linked to trauma treatment records from 3 Boston-area level 1 trauma centers participating in the Functional Outcomes and Recovery after Trauma (FORTE) project. Patients included in the study experienced moderate-to-severe trauma, defined as an Injury Severity Score (ISS) of 9 or greater, and participated in phone interviews conducted 6 to 12 months after trauma center discharge. Results were published in the American Journal of Surgery (abstract only available for free).

    Researchers were interested in patient answers to 2 primary questions: whether they received any rehabilitation services by way of discharge to a rehabilitation facility or skilled nursing facility, or through home or outpatient services such as physical therapy; and whether they received injury-related outpatient follow-up in a clinic setting. Participants also were asked about use of emergency departments (EDs) for an injury-related problem.

    The findings: of 1,299 patients studied, 79.8% of Caucasian patients reported receiving rehabilitation services, compared with 64.3% of patients who were African American. Injury-related outpatient clinic visits were reported at a rate of 47% for Caucasians and 40% for African Americans. Injury-related ED visits were reported by 10.1% of Caucasians, compared with 18.7% of African Americans.

    Researchers further analyzed the data by using a "Coarsened Exact Matching" algorithm to create groups of Caucasians and African Americans that were comparable in terms of injury type and severity as well as age and gender. That process reflected similarly significant differences in rehabilitation and outpatient visits but did not show a difference related to use of the ED.

    Other differences in the patient populations also emerged in the study. Caucasian patients tended to be older, with a mean age of 65 compared with a mean age of 45 for African Americans; additionally the Caucasian population reported a move even gender distribution (51% male) compared with the African-American group (67% male). Initially, researchers found differences in the discharge dispositions (home versus rehab facilities) among the groups, but those differences disappeared after adjusting for demographic and injury-related variables. Almost all participants had health insurance.

    "Our results suggest that racial disparities exist in the post-discharge utilization of health care services, which we know affect long term functional outcomes after injury," the authors write, noting that while discharge dispensation may not differ between the groups, patients reporting as African American were less likely to actually receive the rehabilitation services. "These racial discrepancies in post-discharge health services utilization may contribute to worse long-term trauma outcomes," they add.

    The study's authors believe there are "likely many factors" that play a role in these differences, but they speculate that "unconscious provider bias, patient understanding, miscommunication, access to care, and evidence of mistrust toward medical providers" are among the elements at work. Pinpointing the causes, they argue, "may provide insight into avenues for equalizing long-term outcomes for traumatically injured patients."

    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.

    CoHSTAR Pilot Study Deadline June 1

    A deadline is fast approaching for Center on Health Services Training and Research (CoHSTAR) opportunities to develop pilot studies that would help set the stage for larger efforts to advance a wide range of health services research. Letters of intent are due by June 1, 2019.

    The selected pilot studies would address research questions in CoHSTAR's 4 areas of specialization—analysis of large data sets, rehabilitation outcome measurement, cost-effectiveness, and implementation of science and quality improvement research—and the CoHSTAR Pilot Study Program webpage lists examples of specific types of studies that would qualify for funding. Each pilot study will receive $25,000 in funding for direct costs.

    APTA was a major financial contributor to the development of CoHSTAR, having donated $1 million toward the center's startup in 2015. In addition to APTA’s $1 million donation, funding for CoHSTAR also came from APTA components, individual PTs, foundations, and corporate supporters.

    Study Identifies 11 Guideline-Based Recommendations for Musculoskeletal Pain

    A multidisciplinary group of researchers, including physical therapists (PTs), has identified a core set of 11 clinical practice guideline (CPG) recommendations for treating adult musculoskeletal (MSK) pain, according to a new article in British Journal of Sports Medicine (BJSM). Authors hope the recommendations will assist emergency and primary care clinicians in providing evidence-based care, as well as help consumers make informed health care decisions.

    Authors write that while "care that is more concordant with CPG recommendations results in better patient outcomes and lower costs," providers across disciplines too often do not practice according to guidelines, resulting in overuse of imaging, surgery, and opioids, and a failure to provide patient education and advice. There are many reasons for this, according to authors: CPGs often are not "user-friendly"; they often lack guidance on how to implement recommendations in practice; and different guidelines for a single condition may include conflicting recommendations.

    To help bridge these "evidence-to-practice gaps"—and help consumers understand what best practice looks like—authors examined 44 CPGs addressing 3 of the most common areas for MSK: spinal pain; hip/knee pain, including hip/knee osteoarthritis; and shoulder pain. The CPGs reviewed were published within the last 5 years, included information on how they were developed, and were published in English. Researchers excluded guidelines that focused on a single treatment modality, traditional medicine, traumatic MSK pain, specific diseases such as inflammatory arthritis, and those that required payment to access.

    Included in the analysis was the Academy of Orthopaedic Physical Therapy guideline "Low back pain: clinical practice guidelines linked to the international classification of functioning, disability, and health."

    Authors performed an AGREE II analysis on each CPG. A guideline was classified as "high-quality" if it received an AGREE II score that was at least half of the maximum possible score in 3 separate areas: rigor of development, editorial independence, and stakeholder Involvement.

    The 11 consistent recommendations include:

    1. Care should always be patient centered. Patient-centered care, according to authors, is characterized by effective communication, individualized care, shared decision making, and prioritizing patient preferences.
    2. Patients should be screened for serious pathology or "red flag" conditions. Providers should screen for causes of pain such as infection, malignancy, fracture, inflammation, neurological deficit, as well as conditions that mimic MSK pain.
    3. Psychosocial factors should be included in a patient's assessment. Providers should assess patients for psychosocial factors—such as depression, anxiety, kinesiophobia, and recovery expectations—that may affect their prognosis, in order to develop an appropriate plan of care.
    4. Radiological imaging is unnecessary in most cases. Many guidelines discourage the use of radiological imaging, except when a more serious pathology is suspected, the patient is not responding to treatment, or the imaging results are "likely to change management" of the patient's condition.
    5. Assessment should include physical examination to assist in diagnosis and classification. Physical assessments mentioned in the CPGs include tests for mobility/movement, strength, position and proprioception, and neurological function.
    6. Providers should evaluate patient progress and use validated outcome measures. In the CPGs authors examined, outcome measures assessed patients' pain intensity, functional capacity and activities of daily living, and quality of life.
    7. Patients should receive individualized education about their condition and treatment options. Authors recommend patient education to "encourage self-management and/or inform/reassure patients about the condition or management."
    8. Treatment should address physical activity and exercise. All of the CPGs reviewed included recommendations on either general or specific exercise and physical activity to increase mobility, strength, and flexibility.
    9. Manual therapy should be used only as an adjunct treatment. Seven CPGs included manual therapy as a "could-do" element of care, but only as part of a more comprehensive plan of care.
    10. Nonsurgical care should be the first line treatment. Unless a "red flag" condition indicates otherwise, patients should receive nonsurgical care before considering surgery.
    11. Treatment should facilitate return to work. Providers should encourage patients to remain active and engage with appropriate social service supports, employers, and health providers to enable a patient to return to work.

    Looking beyond the clinical application of the recommendations, authors suggest that a "broader strategy" for policy makers and health services researchers "could be the continued development of the common recommendations into a set of quality indicators that could be used for reporting or to benchmark care quality."

    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: Patients in Cardiac Rehab Are Older, Less Healthy, and Have More Diverse Needs Than Patients 20 Years Ago

    The use of cardiac rehabilitation (CR) has grown over time, but with that growth comes changes to patient demographics that present new challenges to providers, say researchers who studied the CR patient population in 1 health system over 2 decades. They describe today's CR patients as older, more overweight, and having a higher prevalence of coronary risk factors than CR patients in the past, with an expanded range of reasons for receiving CR that makes the population more diverse than ever.

    The study analyzed data from 5,396 patients who received CR at the University of Vermont Medical Center over a 20-year period between 1996 and 2015, taking in a host of variables, including the reason for participation in CR, the presence of comorbidities, BMI, age, sex, and medications taken. Results were published in the Journal of Cardiopulmonary Rehabilitation and Prevention (abstract only available for free).

    Among the findings:

    • The average age of CR patients changed from 60.8 to 64.2 over the study period—an average yearly increase of 0.23 years. The number of CR patients 65 and older grew at an average yearly rate of 0.6%, while the yearly growth rate for patients 75 and older grew by 0.4%.
    • Women, while still underrepresented, are a growing part of the CR population, and now make up 29.6% of patients, compared with 26.8% in 1996.
    • The percentage of patients considered obese (BMI of 30 or more) increased from 33.2% to 39.6%, reflecting an average yearly increase of 0.5%. While mean weight and waist circumference didn't change, researchers attribute the more steady rates to the growing number of women receiving CR, which tamped down the rise of overall averages. When waist circumference and weight were controlled for sex, both were shown to have increased significantly over time.
    • The prevalence of cardiac risk factors increased in several areas. The rate of diabetes rose from 17.3% to 21.7% of patients, while the percentage of patients with hypertension increased from 51% to 62.5%. The number of patients reporting current smoking also increased, from 6.6% to 8.4%. Both diabetes and smoking rates were about the same between men and women, but women had an 11% higher rate of hypertension.
    • The underlying reasons for receiving CR were among the most dramatic shifts noted by researchers, with the percentage of heart valve replacement patients rising from 0% to 10.6% of the overall CR population. Patients receiving CR as part of treatment for myocardial infarction also increased to 39.6% of the CR population, compared with 29.7% in 1996. At the same time, the percentage of coronary bypass patients decreased significantly, from 37.2% to 21.6%, as did angina patients (5.4% to 1.5%).
    • The use of cardiovascular medications has also increased, with the most dramatic change being in the use of statins by 98.7% of the CR population. Statin use was at 63.6% in 1996.
    • Despite its growth, authors describe CR as still "underutilized," with only 35.5% of people who survive a myocardial infarction participating.

    Authors say that the wider use of CR is fueling at least some of the changes in patient characteristics, with heart valve replacement patients having a seemingly significant impact. The valve replacement patients were, on average, 2.3 years older than other CR patient groups, with a higher percentage of women, lower obesity rates, and generally lower prevalence of cardiac risk factors. As an example of the way valve replacement patients may be shifting overall numbers, authors point out that when valve replacement patients are taken out of the total CR population, the obesity rate jumps from 39.2% to 41.2%.

    Authors acknowledge that their study is limited by its focus on a single health system with a "relatively homogeneous" population, and a less-than-comprehensive range of diagnostic categories included. They assert, however, that the changes observed over time need to continue to be monitored for future trends—and should inform current practice.

    "Given the increase in patient heterogeneity, programs could benefit from having staff with diverse skill sets and able to handle the unique needs of patients with different medical needs," they write. "The ability to individualize patient treatment plans will need to increase. Patient complexity will also differ, suggesting a potential need for increasing staffing ratios."

    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.

    30 Minutes of 'Acute' Exercise Temporarily Boosts Memory-Related Brain Activity, Strengthens Brain Over Time

    That name on the tip of your tongue might be easier to retrieve after 30 minutes of moderate-intensity exercise, according to new research that links "acute" bouts of exercise with increased activity in areas of the brain associated with a certain type of memory. Researchers believe that the postexercise spike in activity may function as a kind of workout for the brain that, over time, can increase neural efficiency and slow cognitive decline associated with aging.

    In the study, published in the Journal of the International Neuropsychological Society, researchers monitored brain activity of 26 adults between 55 and 85 years old as they were quizzed on their recognition of famous names (the "Famous Names Task," or FNT). Each adult was tested twice: once after sitting quietly for 30 minutes, and on another day after engaging in 30 minutes of moderate-level exercise on a stationary cycle.

    The computer-based FNT presents subjects with names of famous people and names of individuals randomly selected from a phone book. Test-takers press 1 key for a famous name, and a different key for a name they don't recognize as famous. For the study, participants' brain activity was monitored as well as their speed and accuracy on the FNT.

    Researchers were focused on areas of the brain associated with semantic memory, the type of memory used to access the store of knowledge humans accumulate over time. Difficulty with semantic memory—for instance, an inability to remember a name—is one of the most common complaints of older adults, and has been associated with early stages of more severe cognitive decline.

    Researchers already knew that regular physical activity can improve cognition in older adults by sparking as-yet understood neurological changes that make the brain work less hard, and that's what they expected to see happening in the brains of participants who had recently exercised. Indeed, participants did score better on the FNT after exercise; but instead of seeing a more efficiently operating brain post exercise, researchers recorded increased levels of brain activity, a kind of short-term supercharging of some of the areas they were studying.

    Authors of the study think that the increased activity is related to the use of "compensatory neural networks," the networks associated with the "cognitive reserve" observed in physically active older adults. In other words, that postexercise brain activity workout may be clearing the way for more efficient cognitive operations over time.

    "We speculate that performing a single bout of exercise elicits a short-term impact on the upregulation and expression of neurotransmitters and neural growth factors that promotes increased neural activation," authors write. "With regular participation in exercise, this process repeatedly occurs; a stress to the system followed by recovery and adaptation. This may promote a greater capacity within neural networks."

    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.

    CDC: Arthritis Affects 1 in 4 in US; More Emphasis on Physical Activity Needed

    The US Centers for Disease Control and Prevention's (CDC's) latest snapshot of arthritis prevalence, severity, and related physical inactivity reported in 2017 looks a lot like its previous one, based on 2015 data. As then, an estimated 1 in 4 US adults have the condition, almost 27% of whom experience severe joint pain. Making matters worse, says CDC, of those with arthritis, around a third report that they don't engage in any physical activity, the very thing that "can improve physical functioning in adults with joint conditions."

    The latest report is based on a nationwide survey conducted in 2017 in which 435,331 adults across the country responded to questions related to whether they have been diagnosed with arthritis, rheumatoid arthritis (RA), lupus, gout, or fibromyalgia; the severity of pain they experienced during the past 30 days; and their participation in any PA (other than PA associated with their jobs) over the past month. Researchers then compared these data with respondent demographics, including geographic areas, to get a picture of how arthritis is affecting the country.

    The findings point to a position long-supported by APTA: increased PA among individuals with arthritis can have a marked impact on reducing pain severity and increasing function. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Among the findings of the CDC study:

    Overall rates of arthritis remain about the same as they were in 2015—and follow the same geographic trends.
    The latest study revealed an estimated 54.4 million US adults have diagnosed arthritis—about 1 in 4 Americans. Of those, about 27% report experiencing severe joint pain. From a geographic perspective, prevalence and pain severity varies by state but are worse in Appalachia and the Lower Mississippi Valley. Prevalence ranges from a low of 15.7% in Washington, DC, to 34.6% in West Virginia, with severe joint pain rates varying from a low of 30.3% in Colorado to 45.2% in Mississippi.

    The prevalence of arthritis increased with age and was higher for some demographic groups, including women.
    Among adults aged 18-44, 8.1% reported being told they had arthritis, RA, lupus, gout, or fibromyalgia. That rate climbed to 50.4% among adults 65 and older. More women than men reported having arthritis (25.4% vs 19.1%), as did adults with obesity compared with healthy weight or underweight adults (30.4% vs. 17.9%). Among ethnic groups, non-Hispanic American Indian/Alaska Natives reported a 29.7% prevalence, while other groups reported rates ranging from 12.8% to 25.5%. Hispanic and non-Hispanic Asians reported the lowest arthritis prevalence among ethnic groups.

    About 1 in 3 respondents with arthritis reported severe joint pain, but that rate declined with age.
    Overall, the rates of "no/mild," "moderate," and "severe" joint pain reported was 36.2%, 33%, and 30.8%, respectively. Among respondents who reported severe joint pain, the rates dropped from 33% of those 18-44 to 25.1% among adults 65 and older.

    Higher rates of severe joint pain were associated with education, socioeconomic status, and sexual orientation, among other characteristics.
    Age-standardized severe joint pain was reported at rates above 40% for respondents who had less than a high school diploma (54.1%) and respondents living at or below 125% of the poverty level (51.6%). Among other demographic groupings, severe joint pain prevalence above 40% was recorded for non-Hispanic blacks (50.9%), retired persons (45.8%), Hispanics (42%), non-Hispanic American Indians/Alaskan Natives (42%), and individuals identifying as lesbian/gay/bisexual/queer/questioning (40.7%, but reported in only 27 states). Two-thirds of those reporting arthritis and identified as unable to work or disabled reported severe pain.

    PA inactivity prevalence varied by socioeconomic factors, too, and included a geographic element.
    Overall, physical inactivity increased with reported pain levels, from an inactivity rate of 22% among those with no/mild pain to a 47% inactivity rate for those reporting severe pain. Groups whose rates of reporting little or no PA in the past month were above 40% included respondents with less than a high school diploma (46.4%) and those at or below 125% of the poverty level (42.6%). Overall inactivity rates also increased as rurality increased, ranging from a 30.7% rate in large metro centers to 38.7% in noncore rural areas.

    In its discussion of the findings, CDC focuses much of its attention on PA levels and engages in a kind of collective head-scratch as to why more Americans aren't pursuing "an inexpensive intervention that can reduce pain, prevent or delay disability and limitations, and improve mental health, physical functioning, and quality of life with few adverse effects."

    "Arthritis-appropriate, evidence-based, self-management programs and low-impact, group aerobic, or multicomponent physical activity programs are designed to safely increase physical activity in persons with arthritis," the CDC states in the report. "These programs are available nationwide and are especially important for those populations that might have limited access to health care, medications, and surgical interventions."

    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 of Health System Reveals Good Functional Outcomes for Patients in Bundled Care Model

    Bundled care models for total joint arthroplasty (TJA) may be popular with payers and policy makers, but do they work for patients? A new study says yes.

    Researchers arrived at their conclusion after tracking TJA episodes in the University of Utah health care system during its switch from a more traditional approach to Medicare's Bundled Payment Care Improvement (BCPI) model 2. Similar to other bundled care models, the BPCI reimburses providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged, rather than for specific services provided during care.

    The before-and-after pictures focus on functional recovery, based on data from 680 prebundle and 1,216 postbundle patients gathered between 2014 and 2016 (the health system launched the BCPI in July 2015). Researchers used the Activity Measure for Post Acute Care (AMPAC) mobility assessment and the PROMIS Physical Function Computer Adaptive Test (PF-CAT) to track function outcomes. The AMPAC was used at various points during the hospital stay, and the PF-CAT tracked function presurgery and then 2 weeks, 6 weeks, and 12 months afterwards. Results were published in Arthroplasty Today.

    APTA members Joshua Johnson, PT, DPT, ATC; Caitlin Miller, PT, DPT; Julie Fritz, PT, PhD, FAPTA; and Robin Marcus PT, PhD, were among the study’s authors. Johnson is a recipient of the 2015 Florence P. Kendall Doctoral Scholarship and a 2017 Promotion of Doctoral Studies I Scholarship from the Foundation for Physical Therapy Research, both of which were used to support the study in part. APTA also provided partial funding for the study.

    Limited to elective procedures only, the study included 1,666 patients associated with 1,896 TJA episodes. The majority of TJA procedures were for knee replacement (57.9%). Patients had an average age of 62, and most were women (57.3%). Here's what researchers found:

    • Postoperative mobility measured through the AMPAC was slightly better for the postbundle group, but not significantly so—and only at day 0. By days 1 and 2, there were no differences in average AMPAC scores.
    • The PF-CAT also uncovered no significant differences between the pre- and postbundle groups at 12 months or any earlier points.
    • The postbundle group averaged slightly shorter hospital stays than the prebundle group, with an average stay of 2.1 days compared with the prebundle group's average of 2.3 days.
    • Bundled care was associated with decreased odds of patients being discharged to a postacute care (PAC) facility: in the study, 10.9% of the postbundle patients were discharged to a PAC, compared with 26.9% of the prebundle group.

    "The big takeaway here is that, at least in the health system in this study, we see that joint replacement bundles achieve patient outcomes that are similar to nonbundled systems, and that's good news," said Heather Smith, PT, MPH, APTA director of quality. "The whole basis of the shift to bundled payment models is to control and decrease costs while still achieving good outcomes, and that's what seems to have happened here."

    Smith acknowledges that part of the study's positive results may be due to overall changes made to TJA care in the year prior to the system's switchover to a bundle model—changes that included adding a swing shift for inpatient physical therapy staff to ensure earlier ambulation postsurgery, as well as greater emphasis on patient education and increased crossdisciplinary work. But she sees this as more good news for bundled care models.

    "The changes the system made to its care pathways are part of the success of this study, but the important point is that the bundled model could absorb them," Smith said. "These kinds of redesigns applied to value-based models represent some real opportunities for physical therapy to become an even more important component of care."

    The results are encouraging for another reason: bundled care is probably here to stay. While voluntary Medicare models such as the BCPI have been around for years, a mandatory Medicare bundle program, known as the Comprehensive Care for Joint Replacement (CJR) was introduced in 2016 and affected some 800 hospitals in 67 geographic areas. The program has been scaled back since then and now applies to about 450 hospitals in 34 geographic areas, but the US Centers for Medicare and Medicaid Services (CMS) doesn't seem poised to dismantle the program—particularly if data show decreased costs and better patient outcomes.

    "CMS may have tapped the brakes on its move toward bundled care in 2017, but it's still moving and focused on shifting to value-based payment models," Smith said. "And if more studies emerge like this one showing that patient outcomes are unaffected by the change, that focus will likely increase."

    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.

    Time to Standardize Acute Care Rehab for Patients Poststroke, Say Researchers

    Not all rehabilitation is equal for acute care hospital patients with ischemic stroke, say researchers in an article published in the May issue of PTJ(Physical Therapy). Authors found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”

    While current guidelines recommend early mobilization during hospitalization for ischemic stroke, authors write, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.

    Overall, authors found that only 85.2% received any rehabilitation services: 61.5% received both physical and occupational therapy; 22% received only physical therapy; and 1.7% received only occupational therapy.

    Patients were more likely to receive any type of rehabilitation services if they were older than 70 years of age, had longer lengths of stay, or had received tissue plasminogen activator (tPA).

    However, patients were 16% less likely to receive rehabilitation services if they were dual-eligible for both Medicare and Medicaid, and 11% less likely if they had a recent prior history of hospitalization. Men also were less likely to receive therapy, and patients with more severe stroke—who required an ICU stay or feeding tube—were significantly less likely to receive rehabilitation services.

    There also was variation in the number of minutes of therapy patients received. While patients received an average of 123 minutes of therapy over 4.8 days, authors write, “dual-eligible patients received 5 minutes less therapy compared with non–dual-eligible patients, and patients receiving tPA received 16 more minutes of therapy.” Patients with a feeding tube received 5 more minutes of therapy than those without, on average. [Editor's note: APTA's PTNow online resource offers a clinical summary on stroke as well as guidelines on interventions to address neuroplasticity.]

    In addition, certain hospital characteristics played a role: Rural hospitals, hospitals with a higher volume of patients with stroke, and hospitals with an inpatient rehabilitation unit were linked to a higher likelihood of receiving rehabilitation services. Patients who received rehabilitation services in a limited teaching hospital or nonteaching hospital received an average 19 and 20 more minutes of therapy, respectively.

    Authors found substantial variability in use of rehabilitation services across acute care hospitals, even after accounting for length of stay and other patient and hospital-level factors. Approximately 38% of hospitals provided significantly less (76.3 minutes during the whole length of stay) than the national average of rehabilitation services minutes (123 minutes), whereas 22.4% provided significantly more (180.7 minutes) than the national average. Authors suggest a number of factors contributing to this variation, including a “lack of clear guidance on rehabilitation timing and dosage in the acute care setting” and a hospital reimbursement structure that encourages cost savings by decreasing length of stay and rehabilitation services.

    However, hospitals with inpatient rehabilitation units were more likely to deliver rehabilitation services to these patients, possibly because they are specialized in providing comprehensive care, and therapists “can be proponents of providing upstream rehabilitation interventions to improve downstream outcomes.”

    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.