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  • Study: Physical Therapy May Be Underused Among Patients With OA

    Aside from taking oral analgesics, patients with osteoarthritis (OA) may be underusing nonsurgical therapies such as physical therapy, say authors of a recent study published ahead of print in Arthritis Care & Research (abstract only available for free). The use of physical therapy, a guideline-recommended first-line treatment, is “a key area for improvement,” researchers write.

    While 70%–82% of participants in 3 clinical trials had used oral analgesics to treat OA symptoms, only 39%–52% had used physical therapy. Other treatments included knee injections (55%-60%) and topical creams (25%–39%). Most participants had used more than 1 type of treatment.

    Yet clinical practice guidelines for OA, authors note, first recommend nondrug interventions such as “self-management education, weight-loss, and physical activity, along with pharmacologic therapy when tolerated and safe.”

    In the study, researchers sought to identify what, if any, patient demographic and clinical factors were associated with use of these guideline-based nonsurgical interventions, as well as how frequently interventions were used. They analyzed data from 3 clinical trials affiliated with Duke University Medical Center primary care practices (PRIMO-Duke), Durham Veterans Affairs Health Care System (PRIMO-VA), and University of North Carolina–Chapel Hill (PATH-IN).

    While physical therapy use was only moderately used, it was still higher than in previous studies, researchers write. They suggest that this difference could be due to older studies being based on referral data from single providers, as opposed to self-report data from patients, who may have been referred by more than 1 provider. Still, authors observe, with just 39%–52% of participants receiving a therapy that is recommended as a first-line treatment, this is “a key area for improvement in OA treatment.”

    Among pharmacologic treatments, the use of NSAIDs, other nonopioids, and opioids aligned with clinical practice guidelines. Opioids are recommended as the last resort for managing OA symptoms; however, opioid use was higher among veterans than in the other 2 clinical trials, “suggesting a gap in OA treatment guidelines and opioid use for OA among veterans,” say authors. However, researchers were unable to determine whether veterans who used opioids did so because NSAIDs either had failed to relieve pain or led to side effects.

    Across all 3 studies, nonwhite participants, on average, were more than twice as likely as white patients to have used topical creams. But authors found that no other “single clinical or socio-demographic participant characteristic was consistently associated with any specific OA treatment.” They also note that other characteristics were associated with use of multiple treatments, including being female, being nonwhite, having higher BMI, and having pain scores. Other patient demographics analyzed include income level, age, “fair/poor self-rated health,” years with symptoms, knee OA, and hip OA.

    The results of the study, say researchers, suggest “potential adherence to OA treatment guidelines for oral analgesics” but also indicate “areas for improvement in opioid use, [physical therapy], and joint injections.”

    “It is imperative that we understand not only how to best manage OA but also how to implement evidence-based guidelines for OA management in the community considering individual demographic and clinical characteristics to reduce the burden of OA pain and disability,” authors write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    2018 Slate of Candidates Posted

    The 2018 Slate of Candidates for APTA national office is now posted on the APTA website. The candidate webpage, including candidate pictures, statements, and biographical information, will be posted on March 26, 2018.

    Elections for national office will be held at the 2018 House of Delegates on June 25, 2018. Please contact Justin A. Lini in APTA’s Governance and Leadership Department for additional information.

    Final CMS Bundling Rule Reduces Number of Mandated Participants, Expands Possibilities for PTs

    The US Centers for Medicare and Medicaid Services (CMS) has issued a final rule on bundled care that largely mirrors what the agency proposed in August: a scaled back knee and hip joint replacement bundled care model—albeit with more opportunities for participation by individual providers—and cancellation of a plan to expand bundled care models to cardiac care and hip and femur fractures.

    Known as the Comprehensive Care for Joint Replacement (CJR) model, the hip and knee bundle program launched in 2016 was the first-ever attempt by CMS to mandate bundled care. The rule as it now stands applies to 67 different geographic areas covering some 800 hospitals: beginning in 2018, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas. CMS estimates that 430-450 facilities will participate in the CJR next year, a number that includes facilities participating voluntarily.

    In addition to reducing the number of geographic areas required to participate in the CJR, the final rule also follows through on a CMS proposal to switch low-volume and rural hospitals in the remaining 34 areas from mandatory to voluntary participation. A CMS fact sheet summarizes the changes in store for 2018.

    At the same time CMS pulls back on the reach of the CJR, it is making it easier for clinicians, including physical therapists (PTs), to be included as qualifying alternative payment model (APM) participants (QPs) under the Quality Payment Program’s Advanced APM track. By expanding the ways providers can make it onto a CMS "affiliated practitioner list" to include clinicians whose contractual relationship with a facility supports a hospital's CJR goals, the new rule would deepen the pool of providers eligible to receive the Advanced APM 5% incentive payment. CMS will continue to maintain ultimate authority for who does and doesn't qualify as a QP, based on Medicare Part B claims data, but says it won't establish a specific threshold a clinician must meet to be considered supportive of a facility's CJR goals.

    The expansion of the requirements to be considered a QP is good news for physical therapists but is tempered by other factors. The reduction of the number of hospitals in the mandatory program will dampen the effects of the change, as will the fact that the increased participation options apply only to facilities participating in "Track 1" of the CJR program—a version with more stringent requirements that also puts facilities at more financial risk.

    As for expansion of mandatory bundling programs into other areas, that's no longer in the works. Just as proposed, the final rule halts a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to begin in February of this year but were delayed until October 1, and then pushed back again to a January 2018 startup date. The rule effectively cancels those programs altogether.

    From PT in Motion: Walking Away From the PT Designation

    Fed up with all the paperwork? Tired of the hassles? Want to focus on all the good you can do for people without the burden of having that "PT" designation after your name? How about just dropping the title and calling yourself something else?

    Simple answer: it doesn't work that way. Less simple answer: doing so could put you in ethical and legal jeopardy.

    This month's "Ethics in Practice" column in PT in Motion magazine tells the story of "Tina," a physical therapist (PT) who was drawn to the profession by way of her love for athletics, and who found her true professional niche as a PT running a cash-based practice, primarily treating already-active clients seeking to boost their athletic performance.

    Tina loves the work, but hates the documentation, which she sees as required only as a way to receive reimbursement. Since her business is cash-based, she decides to forget the standard documentation procedures in favor of her own far less rigorous approach. When Tina asks a fellow PT to fill in for her while on a trip, the substitute is unnerved by the lack of proper documentation, and warns Tina that she could be in trouble if faced with an audit.

    Tina understands the point, but comes up with what she thinks is a clever solution: she'll just stop referring to herself as a PT, removing the designation from her business cards, taking down framed licenses and diplomas, and explaining to clients that she has evolved into a "wellness expert

    Simple, right? Wrong, writes column author Nancy Kirsch, PT, DPT, PhD. Tina's actions call issues of professional responsibility into question. The idea of voluntarily surrendering a PT credential clearly poses legal issues, but it also presents ethical challenges should the practitioner in question continue to rely on knowledge and skills acquired through her or his training and professional development as a PT. As Kirsch writes, "Does Tina's desire to avoid documentation obviate her responsibility to tap the full extent of her abilities on behalf of her clients?" Check out this month's PT in Motion to learn more.

    "Name Game" is included in the December issue of PT in Motion . Hard copy versions of the magazine are mailed to all members who have not opted out; digital versions are available online to members. Know a nonmember PT or PTA? Invite them to read “What to Expect When They’re Expecting,” the issue’s cover feature that’s open to the public. Then invite them to join APTA to take advantage of all the association’s member benefits.