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  • Using MI in the Clinic: A Student's Perspective

    In a new APTA podcast, Kim Redlin, a third-year doctor of physical therapy student at St Catherine University, shares how she has incorporated motivational interviewing (MI) into her interactions with patients. Specifically, Redlin describes how while working with a patient who had knee replacement surgery she was able to obtain meaningful information about the patient's efforts to quit smoking that "slowly opened the door" for her to provide education about behavior change. Redlin also discusses how MI "can be a real challenge for both students and professionals." She asks, "[Y]ou want to make sure that all boxes get checked – get informed consent, get a pain rating, get a range of motion measurement, use an outcome measure, but how often is there a box to check for addressing health behaviors and talking about change?"

    This podcast is the fourth in a series on behavior change.

    APTA podcasts are prerecorded discussions and interviews, not live events. Members can listen to podcasts at their convenience by clicking on the links provided in News Now articles, visiting www.apta.org/podcasts/, or subscribing to APTA podcasts on iTunes.

    New in the Literature: Squatting as a Clinical Marker of Function After Total Knee Arthroplasty (Am J Phys Med Rehabil. 2013;92(1):53-60.)

    In patients who have primary unilateral knee arthroplasty, as rehabilitation visits increased there was a direct association to improved interlimb weight-bearing symmetry when squatting to 60 degrees, say authors of an article in American Journal of Physical Medicine & Rehabilitation

    For this study, the percentage of body weight placed over both limbs during stand and 30- and 60-degree squats in 38 patients (25 women and 13 men) who had primary unilateral knee arthroplasty was determined. An asymmetry index was used as a marker that could discriminate between patients who perceived at least moderate difficulty with functional tasks and those who perceived only slight or no difficulty with functional activities based on the physical function dimension of the Western Ontario McMaster Universities Osteoarthritis index approximately 1 week after surgery. Stepwise regression was conducted to determine whether clinical characteristics predicted weight-bearing asymmetry at discharge.

    At initial visit (first observation), compared with the uninvolved side, individuals placed significantly less body weight over the involved or operated limb for stand and 30- and 60-degree squats. Results were similar at last rehabilitation visit (second observation). Identifying at least moderate self-reported difficulty with functional tasks based on the receiver operator characteristic curve for the asymmetry index for the stand position was 0.64, whereas for the 30- and 60-degree squats, the area under the curve was 0.81 and 0.89, respectively. At discharge from rehabilitation, there was a moderate to good direct relationship (r = 0.70) between the number of rehabilitation visits completed and the weight-bearing asymmetry index for the 60-degree squat.

    APTA member Mark D.Rossi, PT, PhD, CSCS, is the article's lead author. APTA members Thomas Eberle, PT, DPT, DMT, FAAOMPT, Denis Brunt, PT, EdD, Marlon Wong, PT, DPT, OCS, MTC, and Matthew Waggoner, PT, DPT, MTC, are coauthors.    

    New Standards Call for Less Intensive Blood Pressure Goals for People With Diabetes

    The American Diabetes Association is recommending changes in blood pressure goals for people with diabetes and clarifying how frequently people with type 1 diabetes should test their blood glucose levels.

    The revised recommendations include raising the treatment goal for high blood pressure from <130 mm Hg to <140 mm Hg, based on several new meta-analyses showing there is little additional benefit to achieving the lower targets. Clinical trials have demonstrated health benefits to achieving a goal of <140 mm Hg, such as reducing cardiovascular events, stroke, or nephropathy, but limited benefit to more intensive blood pressure treatment, with no significant reduction in mortality or nonfatal heart attacks. There is a small but statistically significant benefit in terms of reducing risk of stroke, but at the expense of a need for more medications and higher rates of side effects.

    The new standards also clarify when people who are taking multiple daily doses of insulin (MDI) or using insulin pumps, typically those who have type 1 diabetes, should test their blood glucose levels. Previously, the standards called for those taking insulin to test "3 or more" times throughout the day, a recommendation that was sometimes misinterpreted to mean that 3 times per day was sufficient. Recognizing that the frequency of testing will differ by individual and by situation, the new standards do not specify the number of times that testing should occur but instead focus on the conditions under which testing should occur. For example, the standards now specify that patients on MDI or insulin pumps should test prior to meals and snacks, occasionally after eating, at bedtime, before exercise, when they suspect low blood glucose, after treating low blood glucose levels until they return to normal, and "prior to critical tasks such as driving."

    Additionally, the new standards highlight that for patients on less intensive regimens or noninsulin therapies, self-monitoring of blood glucose needs to be linked to educating the patient about how to use the information about glucose levels appropriately. These patients must also be educated about how frequently they need to test and under what conditions.

    The new guidelines will be published in a special supplement to the January issue of Diabetes Care as part of the association's revised Standards of Medical Care, which are updated annually to provide the best possible guidance to health care professionals for diagnosing and treating adults and children with all types of diabetes. The standards are based upon the most current scientific evidence, which is reviewed by the association's multidisciplinary Professional Practice Committee.

    More Than 1,400 Hospitals Penalized Under Readmissions Reduction Program

    Medicare is rewarding 1,557 hospitals with bonuses and reducing payments to 1,427 others based on their readmission rates for heart attack, heart failure, and pneumonia, says a Kaiser Health News  article.

    The biggest bonus is going to Treasure Valley Hospital, a physician-owned, 10-bed hospital in Boise, Idaho, that is getting a 0.83% increase in payment for each Medicare patient. Auburn Community Hospital, a nonprofit near Syracuse, New York, is facing the biggest cut, losing 0.9% of every payment.

    On average, hospitals in Maine, Nebraska, South Dakota, Utah, and South Carolina will fare the best. Hospitals in the District of Columbia, Connecticut, New York, Wyoming, and Delaware are among the worst, the article says. 

    Results for hospitals within the same system often varied. For instance, in Rochester, Minnesota, the Mayo Clinic's Methodist Hospital will get a bonus. But Mayo's flagship St Mary's Hospital, also in Rochester, will lose money. Michael Rock, MD, an orthopedic surgeon at the Mayo Clinic, said that Medicare's scoring system tends to favor hospitals such as Methodist, which primarily does elective surgeries, over hospitals with lots of trauma and emergency cases, which St Mary's handles.

    Under the Affordable Care Act's Hospital Readmissions Reduction Program, Medicare will begin adjusting payments next month through September 2013 and will retroactively apply the changes to payments made in the last 3 months of this year.

    The bonuses and penalties do not apply to money Medicare pays hospitals for capital expenses, to teach residents, or to treat large numbers of low-income patients. Hospitals with too few cases and ones that only offer specific specialties, such as psychiatry, long-term care, rehabilitation, and cancer treatment, are exempted. Maryland hospitals also are excluded because the state has a unique reimbursement arrangement with the federal government.

    In August, Kaiser Health News reported that more than 2,000 hospitals were expected to be penalized.

    Physical therapists can help serve an important role in patient care transitions and care coordination and can help reduce readmissions by providing recommendations for the most appropriate level of care to the health care team prior to and during care transitions. For more information and to find clinical practice and patient education resources to reduce readmissions, visit APTA's Hospital Readmissions webpage