Transcript Procurement Management

Impact of Risk Adjustment & Formal Education on
Clinical Outcomes
Jason Rodeghero DPT, PhD, OCS, FAAOMPT
Am I a better PT because of my training?
 Of course it makes us better!
– Or has it?
 Confirmation bias,
perhaps
 What does the literature say?
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Does it change practice?
 Management strategies before & after CE (Stevenson et al
2006)
– PTs in favor of EBP but reluctant to change
– 2 groups of PTs managing patients w/ low back pain
– 1 had EBP coursework on LBP management
– Other had course on knee pathologies
 No change in what therapists perceived to be important for
patient recovery
 No changes to clinical practice
 We favor
it… but don’t readily change
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What about all those letter?
PT, MPT, tDPT, PhD, ATC, MTC, OCS, FAAOMPT, WTF…
 Hart & Dobrzykowski
2000
– 14 PTs; 7 with OCS / 7
without OCS
– 258 patients
– OCS PTs had fewer
visits
 Resnik & Hart 2003
– OCS, FAAOMPT, MTC
therapists – experts
– No influence from years of
experience
 Resnik & Hart 2004
– 26 OCS; 5 FAAOMPT;7
MTC; 2 FAAOMPT, OCS
– Outcomes better w/ MTC
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Residency & Fellowship
Is where it’s at! (or is it?)
 Survey of ortho residency grads (Smith et al 1999)
– Greater ability to logically reason
– Examination skills
– Improved diagnostic skills
– Treat effectively
– Greater efficiency
– Nothing about actual outcomes of patients
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 Duncombe et al 2009; abstract
 Outcomes associated with an Orthopedic Manual Physical
Therapy Fellowship Training Program in patients with low
back pain
 Outcomes do improve with fellowship
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Already surrounded & being consumed by it
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BIG Data
Pros
Cons
 Lots of data!
 Accuracy of data
 Timely access
 Incomplete
 Variety
 Heterogeneity
 Predictive (sometimes)
 Privacy/confidentiality
 Cheap (?)
 Potential for biased
fishing expeditions
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What about PT databases?
 Focus on Therapeutic Outcomes (FOTO)
 Optimal
 LIFEware
 AM-PAC 6-Clicks
Could we tap into any of these to answer some of our
BIG QUESTIONS?
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On to why I was invited…
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Patient data available from
 Age
 BMI
 Gender
 Insurance
 Fear Avoidance
Beliefs
 Diagnoses
 Medications
 Acuity
 Exercise habits
 Duration of symptoms
 Number of treatments
 Comorbidities
 Functional Status
change
 Surgical history
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Physical Therapist FOTO User Survey
 General demographics
 Transitional DPT
 Entry-level education
 Post-professional
academic degrees
 Residency completion
 Fellowship trained
 Post-professional
certifications
– Board certification
– Advanced Master’s
– PhD, DSc, etc
 Years of experience
 Practice Setting
– MTC – any school of
OMPT
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Efficiency
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Magnitude of change
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 Data support clinical benefit of fellowship trained PTs
 Residency differences not observed
 Caution with interpretation
– First analysis of its kind
– Small numbers reach significance easier w/ BD
• Statistical significance relative to clinical meaningfulness?
– No control for accuracy of provider reporting
– Did not look at specific programs
– Not meant to discredit the value of any program
– Meant to explore data and serve as impetus for data collection
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Influence of tDPT
Unpublished data
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Years of
experience
6379 patients
with low back
pain
Unpublished data
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Provider Characteristic Clusters
 DPT, OCS, & FAAOMPT
 Predicting a poor outcome (0% or less of a functional
change); improvement for each skill obtained observed
– 0 credentials, 13.6% risk;
– 1 credential, 12.3% risk;
– 2 credentials 9.8% risk;
– 3-4 credentials, 9.7% risk
 Similar pattern for 20% improvement
 These credentials may reduce risk of poorer outcomes
 8% difference between no credentials and credentials
Rodeghero JR, Cook CE, Cleland JA, et al. Physical therapist characteristics influencing outcomes.
Manuscript in preparation
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More about Risk…
 Stratification of patients based on risk
 Identifying predictive characteristics
– Based on PT treatment data
– Low, Medium, High utilization of care
– Certain diagnostic groups: back pain, knee pain, etc
 Can we use data to structure management of patients
– More effectively
– More efficiently
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 6,379 patients
 Low Risk
– Younger age
– Male gender
– Shorter duration of
symptoms
– No surgical hx
– Higher baseline disability
– Insurance status
 High Risk
– Older age (55)
– Longer duration of
symptoms
– Surgical hx
– Current use of medications
– Lower baseline disability
– Insurance categorization
(work comp / auto)
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 Same methodology (3,137 patients)  High Risk
 Low Risk
– Younger age
– Shorter duration of symptoms
– No surgical hx
– Longer duration of
symptoms
– Surgical hx
– Lower levels of baseline
disability
– Fewer comorbidities
– Higher baseline disability
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Embrace Big Data
 Tremendous value to our profession
 Not meant to replace clinical trials
 Influence big changes – drive evolution of practice further
 Big data speaks LOUDLY & makes people pay attention
 Already being used by third parties & patients
 Need as many PTs collecting structured data as possible
 Powerful tool to bring us together!
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References

Austin T, Graber K. Physical therapists' perspectives on the role and effectiveness of continuing education. J Allied Health. 2007;36:216223.

Brennan G, Fritz J, Hunter S. Impact of continuing education interventions on clinical outcomes of patients with neck pain who received
physical therapy. Phys Ther. 2006;86:1251-1262.

Childs JD, Harman J, Rodeghero JR, Horn M, George SZ. Implication of Practice Setting on Delivery of Physical Therapy Services. J
Orthop Sports Phys Ther. 2014; 44(12): 955-963.
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Cleland J, Fritz J, Brennan G, Magel J. Does Continuing Education Improve Physical Therapists' Effectiveness in Treating Neck Pain: A
Randomized Controlled Trial. Phys Ther. 2009;89:38-47.

Cook C, Rodeghero J, Cleland J, Mintken P. A Preliminary Risk Stratification Model for Individuals with Neck Pain. Musculoskeletal Care.
2015; In Press
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Fritz JM et al. Primary Care Referral of Patients With Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and
Costs. Spine. 2012;37(25): 2114-2121.

Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low
back pain in primary care: associations with future health care utilization and charges. Health Services Research. 2015; 1-14.

Gunn H, Goding L. Continuing Professional Development of physiotherapists based in community primary care trusts: a qualitative study
investigating perceptions, experiences, and outcomes. Physiotherapy. 2009;95:209-214.

Hart D, Dobrzykowski E. Influence of orthopaedic clinical specialist certification on clinical outcomes. J Orthop Sports Phys Ther.
2000;30:183-193.

Rodeghero JR, Cook CE, Cleland JA, Mintken PE. Risk stratification of patients with low back pain seen in physical therapy practice . Man
Ther. 2015;20(6): 855-860.

Cook CE, Rodeghero JR, Cleland JA, Mintken PE. A preliminary risk stratification model for individuals with neck pain. Musculoskeletal
Care. 2015;13(3): 169-178.
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Rodeghero JR, Wang YC, Flynn TW, Cleland JA, Wainner R, Whitman J. The influence of post-graduate physical therapy residency and
fellowship programs on clinical outcomes for patients with common musculoskeletal impairments. J Orthop Sports Phys Ther. 2015;45(2):
86-96. doi:10.2519/jospt.2015.5255
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Rodeghero JR, Cook CE. The use of big data in manual physiotherapy. Man Ther. 2014; 19: 509-510.
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