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The Quality Cure

Attached is an article that Larry Benz sent me outlining David Cutler's viewpoint on how to reign in skyrocketing healthcare costs. To give some perspective, Mr. Cutler was instrumentally involved in drafting the 1993 healthcare reform policies in the first Clinton administration, which was a dismal failure.

Regardless of your political leanings, he offers great insight on how best to get our healthcare system under control. For those who identify with evidence-based practice, these ideas will not be all that surprising, however they are radically different from the current model focused on restraining costs. The gist of this approach is that we should forget about costs and direct all of our attention toward improving quality. The notion is that the healthcare system should pay for performance (defined as improved health), rather than focusing on consuming less healthcare. I won't steal his thunder, but here is a key summary.

"Cutler's approach is radically different. He says that most health-care spending is actually good. Spending has been rising, he says, because it delivers positive, and measurable, economic value, and because it can do more things that Americans want. Therefore, Cutler says, we should focus on improving the quality of care rather than on reducing our consumption of it. Rather than pay less, he wants to pay more wisely -- to encourage health-care providers to do more of what they should and less of what is wasteful."

We have a long way to go toward this end, but the ideas are compelling for any healthcare practitioner who identifies with evidence-based practice. Enjoy the read.

John

Download the_quality_cure.pdf

Special Tests

I'm not going to be able to reference this very well because the journal is in long term parking at the airport.  The recent JOSPT article regarding manipulation of the cervical spine that many of you were involved in writing has me thinking in a more broader, bigger picture way. 

How is it that we as a profession have so many special tests for various body parts or diagnoses but it actually seems that a lot of them are worthless?  At the same time, clinical decisions are being made every day based upon many of these special tests that may not be valid and reliable, may not have high specificity or sensitivity qualities.  When will it be that as clinicians we will begin to have a test or a set of tests that provide consistent results to help make better, more accurate clinical decisions?  Maybe it's just me, but it seems that if we have a shaky foundation that is the core of the beginnings of our clinical decision making process in which we build... then what happens to the treatment aspect of what we do when it is based on something that isn't solid and strong?  Just some thoughts in my head that maybe some of you wiser therapists would happen to know the answer.

Fusion versus Physical Therapy in Patients with Chronic Low Back Pain

My wife Amy sent me the following press release even before I came across the published papers in the most recent issue of the BMJ (and I am fairly astute at accessing information quickly). This reminds me that the information gap is quickly closing, empowering patients with timely information that may help them make informed decisions about possible treatment options before ever visiting a healthcare professional! If it hasn't happened to you yet, be prepared. Lest you keep up with current evidence, you will find yourself explaining to the patient sitting in front of you why you have no idea what the patient is talking about!

The overall results of the these 2 papers are quite favorable. Clinical outcomes between surgery and intensive rehab are similar, but the costs are not surprisingly much higher in the surgery group. This is one of those large trials that will receive much press over the next several weeks. More to come, but the overall results are quite favorable for physical therapy practice.

John

Download surg_stab_clinical_outcomes_bmj_2005.pdf

Download surg_stab_cost_bmj_2005.pdf

 

A Prediction Rule for DVT in Patients with Orthopaedic Conditions

Attached is a nice paper just published by Dr. Dan Riddle and colleagues that validates a prediction rule for diagnosing DVT in patients with orthopaedic conditions, the subgroup of patients most at risk. Each of the factors in the rule (Table 1) are based on clinical examination findings, making the rule easy to use in a busy clinical practice. This is a helpful contribution to the literature, the results of which may improve decision-making in physical therapy practice.

John

Download Riddle-dvt.pdf

Manipulation and Stabilizing Exercise for Chronic Low Back Pain

Attached is a recently published paper by Niemisto and colleagues reporting a 2-year follow-up regarding the cost-effectiveness of manipulation, stabilizing exercises, and physician consultation versus physician consultation alone for patients with chronic LBP. Although clinical outcomes favored the combined manipulation and stabilizing exercise group (both pain and satisfaction), the one-point VAS improvement came at a cost of $512. The authors concluded that "physician consultation alone was more cost-effective for both health care use and work absenteeism, and led to equal improvement in disability and health-related quality of life." There are some potential classification issues that may have muted some of the potential differences, but it's nice to see research that incorporates a cost-related analysis. The published report at 1 year (also attached) was more favorable, reminding us that treatment may still be worthwhile (getting patients better earlier), despite the fact that treatment effects may wash out 2 years later. 

John

Download niemisto_spine_2005.pdf

Download niemisto_spine_2003.pdf

Washington State Practice Act

Washington state must truly have an arcane practice act. APTA has posted a press release regarding the recent signing of a modernized practice act. It is couched as a "victory", saying that the updated definition of physical therapy "reflects the actual treatment techniques practiced by physical therapists on a daily basis". Perhaps there are some small victories here, but on the issue of thrust manipulation, the practice act still reads as follows:

"'Physical Therapy' means the care and services provided by or under the direction and supervision of a physical therapist licensed by the state. The use of...spinal manipulation, or manipulative mobilization of the spine and its immediate articulations, are not included under the term 'physical therapy' as used in this chapter." The marked up copy is attached.

In my opinion, victory will await us until patients in the state of Washington (and other states with restrictive practice acts) have access to the full complement of diagnostic and therapeutic interventions performed by physical therapists in the overwhelming majority of other states.

John

Download wa_practice_act.pdf

What about a therapist's voice?

Interesting article on the fact that women are better at communicating with physician's and more likely to visit physician's more frequently.  In addition, the study reported that Doctor's use 3 voices:  'doctor voice' (seeking information), 'educator voice' – when seeking to inform and educate the patient about their condition, and the 'fellow human voice' – when trying to get patients to talk about their problems.

Anyone familiar with this type of research in PT?  We have seen from an EBP perspective that the only two major consumer categories seeking best evidence on the web are college educated women and patients that have been diagnosed with something fatal.  From a marketing perspective, there is no doubt that we need to primarily market the key decision makers in health care-women.

Recent evidence for PT in knee OA

Here are a couple of recently published papers related to the effectivess of physical therapy intervention in patients with knee OA. I have not reviewed but am attaching fyi.

John

Download pt_knee_oa.pdf

Download pt_knee_oa_2.pdf

Prediction of Hip OA progression

Attached is a paper just published in the BMJ that atempted to identify factors that predicted the progression of hip OA. The study found that the Kellgren and Lawrence score at baseline was by far the strongest predictor of progression, particularly in patients with existing hip pain at baseline.

John

Download radiography_and_hip_oa_bmj_2005.pdf

Cognitive-Behavioral Approach to LBP

Hi, everybody.

Given the recent attention in the literature on the cognitive-behavioral treatment approach for pain, and specifically back pain in general, do you address this in your clinics, and if so, how?

At CSM this year, Tony Delitto gave a good talk on CBT treatment and referenced a recent article:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15722803&query_hl=1

Effects of Cognitive-Behavioral and Physical Therapy Preventive Interventions on Pain-Related Sick Leave, Clinical Journal of Pain, Mar/Apr 2005.

The gist of it was that there was a pretty strong effect size for the CBT group, and there was no difference in preventing sick leave between those in the PT+CBT group and the CBT group alone (!!).

This really plays well into the early identification of fear-avoiders using the FABQ, and I wondered if anyone has a working CBT intervention strategy they use in conjunction with their treatment?

If you do have a CBT program or intervention, what does it look like, and how do you do it?

Thanks.

Jason.