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Implementing Evidence

 A policy change to clearly outline defined care, based on some level of evidence, should be viewed positively.  I'm completely horrible with geography, but I believe the United Kingdom began an initial step toward defining the care options for people with low back pain this month.  It is a bit difficult for me to easily understand politics or the medical systems in other countries, but this change did appear to have reasonable evidence to support the options for care.

The next day, crap hit the fan.  The public had its own perception.  Since painkilling jabs (routine facet joint injections) were not included in the options for care, this was interpreted as cutting corners and costs.  Granted, sure, costs were being cut but the rationale was because of the lack of cost effectiveness.  I also noticed a vibe.... people in pain deserved painkilling jabs. 

Obviously, our health care system needs an overhaul.  If policies were to change based on cost-effectiveness and outcomes, how could the changes be implemented such that public support occurs?  How can new policies have positive public perception?  Is public perception accurate with the belief that people in pain deserve whatever it is that they want?

~Selena

From Bulldog Award to... WhatCanBe Award

Remember over a year ago the bulldog award?  I know I wasn't too impressed with the efforts of that company.

Now, over a year later, we have... the WhatCanBe Award.  I'm thinking Deborah Myers (along with her team) at CRT/tanaka is quite deserving of the award for her work and creativity.  For those of us present at CSM 2009, we saw the brand that was launched.  Via the APTA website, you have to be a member to see the video we all saw.  Well.. it is a YouTube video, so hello... it is public.  For those of you interested and NOT members, here it is:  Move Forward video.   Along with the video is a consumer website that is beneficial for ALL physical therapists.  This website is Move Forward.  

A much better message is being delivered to consumers.  If I were a consumer who was unaware of physical therapists and the role a physical therapist could have for me, I believe this current work better depicts the role of physical therapists.  The video tells a story which will emotionally involve consumers. 

Personally, I'd hack out the "hero" thing... The "hero" thing is too much of an abrupt change from focusing on the patients and the patients' stories to the physical therapist.  It's almost like the video is connecting 2 separate messages 1) the role a physical therapist can have and 2) come be a physical therapist and be a hero.  Too bad there wasn't a short video clip of someone with obvious back pain.  Physical therapists treat a lot of people with back pain.  A seed could have been planted to consider a physical therapist for resolution of back pain.

Overall, if I were to rate the brand and the work put forth thus far, I'd give it a solid 8 out of 10.  What do others think?

~Selena

Quality Initiative within CMS is an Optional Reimbursement Cut

I am referring to the Physician Quality Reporting Initiative (PQRI). 

This voluntary program provides financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the medicare fee schedule.  You have to gather approved measures on at least 80% of appropriate patients and submit the specified quality-data codes for services paid under the fee schedule during the reporting period.

Per CMS website:

“Eligible Professionals have the opportunity to use participation in the PQRI program to improve the care of the patients they serve through evidence‐based measures that are based upon clinical guidelines. Participating in PQRI is a way to prepare for future pay‐for‐performance programs.”

I can’t understand why more legit criticism isn’t leveled at this initiative.  It’s as though we are giddy celebrating as a profession being part of it simply because we are included like MD’s as part of this nonsense. 

PQRI really is an optional reimbursement cut. There is talk of making this program mandatory.  The cost of administering it properly including training, compliance, integration, and auditing for clinical and billing staff far surpasses the percent reimbursement (with caps) that you get back from CMS (or if you get back).  It is yet another example of those that have no clue as to clinic operations imposing their puritanical and philosophical views on the operators that are left having to deal with the details and execution of this misguided directive.  (side note: the response to criticism yields a predictable kneejerk “but its a start and we are included with physicians” response).

Here is a good test for PQRI now that it has been around for awhile (please comment):

1. How many practices have integrated PQRI?

2. Have you received any reimbursement for PQRI efforts by CMS?

Most practices that I know aren’t using PQRI. The one’s that I know either haven’t gotten paid a penny (much greater than a year in the waiting) or received de minimus only after multiple appeals which further increase the admin cost of the practice.

This doesn’t by any means suggest that practices not integrating PQRI are lazy or unconcerned with quality.  They are simply using standardized outcome instruments on all patient populations (not just medicare) or participate in a national process like FOTO. 

Let’s not let the consistent lack of criticism of PQRI be viewed as support of this “quality initiative”.  Let’s call it for what it is-an optional reimbursement cut.

Your thoughts, experiences, comments, and answers to the above questions are appreciated.

larry@physicaltherapist.com

Washington/Sockington

Hey there,  evidence-based manual therapy fans!  Online registration is now open for the 2009 AAOMPT conference, to be held in Washington, DC  from October 14 through 18.

As always, there are world-class speakers, excellent pre-conference courses, and even a breakout session discussing the role of social media in physical therapy branding…. Hmmm…I wonder what that could be about?  Anyway, click here for more information.

And speaking of social media…I bow in humble admiration to fellow gray tuxedo cat Sockington, of Twitter fame. It seems that Sockington,  aka Socks, has amassed over 500,000 followers on Twitter! Visit him at www.Sockington.org, and tell him that Smokey the Evidence-Based Cat sent you!

Rock on, Sockington!

I'm Smokey the Evidenced-Based Cat, and I'll see you in Washington, DC!

Check Out EIM's Hands-On Evidence-based Continuing Education Courses!

EIM offers over 25 online and hands-on CE courses that enhance practical skills while granting flexibility so you can maintain your competitive position in the marketplace. 

 

You will benefit from EIM’s CE courses if you:

·         Desire to make evidence-based practice an immediate reality in your clinical practice.

·         Want to enhance your critical thinking and psychomotor skills to improve decision-making and outcomes of care.

·         Desire to learn from faculty who are widely published in the peer-reviewed literature.

·         Appreciate user-friendly online, on-site, and traditional class formats.

 

Click here for a course schedule or email us for more information.

 

Random Thoughts on Profession of Physical Therapy

So many thoughts, so little time to blog.  Thought I would send out some randomness:

-If anybody doesn’t think that we are our own worst enemy, look at this article that made national press release and that I sent to twitter world with the proviso that it is 20 years old

-lots of chatter on the listserves about Dubin Orthopedic Clinic who appears to me to be one of many unscrupulous docs that over the years has sent unsuspecting patients to his “physical therapy” space within his clinic. Of course, the “therapy” was administered by non PT’s.  Thankfully, the good folks at the KY licensure board sought to protect the public due to the protection of the physical therapy term and numerous decisions, overturned decisions, etc. ensued. Of course we need to protect the term and ensure that the public is served in fact by PT’s if our term is used.  However, I found it fascinating that in one of the decisions that it is clear that PT is not “defined” by the CPT codes that we use in physical therapy.  I consider that a huge positive to fight the growing number of number within our profession that want CPT codes and medicare rules to become the ruling practice of physical therapy. Thank goodness the scope of what we do is governed at the highest order of our state practice act and the licensure board that assures its integrity. Left to our own devices, we will regulate ourselves out of existence.

-speaking of CPT codes, it has been pointed out to me by more than one very credible source that my criticism of the current codes needs to be viewed historically.  They are correct, the CPT codes now are much better than the old days of hot packs for 30 min on comparable terms of therex.  While improved, I strongly believe they are out of lockstep with current best evidence and the way in which PT currently exists in its finest form.  Refinements are definitely needed but it is a lot easier to come up with solutions than it is to get them implemented in large part due to the whole notion of “budget neutrality” in code weighting and the obvious reality that CPT is typically preceded by “AMA CPT”.  We don’t own codes that we are forced to use. I hope we can get some progress amending these in a beneficial way.

-is there any more stupid and redundant term than “skilled physical therapy”?  Assuming that a medicare patient has met the criteria of medical necessity, what is meant by “skilled”?  We can argue about effectiveness and outcome but the fact of the matter is that a patient under the care of a physical therapist is getting skilled care-100% of it.

-Much kudos to APTA on their response to Senate Finance committee Health Care Reform Policy Options.  Their well thought out and written response includes items on POPTS, SGR, and efforts to reduce hospital admissions.  You can access if you are an APTA member. If your not a member, dont’ be critical without joining first!

-I will be appearing at PT2009 in Baltimore at what I think is the 4^th annual Rothstein Debate (my 3^rd one-maybe they are just giving me multiple chances at improving).  The topic is on Medicare Regulation and the growing attempt by PT’s within our profession that aren’t practicing day to day to make those the de facto rules of all PT including several of their superimposed nonsensical regulations that fall outside our practice acts.  I know it is hard to believe that there are those within our profession that want medicare rules applied universally but it is a growing number. I only hope that whoever is debating me goes undercover and actually works seeing medicare patients in a clinic for at least 8 hours before attempting to defend the indefensible notion that we should sell out our practice acts for medicare rules. If you can’t attend, perhaps we can have a live twitter report at this lively discussion!

Thoughts?

larry@physicaltherapist.com

Ultrasound... yes? no?

Okay, before you grab the ultrasound machine.. before you squirt the gel... before you reach for that ultrasound head... ask yourself why?

Why are you choosing to use ultrasound for someone with adhesive capsulitis of the shoulder?

a)  The deep heating properties of ultrasound will increase the extensibility of the joint capsule.
b)  You learned in your graduate or post-graduate program about modalities; ultrasound to the axillary fossa was deemed an acceptable intervention in your classroom scenarios.
c)  Everyone else uses it.
d)  You need to maintain your productivity units.
e)  You just want to sit down, have a break and chat with your patient as you move the magic wand.
f)  You really don't care about your patient and want to really jinx the likelihood of a favorable outcome.

You could have many potential reasons for using ultrasound. 

You have two excellent reasons not to choose ultrasound.  The hard cold facts seem to indicate ultrasound reduces the odds of improvement in function.  The cold hard facts seem to indicate ultrasound reduces the odds of improvement in pain.

Outcome evidence suggests joint mobilization and exercise as interventions of choice for shoulder adhesive capsulitis to increase the likelihood of favorable outcomes in physical function and bodily pain.  Interesting work done by  Dianne Jewell, Daniel Riddle, and Leroy Thacker. 

For some, it might be time to break tradition.

~Selena

Lights, Camera, Action

News... is it all about being IN the news or CREATING the news?  I suppose it depends on the content of the news.

I was completely impressed with a string of articles Google Alert fed me last week.  A reporter for Deseret News focused some health articles on low back pain, incontinence and physical therapists.  The "series" all started on May 7th with the topic for Saturday's Deseret News/Intermountain Healthcare Hotline.  This wasn't just a lone announcement.  There was also an article published about incontinence and low back pain.  The news didn't stop there... on May 8th there was another article published about low back pain.  Amazingly, another article about chronic back pain and physical therapists was published on May 9th!  It won't be ending there either.  On the 15th answers to emails on the topic will be posted on deseretnews.com

Jake Magel, PT, DSc and  Susan McLaughlin, PT really did a nice job throughout that whole series.  I couldn't put my finger on it initially, but as I sit here writing, I can now tell you exactly why the whole series was impressive for me.  Jake and Susan were being "Freds."    They were sharing evidence in a manner that was genuinely helpful to the public yet at the same time not self-serving. 

When I see quality like those articles, for some reason, I have a need to reach out and learn more.   Poor Jake... he was the one in my line of fire.  Let's just say I peppered him with enough questions that I can give you all the scoop on how something like what he and Susan did can happen in your community.

It all started with an opportunity.  As with anything else in life, if you see an opportunity, you either take it or leave it.  If I am understanding correctly, the Intermountain Health public relations department has a working relationship with the Deseret News.  Apparently for the last 17 years, Intermountain Health and Deseret News have joined together to help the community in their health by offering health hotlines on predetermined topics.  Jake happened to be contacted by the PR department to see if he was interested in some sort of women's health related issue (being close Mother's Day and all).

The articles were published to meet a need.  Deseret News in working with Intermountain Health needed to have material in order to really reach the community.  I'd assume that just announcing a health hotline date, time and topic wouldn't capture participation of the community at large without some effort being put into educating the community to interest them enough to want to call in and learn more.

When Jake mentioned he and Susan were interviewed, I had this slight feel of anxiety in my gut.  Whoa... interview?  This wasn't some written "news release" kind of deal that was sent in to Deseret News?  Rest assured, the reporter didn't interview in person.  Jake and Susan just had to call in and have a conversation with the reporter.  I shouldn't say "just call in," because based on what I read in those articles, Jake and Susan had to have spent some time mentally preparing and envisioning what information would be the most relevant for the community.  The beauty of being an "expert" in something is that you will have more control of the information because the person interviewing you probably isn't going to know enough and will need your assistance in focusing on the relevant information.  (Now, Jake didn't say that, I'm just taking liberties with what he did say.)

Jake and Susan were the physical therapists involved in both the interviews and the hotline phone calls.  Jake indicated there wasn't any quiet time on Saturday from 10-noon and the calls actually started before 10 and continued after noon.  Jake thought about 60% of the calls were incontinence issues and 40% low back pain issues.  The feedback Jake received from PR was that Jake and Susan's session was "one of the 6 or 7 most successful" in the last 17 years.

At this point in time, Jake doesn't know the departmental impact the recent health hotline will have on referrals.  He did mention by Tuesday 3 new patients scheduled due to the articles.

The public really doesn't know the role physical therapists can have in improving lives.  As physical therapists, we really don't have training in marketing, interviewing or managing a business.  What Jake and Susan did probably isn't within our comfort zone.  At the same time, the unknown brings fear.  Often times that fear is just in our imaginations and holds us back from acting. 

Hopefully, the time Jake took responding to me can be helpful for you.  Who better than physical therapists to create the news about how we can help?  Even if it costs money to educate the public, I liked that Jake did mention there was an immediate response due to a need for the services of a physical therapist.  That means, from a business perspective, there will be some return on your investment.

Thank you, Jake, for sharing.  It was kind of fun learning this way.  I'm also sorry for interrupting you with so many questions...  I honestly didn't realize you were working on a deadline.  I'm assuming you have many emailed questions that need a response to be posted at deseretnews.com

~Selena

Health 2.0 and Lack of Control of Information

The world seems so much smaller.  It seems as though everyone has an opinion. 

Is it true the more "followers" one has the more valid the person being "followed?"  Has this become like a status symbol of expertise or something?  Has this become the status symbol of a leader?

More and more consumers are turning to the internet for medical information.  This can be good... but at the same time, I question the validity and the reliability of the information they receive.  I recently watched a presentation that suggested that consumers tend to place the same level of value of what others in their same situation believe as they do their physicians.  I have mixed feelings about some of the Health 2.0 networking that occurs.  I think it can be great from a support group kind of perspective; I'm a bit leary about consumers telling each other "what worked" for them. 

It seems as though everyone has a blog these days.  Everyone has a right to an opinion.  What if that opinion is wrong?  What if the information being shared is wrong?  How much impact does a blogger have on consumers?  Who "follows" the blogger?  How strong is the alliance between the blogger and the "followers?"

I've decided that if I see something that really, really seems to be inaccurate about physical therapists, I WILL step in and comment. 

My Google Reader fed me a recent blog post:  The Ugly Truth About Physical Therapists.  I couldn't bear to let the post go without an appropriate comment.  Poor Jamie still didn't understand and a follow up comment was definitely required in Personal Trainer vs Physical Therapist - the "deathmatch."

I don't know about the rest of you, but it is irritating to have a lack of control of what consumers can learn about physical therapists.  Who knew that personal trainers, according to Jamie, are becoming more and more similar to physical therapists?  What a bad, bad seed to plant for consumers....

Anyways... be an advocate for physical therapists.  Who knows what we do or have to offer better than ourselves?  Help consumers understand their options. 

~Selena

Assessing Chronic Back Pain

Pain... pain is definitely not a simple subject.  We see people in pain every day and need the knowledge to effectively address the complaint of pain.  I'm willing to bet the majority of patients seen in the outpatient setting have a complaint of low back pain.  Most of us here realize that drugs and surgery are inadequate in resolving back pain complaints.  Drugs and surgery are not without risks and side effects and failure rates (in the case of surgery).  Surgical risks and surgical failure rates aren't a secret; mentioning "unneccesary surgery" in a new study creates a positive spin on drugs.

Joachim Scholz has obviously spent some time studying pain.  It appears to me that Scholz has recognized the ineffectiveness of treatments directed toward pain due to the failure of the provider (and maybe even drug manufacturer) to consider pain mechanisms.  Scholz and colleagues recently published (April 9, 2009) a Standardized Evaluation of Pain (StEP) for the low back.  It's great to see work outside our field being done on classifying patients with low back pain according to pain characteristics.  It's great to see the type of pain being considered as an important factor for those with low back pain.

The downside is they are barking up the wrong tree.  I say this because of the funding for the study:  

"This study was supported by an unrestricted grant initially awarded by Pharmacia through The Academic Medicine and Managed Care Forum, with supplementary support from Pfizer. Some of the study authors have disclosed various financial relationships with Pfizer, GlaxoSmithKline, Pharmacia, Elan, Allergan, Progenics, Alpharma, Janssen, Merck, Novartis, OrthoMcNeil, Union Chimique Belge, Bristol-Myers Squibb, Eli Lilly, Roche, Abbott, Endo, Hydra Biosciences, Taisho, Solace Pharmaceuticals, Ferrumax Pharmaceuticals, and PLoS Medicine. The General Hospital Corporation owns the copyright on StEP."

Maybe one day it will be common knowledge that a drug isn't the best option for chronic back pain.

~Selena