Centers for Medicare and Medicaid Services Policy Regarding Supervised Exercise for Patients With Intermittent Claudication: The Good, the Bad, and the Ugly.

On May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a decision memo establishing coverage for supervised exercise therapy (SET) for Medicare beneficiaries experiencing intermittent claudication due to peripheral artery disease (PAD). A meaningful impact on population health is possible with greater freedom to participate in regular physical activity. The authors of this editorial explain the potential roles of physical therapists in the SET program and argue for further integration of physical therapists through collaborative practice. J Orthop Sports Phys Ther 2017;47(12):892-894. doi:10.2519/jospt.2017.0111.

Use of quality indicators in physical therapist practice: an observational study.

BACKGROUND: The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 contain provisions specific to health care quality that apply to physical therapists. Published evidence examining gaps in the quality of physical therapy services is limited. OBJECTIVE: The primary purpose of this study was to determine the use of quality indicators in physical therapist practice. DESIGN: This was an observational study. METHODS: All members of the Orthopaedic and Private Practice sections of the American Physical Therapy Association were invited to participate by completing an electronic survey. The survey included 22 brief patient descriptions, each followed by questions regarding the use of examinations and interventions based on the 2009 list of Medicare-approved quality measures. Separate multivariate logistic regression models were used to determine the odds ratios related to the performance of each examination and intervention on more than 90% of patients, given perceptions of its importance to care, the burden of performing it, and the level of evidence supporting its use. RESULTS: Participants (n=2,544) reported a relatively low frequency of performing examinations and interventions supporting primary and secondary prevention (3.6%-51.3%) and use of standardized measures (5.5%-35.8%). Perceptions of high importance and low burden were associated with greater odds of performing an examination or intervention. Importance and burden were more influential factors than the perceived availability of evidence to support use of identified techniques. LIMITATIONS: The survey was not assessed for test-retest reliability. A low response rate was a source of potential bias. CONCLUSION: The study findings suggest that physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome.

Patient age is related to the types of physical therapy interventions provided for chronic low back pain: an observational study.

STUDY DESIGN: Retrospective analysis of a longitudinal cohort of patients treated for chronic low back pain (CLBP). OBJECTIVES: To determine whether patient age is associated with types of physical therapy interventions received for CLBP. BACKGROUND: Advancing age is associated with less positive treatment outcomes in patients with CLBP. If patient age influences a therapist's choice of interventions, it may partially explain the difference in treatment outcomes. METHODS: Data were examined in a sample of 7392 patients (62% women, 38% men; mean ± SD age, 56.7 ± 16.5 years) with CLBP. We used a generalized estimating equation to examine the probability of each subject receiving each of the individual intervention categories in the presence of the other intervention categories. RESULTS: A significant interaction between intervention category and age existed after controlling for gender, duration of symptoms, comorbidities, payer source, and functional status at initial intake (χ(2) = 130.27, df = 8, P<.0001). The changes in probability of receiving an intervention category averaged 10% as patient age increased. The probability of receiving exercise or task-specific training did not change with advancing age. The probability of receiving postural exercises, pain modalities, joint mobility techniques, ice, or McKenzie exercises decreased with advancing age. The probability of receiving augmented soft tissue mobilization and balance/mobility training increased as age increased. CONCLUSION: The impact of age on physical therapist treatment choices varies depending on the type of intervention. Other variables in addition to age may have an impact on treatment choice. Further research is needed to determine how therapists incorporate age into their clinical decision making.

Academic difficulty and program-level variables predict performance on the National Physical Therapy Examination for licensure: a population-based cohort study.

BACKGROUND: Several factors have been shown to influence first-time pass rates on the National Physical Therapy Examination (NPTE). It is unclear to what extent academic difficulty experienced by students in a physical therapist education program may affect NPTE pass rates. The effects of institutional status (public or private) and Carnegie Classification on NPTE pass rates also are unknown. OBJECTIVE: The aim of this study was to quantify the odds of failure on the NPTE for students experiencing academic difficulty and for institutional status and Carnegie Classification. DESIGN: This investigation was a retrospective population-based cohort study. METHODS: Quota sampling was used to recruit a random sample of 20 professional physical therapist education programs across the United States. Individual student demographic, preadmission, and academic performance data were collected, as were data on program-level variables and data indicating pass/fail performance on the NPTE. A generalized linear mixed-effects logistic regression model was used to adjust for confounding factors and to describe relationships among the key predictor variables-academic difficulty, institutional status, and Carnegie Classification-and the dependent variable, NPTE performance. RESULTS: Academic difficulty during a student's professional training was an independent predictor for NPTE failure. The odds of students who had academic difficulty (relative to students who did not experience academic difficulty) failing the NPTE were 5.89 (95% confidence interval=4.06-8.93). The odds of NPTE failure also varied depending on institutional status and Carnegie Classification. LIMITATIONS: The findings related to Carnegie Classification and institutional status should be considered preliminary. CONCLUSIONS: Student performance on the NPTE was influenced by multiple factors, but the most important, potentially modifiable risk factor for poor NPTE performance likely is academic difficulty during professional training.

Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis. PARTICIPANTS: Data were examined from 2,370 patients (mean age=55.3 years, SD=12.4; 65% female, 35% male) classified into ICD-9 code 726.0 who had completed an episode of outpatient physical therapy. METHODS: Principal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50% or greater change in Physical Component Summary-12 (PCS-12), physical function (PF), bodily pain (BP), and hybrid function (HF) scores. RESULTS: None of the patients achieved a 50% or greater improvement in PCS-12 scores. Improvement in BP scores was more likely in patients who received joint mobility interventions (odds ratio=1.35, 95% confidence interval=1.10-1.65). Improvement in HF scores was more likely in patients who received exercise interventions (odds ratio=1.50, 95% confidence interval=1.03-2.17). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19% to 32%. LIMITATIONS: The authors relied on clinician-identified ICD-9 coding for the diagnosis. Impairment measures were not available to support the diagnosis, and some interventions were excluded because of infrequent use by participating therapists. DISCUSSION AND CONCLUSION: These results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

Use of demographic and quantitative admissions data to predict performance on the national physical therapy examination.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether admissions data could be used to estimate physical therapist student risk for failing the National Physical Therapy Examination (NPTE). SUBJECTS: A nationally representative sample of 20 physical therapist education programs provided data on 3,365 students. METHODS: Programs provided data regarding demographic characteristics, undergraduate grade point average (uGPA), and quantitative and verbal Graduate Record Examination scores (qGRE, vGRE). The Federation of State Boards of Physical Therapy provided NPTE data. Data were analyzed using hierarchical logistic regression. RESULTS: A prediction rule that included uGPA, vGRE, qGRE, and race or ethnicity was developed from the entire sample. Prediction rules for individual programs showed large variation. DISCUSSION AND CONCLUSION: Undergraduate grade point average, GRE scores, and race or ethnicity can be useful for estimating student risk for failing the NPTE. Programs should use GPA and GRE scores along with other data to calculate their own estimates of student risk.

Use of demographic and quantitative admissions data to predict academic difficulty among professional physical therapist students.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether admissions data could be used to estimate physical therapist students' risk for academic difficulty. SUBJECTS: A nationally representative sample of 20 physical therapist education programs provided data on 3,582 students. METHODS: Programs provided data regarding student demographic characteristics, undergraduate grade point average (uGPA), quantitative and verbal Graduate Record Examination scores (qGRE, vGRE), and academic difficulty. Data were analyzed using logistic regression. Rules for predicting risk of academic difficulty were developed. RESULTS: A prediction rule that included uGPA, vGRE, qGRE, age, and race or ethnicity was developed from the entire sample. Prediction rules for individual programs showed large variation. DISCUSSION AND CONCLUSION: Undergraduate grade point average, GRE scores, age, and race or ethnicity can be useful for estimating student academic risk. Programs should calculate their own estimates of student risk. Academic programs should use risk estimates in combination with other data to recruit, admit, and retain students.

Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica.

BACKGROUND AND PURPOSE: The purpose of our study was to determine whether physical therapy interventions predicted meaningful short-term improvement in physical health for patients diagnosed with sciatica. SUBJECTS: We examined data from 1,804 patients (age: mean=52.1 years, SD=15.6 years; 65.7% female, 34.3% male) who had been diagnosed with sciatica and who had completed an episode of outpatient physical therapy. METHODS: Principal components factor analysis was used to define intervention categories from specific treatments applied during the plan of care. A nested-model logistic regression analysis identified intervention categories that predicted meaningful improvement in physical health. Meaningful improvement was defined as a change of 14 or more points on the Physical Component Scale-12 (PCS-12) summary score. RESULTS: Twenty-six percent (n=473) of patients had a meaningful improvement in physical health. Improvement was more likely in patients receiving joint mobility interventions (odds ratio [OR]=2.5, 95% confidence interval [CI]=1.5-4.4) or general exercise (OR=1.5, 95% CI=1.2-2.0). Patients who received spasm reduction interventions were less likely to improve (OR=0.77, 95% CI=0.60-0.98). DISCUSSION AND CONCLUSION: Physical therapists should emphasize the use of joint mobility interventions and exercise when treating patients with sciatica, whereas interventions for spasm reduction should be avoided.

A method for predicting a student's risk for academic probation in a professional program in allied health.

Identification of students at risk for academic difficulty in a physical therapy program would provide opportunities to implement preemptive measures designed to enhance successful academic performance. The purpose of this study was to determine if a method advocated for use in evidence-based practice could be adapted for use in predicting probationary status for students in a program in allied health, specifically physical therapy. Preadmission combined math and science grade point average; cumulative grade point average (TGPA); verbal Graduate Record Examination score (VGRE), quantitative Graduate Record Examination score (QGRE), and analytic Graduate Record Examination score; and probation status were obtained for 305 students (mean age, 25.5 years; SD, 4.14) accepted into one physical therapy program from 1995 to 2000. Predictors of probation were identified using stepwise logistic regression. Likelihood ratios were calculated for three score intervals derived from receiver operating characteristic analysis. TGPA, VGRE, and QGRE were significant predictors in the regression model (p < 0.05). VGRE was the only variable that consistently showed predictive capability (likelihood ratio, 2.9; 95% confidence interval, 1.2-6.9). Quantitative preadmission data can be used in combination to improve the predictive power of estimates of probation risk. We contend that the analytic methods illustrated in this report could be used in academic programs to assist faculty with management of students who are at risk for academic difficulties.