Impact of Risk Adjustment Formal Education on Clinical

Impact of Risk Adjustment & Formal Education on Clinical Outcomes Jason Rodeghero DPT, Ph. D, 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? 2

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 3

What about all those letter? PT, MPT, t. DPT, Ph. D, 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 4

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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 6

§ 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 7

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Already surrounded & being consumed by it 11

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 12

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? 13

On to why I was invited… 14

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 15

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 – Ph. D, DSc, etc § Years of experience § Practice Setting – MTC – any school of OMPT 16

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Efficiency 19

Magnitude of change 20

§ 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 22

Influence of t. DPT Unpublished data 23

Years of experience 6379 patients with low back pain Unpublished data 24

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 25

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 26

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§ 6, 379 patients § Low Risk – Younger age § High Risk – Older age (55) – Longer duration of symptoms – Male gender – Surgical hx – Shorter duration of symptoms – Current use of medications – Lower baseline disability – No surgical hx – Insurance categorization (work comp / auto) – Higher baseline disability – Insurance status 28

§ 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 29

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! 30

References § Austin T, Graber K. Physical therapists' perspectives on the role and effectiveness of continuing education. J Allied Health. 2007; 36: 216 -223. § 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. § 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 § 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. § 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 § Rodeghero JR, Cook CE. The use of big data in manual physiotherapy. Man Ther. 2014; 19: 509 -510. 31