"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Thursday, September 10, 2009

The 10 Most Important Words in Evidence Based Physical Therapy

Bias – the systematic deviation from the truth.

Atun Gawande, MD said it this way:
"Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes.

The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly.

It is unduly swayed by desire and emotion and even the time of day. It is affected by the order in which information is presented and how problems are framed."

Diagnosis is to “discern” or “distinguish” the nature of the patients’ problem. The original Greek word meant “to learn”.

In physical therapy, diagnosis is the process of integrating data obtained from the patient examination in order to treat and inform the plan of care, perform interventions and to make a prognosis (prediction).

Gold Standard – a test that is assumed to be valid can be compared to the measure of interest. In TBC, outcomes are the measure of interest. The manipulation and stabilization derivation studies used a 50% improvement in the Oswestry Disablement Score as the gold standard.

Many medical gold standards are imaging findings because medical tests are trying to confirm a pathoanatomic diagnosis.

Pretest Probability – the prevalence of a disease in the population (of your patients) at a given point in time. Steven McGee, in Evidence Based Physical Diagnosis states:
Pretest probability is the starting point for all clinical decisions.”
Positive Likelihood Ratio “describes how probability changes when a test finding is present.

Findings whose LR is greater than one increase the probability of disease; the greater the LR the more compelling the argument for disease.” (Steven McGee)

The relationship between the finding and the diagnosis/outcome is defined numerically by the positive likelihood ratio.

Negative Likelihood Ratio “describes how probability changes when a test finding is absent.

Findings whose LR lie between zero and one decrease the probability of disease; the closer the LR is to zero the more convincing the finding argues against disease” (ibid)

The relationship between the finding and the diagnosis/outcome is defined numerically by the negative likelihood ratio.

Cookbook Medicine - a term used to deride the algorithmic simplicity of evidence based medicine, usually by those who prefer an observational, personal or ambiguous approach to decision making.

Diagnostic Perfection - the 'elusive search for diagnostic perfection' is defined by the test that identifies all patients with the condition of interest and rejects all patients without the condition of interest.

This impossible ideal is numerically defined by a test with a sensitivity and a specificity of 1.0.

A culture of measurement is another ideal that may be possible.

New tools have been described that trump the puny skills I graduated with in 1992 (eg: MMT) - perhaps the physical therapy profession is reaching a critical mass where measurement will become the standard and not the ideal.

Compliance – a legalistic term rather than a clinical term. Compliance cannot be memorized or practiced according to evidence-based standards.

Compliance is an ongoing, evolving process of the following:
  1. self-audit
  2. standardization
  3. accountability
  4. training
  5. corrective action
  6. communication
  7. publication of your work
Physical therapy managers struggle trying to balance the paperwork burden of compliance and optimizing the therapists' time treating patients. More paperwork usually make the corporate lawyers happy while more time treating patients makes the therapists and the patients happy.

Ironically, too much paperwork forces corporate PTs and hospital PTs to rely more on unskilled aides, which may increase audit liability when you're caught.

So, how come compliance is an important word in evidence based physical therapy?

Well, consider this...

Recently, the incoming American Medical Association President Dr. J. James Rohack declared...
"Defensive medicine is another cost driver in the health system that will only abate with medical liability reform. For example, adherence to nationally recognized evidence-based guidelines can reduce the ordering of unnecessary tests if physicians no longer have to fear merit-less lawsuits.

President Obama has recognized the need for liability reform, and we urge Congress to include effective liability protections when guidelines are followed."
What if we recognized that 40% of physical therapy Medicare denials are "maintenance therapy" based on an auditor's judgement of a PT note. The note may appear "unskilled" since therapeutic exercise is, by nature, repetitious.

The physical therapy plan of care could appear repetitive even though the patient gets better, goals are met and outcomes improve.

Medicare audits and audit protection activities are a cost driver (part of the estimated 31% administrative costs in health care) that will only abate when Medicare stops auditing the process of how physical therapists deliver care (eg: "skilled" care, 8-minute rule, -KX & -59 modifiers, etc.) and starts looking at the outcome of care.

How much health care value will be unlocked when physical therapists are free to focus on patient outcomes instead of writing down every set, rep, position and variation of treatment we prescribe?

What process do auditors use to evaluate physical therapists charts? Could that process be subject to bias?

American medicine has recognized the need for an outcomes oriented system and we urge Medicare auditors to go easy on physical therapists when evidence based guidelines are followed.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

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