"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

Friday, May 21, 2010

What is the role of the Physical Therapist's Diagnosis?

Another take on the problem of regional variation, excessive diagnostic testing and paying for quality...

A new study in the May 12th New England Journal of Medicine revealed a 'striking' new finding: that Medicare patients who move to high-intensity healthcare regions in the USA get diagnosed with more diseases, appear sicker and, ultimately, receive more invasive testing and diagnostic imaging services.

Excessive diagnostic testing is a problem because it increases costs and leads to unnecessary procedures.

Going forward, Medicare's Pay for Performance scheme will morph into a true outcomes-based health care system and will rely on diagnostic 'risk adjustments' to pay hospitals, doctors and physical therapists that treat sicker patients.

Some of these 'sicker' patients just appear sick because doctors are diagnosing too much - because they are paid to do so.

An example given in Dr. Maggie Mahar's The Health Care Blog of Regional Variations in Diagnostic Practices by Dr. Yunjie Song et al of men diagnosed with prostate cancer reveals that most of these men will never experience symptoms and will never need advanced cancer treatment (eg: surgery).

Subsequent outcomes measurement of treatments given to these men will reflect their cancer diagnosis and will increase the hospital's 'risk adjusted' payment - even though these men may never get 'sick' from cancer.

Physical Therapy Diagnosis

In physical therapy, many treatments are performed (eg: electric stimulation, ultrasound, diathermy or heat/ice) based on a pattern recognition approach.

Pattern recognition is efficient but subject to cognitive bias such as the following:
  • Anchoring - you believe that ultrasound is an appropriate treatment for your current patient because you were taught this approach in PT school.
  • Confirmation bias - you believe that ultrasound is the appropriate treatment for your current patient even though your patient mentions that they have used this modality previously to NO effect.
  • Availability heuristic - you believe your current patient is a candidate for ultrasound because your last patient got better with ultrasound and she "just loves" ultrasound.
The alternative to pattern recognition is a 'rational analysis' approach - in Physical Therapy the best example of rational analysis is Treatment Based Classification (TBC) - where the physical therapist measures several, fundamental patient characteristics and 'decides' on a particular treatment approach.

An "ultrasound" decision rule could identify who WILL NOT benefit from ultrasound. Alas, no such rule exists.

No TBC rules exist for other vague, high-frequency conditions seen in physical therapy either, such as:
  • future falls risk,
  • general conditioning and
  • pain control.
Physicians testing for pathology usually involves invasive, irradiating or expensive procedures which begs the question in medicine: Is more testing better? Does a medical diagnosis improve your chances? Does more healthcare lead to better health?

Diagnosis or Prognosis?

Fortunately, physical therapists already have tools to assess factors that contribute to outcome - and the authors of the diagnostic variation study seem to be aware of the importance of these tools...
“...measures of health risks reported by patients (e.g., smoking and exercise patterns) and functional status (physical, social, and role function) could be incorporated in risk-adjustment models.”
It seems likely that physical therapists, unlike physicians, could benefit their patients by additional testing, measurement and diagnosis of patient characteristics that contribute to outcome.

It also seems likely that the new role of the physical therapist under an outcomes-based healthcare system will be that of diagnostician: searching for risk factors that predict the outcome of an episode of physical therapy care, rather than primarily delivering interventions.

Is it possible that your search for diagnoses will be rewarded similar to, but more consistently, to the way physicians are rewarded for diagnosing today? And if diagnostic variations can be 'evened out' can we assume that this new system will be equitably rewarding for the patient?

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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"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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