New Treatment Based Classification Chart with Hyperlinks

These are the Treatment Based Classification rules I've been using the past couple of years. Please use this chart, including the hyperlinks. Let me know if you see any ommissions or if you recommend a rule I have not included.

Rule	Author	Year	Level of Rule Development
Cancer Rule in Lower Back Pain Patients	Joines et al	2001	Cost Effectiveness study
Lumbar Manipulation Rule	Flynn et al	2002	Broad Validation
Lumbar Stabilization Rule	Hicks et al	2005	Derivation
Lumbar Traction Rule	Fritz et al	2007	Expert Consensus
Thoracic Manipulation Rule for Neck Pain	Cleland et al	2007	Broad Validation by Cleland in 2010 demonstrated NO rule is needed - ALL neck pain patients without "red flags" get manipulation
Ankle Mobilization for Inversion Injuries	Whitman et al	2007	Derivation
Hip Manipulation Rule for Knee Pain	Currier et al	2007	Derivation
Specific Directional Exercise for Lower Back Pain	Browder et al	2007	Expert Consensus
Lumbopelvic Manipulation for Anterior Knee Pain	Iverson et al	2008	Derivation
Cervical Traction Rule	Raney et al	2009	Derivation
Thoracic Manipulation Rule for Shoulder Pain	Mintken et al	2010	Derivation

This chart is regularly updated at www.BulletprootPT.com.

Why Do Physical Therapists Need to Track Florida's 2012 Legislative Bills?

I think it was Mark Twain who said:

"We should never watch laws or sausage being made, for if we did we would lose our appetite for both"

Yet I'm now going to suggest to you that you sign up for the Bill Tracker features on the Florida Senate and the Florida House websites.

These features will give you a blow-by-blow stream of e-mail messages on the progress or barriers to the 2012 Florida Physical Therapy Association's legislative bills.

Senate Bill 1128 by Senator Montford and House Bill 799 by Rep. Goodson will enact Temporary Licensure for Physical Therapists and Physical Therapist Assistants by making changes to the physical therapist practice act (FS 486).

So, why should you want to watch our legislation being made (hopefully) into a new law for the State of Florida?

Here are some suggested reasons to sign up for Bill Tracker:

• You will stay current with the FPTA bill's progress or setbacks.
• You will receive periodic updates
• You will be able to mobilize your local Key Contacts should the bill get stuck in committee.
• You will know at a moments notice if your presence is needed in Tallahassee for testimony before committee.

Here is a short video (1:41) showing the set-up process of the Florida Senate website

Its free. Its easy.

I just hope you don't lose your appetite for the legislative process.

Support New York Physical Therapists' CoPayment Legislation

Physical therapists will again put CoPayment reform legislation before the New York legislature in 2012. Twice now the legislation has been put forward for consideration.

In 2011, CoPayment was advanced but not all the way to a vote in the legislature (in general, fewer than 10% of bills in ANY state each year are passed into law).

This article in the New York Daily News describes grassroots efforts to advance CoPayment in New York, once again.

Please comment.

Your comments in this newspapers' web site will influence the media perspective of physical therapist CoPayment legislation.

We want the media to know this is an important issue for patients, physical therapists and payers.

Physical therapists in New York NEED your comments!

Help the Physical Therapy Alliance of Upstate New York (PTAUNY) and the New York Physical Therapy Association push CoPayment legislation forward in the New York state legislature in 2012. 

Please comment on this newspaper story so it gets more media attention.

Thank you.

Healthcare CEOs Richest 1% in North America

Healthcare CEOs are the among the richest American executives across all industries.

Three of the top-earning 10 executives across all industries were in healthcare:

• Healthcare company McKesson Corp. Chief Executive John Hammergren topped the list with nearly $145.3 million in compensation in 2010
• Following McKesson is Omnicare's CEO in second place for the highest paid exec with $98.3 million
• Former CEO of health insurance company Aetna Ronald Williams received a total of $57.8

"The survey, called the most extensive study of CEO pay in North America, demonstrates the widening gap between incomes, especially in light of protesters of Occupy Wall Street who call attention to "the 1 percent," reports The Guardian."

The salary survey was performed by research group GMI Ratings:

“The 36.5 percent increase in realized compensation is particularly notable when it’s put in context of the modest growth of the economy in 2010 and general public company performance last year,” said Paul Hodgson, Chief Communications Officer and Senior Research Associate at GMI"

In a time when workers, patients and private practice physical therapists are struggling the income granted to these individuals seems excessive.

Their claim to create "value" for all stakeholders, not just the chareholder, seems unfounded.

Who else thinks America's market-based system has come off the rails - at least in healthcare?

The advantage of capitalism over central planning is that it distributes resources MORE efficiently.

This story suggests that WINNER TAKE ALL is the new normal.

Thoughts?

Distracted Doctoring Raises Risks For Patients

This free New York Times article discribes a disturbing trend for which peer-reviewed research is just beginning to emerge:

• nurses and doctors gued to their iPads in the hospital
• technicians who monitor bypass machines talking on cellphones during heart surgery
• a neurosurgeon making personal calls during an operation
• a nurse checking airfares during surgery
• providers routinely texting during surgical or medical procedures

This January 2011 article in Perfusion describes cell phone use during heart bypass procedures.

Do physical therapists routinely use mobile devices, such as iPhones, in the clinic?

Does mobile device use in the ambulatory outpatient setting pose the risk to patient safety that the same behavior in surgical settings poses?

My assessment is no.

What do you think?

Please comment.

Sitting Disease Cured by Exercise!

Fair CoPayment Web Page Now Online at APTA

The new American Physical Therapy Assocation (APTA) Fair CoPayment web page went live on December 7th, 2011.

Physical therapists advocating for improved patient access at the state level should look at the resources available here to help your state association craft your legislative strategy.

It's exciting to see the momentum this issue is beginning to generate.

I'm curious to see which states in 2012 advance CoPayment legislation for consideration.

The Process of Profitability

Physical therapists can learn from this highly successful company. They sell 10% af all the furniture in the world, they made $30 BILLION in revenue in 2010 and their estimated profit margin is 10%.

This company has created a process for customers to buy their products, become loyal customers, leave their stores highly satisfied and eagerly look forward to coming back and spending more money.

The customer is encouraged to browse the store, selecting what they want to purchase while following a SPECIFIC PATHWAY.

Who is this company? Follow the arrows to find out.

The "process" is easy - this company paints arrows on the floor of their HUGE stores to help customers navigate through the thousands of products they offer.

Not every product is costly - you can spend as little as 50 cents on some items. You may also spend thousands of dollars in their store. The average customer spend $85 dollars per visit. A single trip to one of their stores may take 3-4 hours so the company has a full-service, sit-down gourmet restaurant for when you get hungry.

What does this company have to do with physical therapists? Physical therapists can learn from them how to make the process of physical therapy easier, more fun and more rewarding for our patients. And, not mention, more profitable for physical therapists.

The "process" of physical therapy is one of the quality measures defined by the National Quality Measures Clearinghouse (NQMC) of Clinical Quality Measures. The five domains are generally described as follows:

• Process
• Access 
• Outcome 
• Structure 
• Patient Experience

The process-of-care is defined as a health care-related activity performed for, on behalf of, or by a patient.

"Process measures are supported by evidence that the clinical process—that is the focus of the measure—has led to improved outcomes. 

These measures are generally calculated using patients eligible for a particular service in the denominator, and the patients who either do or do not receive the service in the numerator. 

Example: The percentage of patients with chronic stable coronary artery disease (CAD) who were prescribed lipid-lowering therapy."

Physical therapy in the United States is unusual in that many of the processes we traditionally perform, such as the following:

• Physician certification of the Plan of Care 
• Written Progress Notes 
• Discharge Summaries 
• Episodic treatment for chronic conditions (eg: three time per week for 1 month) 
• etcetera 

...are NOT supported by evidence that they lead to better outcomes, lower costs or a better patient experience.

Innovative physical therapists will need to find a way to get these Medicare-mandated processes performed while improving the patient experience.

Innovation is what drives this company. They are the global arbiters of style in home furnishing.

Additionally, they have discovered that customers don't really want furniture - we want a place to sleep, something to write on and something to sit on. The actual pieces of wood that this company sells are not the highest "quality" - as defined by contemporary standards of furniture quality.

But, customers buy them.

Who is this company?

Ikea.

What innovations can physical therapists propose, within the Medicare-mandated process-of-care, to improve the patient experience in the United States?

Please comment.

Hospitals Bounce Back but Florida Physical Therapists May Still Get the "Take Back Letter"

Florida physical therapsists may still be on the hook, beginning January 1, 2012, resulting in the dreaded "Take Back Letter" from Medicare for services provided to orthopedic patients who don't meet new Medical Necessity requirements under Recovery Audit Contractors (RAC).

"The physicians will receive a form letter which will be entitled a “Take-Back Letter” requiring return of any funds paid in conjunction with the affected hospitalization. 

This will affect all cardiologists and orthopedists involved in the care – both invasive and noninvasive.  

This may include outpatient reimbursement for follow-up care related to the hospitalization. It’s not clear whether other specialists or primary care physicians will also receive Take-Back Letters."

Peter R. Kovacek, PT, DPT, MSA of PT Manager reported Friday, December 3rd that Medicare was Tightening the Screws on high-utilization providers in high-utilization states, such as Florida, California, Michigan, Texas, New York, Louisiana, and Illinois.

The Financial Times, on Monday December 6th, reported that hospital operators, such as Tenet Healthcare, bounced back from the 11% share price drop on Friday:

"...but analysts remained concerned that government healthcare schemes may limit expensive cardiovascular and orthopedic treatments."

Physical therapists who treat post-surgical patients could see a drop in patient volume, beginning January 2012, from orthopedic surgeons.

The Art and Science of Physical Therapy

The 2011 Oxford Debate at the APTA Annual Conference in Washington DC pitted clinical decision rules - algorithms - against clincial intuition. You can see some of the debaters coments here.

I wrote, at the time, that this was a false choice. Algorithms and intuition can BOTH be used by the physical therapist to improve patient outcomes and speed the clinical workflow.

It's not an either-or decision. The question is WHEN to use the algorithm and WHEN to use your intuition.

A recently published systematic review by Henschke to diagnose spinal fractures provides an example of HOW physical therapists can use algorithms and intuition together.

I included Henschke's original decision rule in my new book, Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting due out January 15th, 2012.

Henschke's new rule was also recently posted to PhysioPedia in a page titled Subjective Exam - Diagnostic Strength by Brian Duffy, Carleen Jogodka, Jeff Ryg, James White of the Evidence in Motion Fellowship program.

Henschke's New Rule to Diagnose Spinal Fractures

Henschke's rule to diagnose spinal fracture in a low risk setting provides physical therapists a unique opportunity to use their clinical intution.

Clinical Decision Rules are usually intended to provide probabilities confirming a diagnosis or predicting an outcome so the physical therapist can make clinical decisions with confidence.

Henschke's rule screens patients for vertebral fractures without the use of expensive and overly sensitive diagnostic imaging. This rule may be employed in two different settings: low risk primary care offices or high risk emergency rooms. The setting determines the pre-test probability, or prevalence.

Here is Henschke's new rule:

• History of major trauma
• Pain and tenderness
• Age < 50 years
• Female
• Corticosteroid use

The base rate of vertebral fractures in a population of 1,172 patients accessing primary care for treatment of lower back pain in Sydney, Australia was 0.5%. Primary care in Australia is defined as offices of physicians, physical therapists and chiropractors.

Low Risk Decision Rule
Screening Finding Present	Likelihood of the Diagnosis
1 present	1% chance of a spinal fracture
2 present	7% chance of a spinal fracture
3 or more present	52% chance of a spinal fracture

The base rate of vertebral fractures in patients accessing the emergency room and specialty physicians’ offices for treatment of lower back pain in Sydney, Australia was 3.0%.

High Risk Decision Rule
Screening Finding Present	Likelihood of the Diagnosis
1 present	5% chance of a spinal fracture
2 present	32% chance of a spinal fracture
3 or more present	87% chance of a spinal fracture

The predictive power of the decision rule varies with the setting in which the clinician sees the patient – high risk patients seen in specialty clinics had a higher prevalence of spinal fracture. The new rule is the same in both settings.

The physical therapist's intuition is especially important in the LOW RISK situation when three or more of the subjective variables were present. In this situation, the clinical decision rule returns a probability of 52% favoring the diagnosis of vertebral fracture. The rule, in this situation, barely performs better than chance.

A physical therapist flipping a coin could do just as well in predicting a spinal fracture (~50%).

In this situation, the physical therapist should rely on their clinical intuition. Intuiton might include additional data points from the physical therapy evaluation, including:

• the patient's history
• subjective pain complaints
• physical examination
• special tests 
• other pathology screening exams.

Also, a medication list, cognitive status and input from family members could add useful data points that might increase or decrease the probability of a fracture.

This example is meant to demonstrate WHY physical therapist intuition is still important, combined with first-pass screening algorithms that supplement human memory for low-frequency events. In these situations, the use of clinical intuition and experience supplements the algorithmic decision rule.

Henschke's rule to diagnose spinal fracture is a useful algorithm for screening high risk patients in the emergency room.

In the low risk setting, such as an ambulatory PT clinic, the rule requires that the physical therapist remain alert to subtle cues that might affect the diagnosis.

Henschke's rule demonstrates clearly how your diagnosis requires both the art and the science of physical therapy.