Impact of Risk Adjustment & Formal Education on Clinical Outcomes Jason Rodeghero DPT, PhD, 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?

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

What about all those letter What about all those letter? PT, MPT, tDPT, PhD, ATC, MTC, OCS, FAAOMPT, WTF… 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 Hart & Dobrzykowski 2000 14 PTs; 7 with OCS / 7 without OCS 258 patients OCS PTs had fewer visits

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

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

Are these people residency graduates? FAAOMPT from fellowship or from challenge exam? MTC from where?

When you hear big data, you may think big brother… NSA sound familiar?

Already surrounded & being consumed by it Every two days now we create as much information as we did from the dawn of civilization up until 2003. Eric Schmidt, CEO, Google @ Techonomy 2010

BIG Data Cons Pros Accuracy of data Lots of data! Incomplete Heterogeneity Privacy/confidentiality Potential for biased fishing expeditions Pros Lots of data! Timely access Variety Predictive (sometimes) Cheap (?)

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?

On to why I was invited…

Patient data available from Age Gender Insurance Diagnoses Acuity Duration of symptoms Comorbidities Surgical history BMI Fear Avoidance Beliefs Medications Exercise habits Number of treatments Functional Status change Most research has stopped with using this info and therapist info from credentials entered in user registration process I needed to know more, a lot more about the therapists to answer big questions; so, developed a survey to send out to all users (not EIM only)

Physical Therapist FOTO User Survey General demographics Entry-level education Residency completion Fellowship trained Post-professional certifications Board certification MTC – any school of OMPT Transitional DPT Post-professional academic degrees Advanced Master’s PhD, DSc, etc Years of experience Practice Setting Created and e-mailed to all FOTO users

Efficiency

Magnitude of change

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

Influence of tDPT * All Bachelor’s FS change less than all Master’s (p < .001) and Doctorate (p = .05) first professional degrees; Bachelor’s with tDPT FS change greater than Bachelor’s without tDPT (p < .001), Master’s with tDPT (p = .003), and Doctorate (p < .001). † All Master’s FS change greater than all Bachelor’s but not Doctorate; Master’s with tDPT FS change greater than Bachelor’s without tDPT (p = .003) but less than Bachelor’s with tDPT (p = .003) and Master’s without tDPT (p = .003); no difference with Doctorate (p = 1.0); Master’s without tDPT FS change significantly greater than all other groups (p ≤ .006) except Bachelor’s with tDPT (p = 1.0) ‡ Doctorate FS change significantly greater than Bachelor’s without tDPT (p < .001); significantly less than Bachelor’s with tDPT (p < .001) and Master’s without tDPT (p < .001) Unpublished data

Years of experience 6379 patients with low back pain Unpublished data

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

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

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

Same methodology (3,137 patients) Low Risk High Risk Younger age Shorter duration of symptoms No surgical hx Fewer comorbidities Higher baseline disability High Risk Longer duration of symptoms Surgical hx Lower levels of baseline disability

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!

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.