1. Impact of Risk Adjustment & Formal Education on Clinical Outcomes
Jason Rodeghero DPT, PhD, OCS, FAAOMPT

2. 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?

3. 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

4. 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

6. 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

7. 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

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

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

11. 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, Techonomy 2010

12. 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 (?)

13. 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?

14. On to why I was invited…

15. 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)

16. 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 ed to all FOTO users

19. Efficiency

20. Magnitude of change

21. 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 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

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

27. 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)

28. 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

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:
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:
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):
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):
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:
Hart D, Dobrzykowski E. Influence of orthopaedic clinical specialist certification on clinical outcomes. J Orthop Sports Phys Ther. 2000;30:
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):
Cook CE, Rodeghero JR, Cleland JA, Mintken PE. A preliminary risk stratification model for individuals with neck pain. Musculoskeletal Care. 2015;13(3):
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): doi: /jospt
Rodeghero JR, Cook CE. The use of big data in manual physiotherapy. Man Ther. 2014; 19: