Associations Between Treatment Processes, Patient Characteristics, and Outcomes in Outpatient Physical Therapy Practice

doi:10.1016/j.apmr.2009.02.005

Archives of Physical Medicine and Rehabilitation

Volume 90, Issue 8, August 2009, Pages 1349-1363

https://doi.org/10.1016/j.apmr.2009.02.005 Get rights and content

Abstract

Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice.

Objective

To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.

Design

Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.

Setting

Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.

Participants

A consecutive sample of 22,019 adult patients (mean age 51.2y, standard deviation=15.7, range 18–96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.

Interventions

Not applicable.

Main Outcome Measure

Functional status at discharge.

Results

Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.

Conclusions

The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

Section snippets

Design

We conducted a prospective, observational cohort study. Treatment processes were not altered. Data were collected prospectively from June 2005 to January 2008 from all patients referred to PT who met the inclusion criteria described below.

Subjects

The study was conducted in the PT service of Maccabi, a public health maintenance organization responsible for providing health care for approximately 1.8 million people in Israel. Patients were Israeli born and new immigrants, including people whose primary

Subjects

Intake surveys were administered for 57,008 patients. There were 17,485 patients (31%) who completed treatment but who did not complete a functional survey at discharge (incomplete protocol), and 17,504 patients (31%) who dropped out of treatment during the episode of care. That left 22,019 patients with intake and discharge measures, a 39% completion rate.⁸ Descriptive data of these patients are provided in Table 1, Table 2, Table 3, Table 4, Table 5. The definitions of variables and

Discussion

Our purpose was to identify associations between FS outcomes during PT, patient characteristics, and treatment processes for patients with lumbar spine, knee, cervical spine, or shoulder musculoskeletal impairments. Many associations were identified. For brevity, we discuss only some of these associations, which characterize our findings and emphasize benefits of practice-based evidence studies to outpatient therapy clinical practice.

Conclusions

This study offers an introductory examination of a large integrated database to investigate associations between patient characteristics, treatments, and outcomes in outpatient PT practice. We found that better functional outcomes were associated with the following: high patient compliance with self-exercises; use of active exercises; number of completed functional assessments during therapy; high participation in routine physical activity; and use of manual therapy. Further studies are needed

Acknowledgments

We thank Rafi Rolnik, BSc, Department of Medical Information System, Avi Hosit and his team, Information Technology Department, and Shlomo Oz, David Amital, MSc, Eyal Kedem, MBA, Orly Shpigel, BA Econ, and Hillel Alapi, BBSc, System Development Department, who all played key roles in the data collection process from the various computerized registries of Maccabi Healthcare Services. We thank the PT research and development coordinators and PT district directors of Maccabi who managed the

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Chronic pain results in plastic changes in cortical processing leading to persistent pain and potential fear-avoidant behavior.23,27 Changes in pain processing can play a role in the patient’s capacity to heal and rate of recovery.6,39-42 Along with alterations to tissue and neuromuscular control, changes in pain processing and beliefs occur in patients with LBP.7,53,59-65
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The mean FS change was 16.997 (n=11,945). Patients with chronic symptoms (>90-d duration) had an FS change of 15.920 (n=7264) across 14.63 visits. Patients with subacute symptoms (15-90d) had an FS change of 21.66 (n=3631) across 14.05. Patients with acute symptoms (0-14d) had an FS change of 29.32 (n=1050) across 13.66 visits. Stepwise regression analysis revealed a significant â for chronicity (−4.155) with all models.
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: Supported by Maccabi Healthcare Services—HMO, Israel; and by the Maccabi Institute for Health Services Research, Israel.

: A commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit on the author or one or more of the authors. Hart is an employee of, and investor in, Focus On Therapeutic Outcomes Inc, a database management company, owner of the outcomes collection software used to collect function outcome for the study.

: Reprints are not available from the author.

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Original articleAssociations Between Treatment Processes, Patient Characteristics, and Outcomes in Outpatient Physical Therapy Practice

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measure

Results

Conclusions

Section snippets

Design

Subjects

Subjects

Discussion

Conclusions

Acknowledgments

J Clin Epidemiol

J Clin Epidemiol

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Clin Epidemiol

Arch Phys Med Rehabil

J Clin Epidemiol

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Am Acad Dermatol

Ann Thorac Surg

J Clin Epidemiol

J Clin Epidemiol

Pain

Pain

Man Ther

Best Pract Res Clin Rheumatol

Spine J

J Hand Ther

Declarations of principle and position statements. 1999

International Classification of Functioning, Disability and Health (ICF)

Practice-based evidence study design for comparative effectiveness research

Med Care

Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial

Arch Phys Med Rehabil

Implementing an integrated electronic outcomes and electronic health record process to create a foundation for clinical practice improvement

Phys Ther

Clinical databases in physical therapy

Physiother Theory Pract

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the NetherlandsCross sectional analyses of data from three clinical databases

BMC Health Serv Res

Clinical practice improvement methodology: implementation and evaluation

Clinical practice improvement: a new technology for developing cost-effective quality care

Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results

Arch Phys Med Rehabil

Quality assurance in physical therapy [thesis]

Pay-for-performance for physical therapy and occupational therapy: Medicare Part B ServicesFinal report

Measurement properties of the short form 36 and health-related quality of life after intensive care in Morocco

Acta Anaesthesiol Scand

Developing the Patient-Reported Outcomes Measurement Information System (PROMIS)

Med Care

The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years

Med Care

Development of a computer-adaptive test for depression (D-CAT)

Qual Life Res

Sensitivity of a computer adaptive assessment for measuring functional mobility changes in children enrolled in a community fitness programme

Clin Rehabil

A computer adaptive testing approach for assessing physical functioning in children and adolescents

Dev Med Child Neurol

Applications of computerized adaptive testing (CAT) to the assessment of headache impact

Qual Life Res

Item response theory: principles and applications

Fundamentals of item response theory

Contemporary measurement techniques for rehabilitation outcomes assessment

J Rehabil Med

Prospective evaluation of the AM-PAC-CAT in outpatient rehabilitation settings

Phys Ther

Introduction and history

Original article
Associations Between Treatment Processes, Patient Characteristics, and Outcomes in Outpatient Physical Therapy Practice