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Ditwiler RE, Swisher LL, Hardwick DD. Doing things you never imagined: Professional and ethical issues in the U.S. outpatient physical therapy setting during the COVID-19 pandemic. Musculoskelet Sci Pract 2022; 62:102684. [PMID: 36356408 PMCID: PMC9617680 DOI: 10.1016/j.msksp.2022.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Despite being the most prevalent physical therapy practice setting in the United States, no literature to date has examined the professional and ethical issues faced by outpatient physical therapists during the COVID-19 pandemic. The purpose of this study was to explore professional and ethical issues experienced by outpatient physical therapists in the United States during the COVID-19 pandemic. DESIGN An explorative semi-structured interview study using reflexive thematic analysis METHODS: Virtual semi-structured interviews explored physical therapists' experiences during COVID-19 in the OP setting. Data was analyzed using reflexive thematic analysis as described by Braun and Clarke. RESULTS Respondents worked predominantly with patients with orthopaedic impairments. Six primary themes and associated subthemes were identified: 1) Disruption of routine professional and personal life. 2) Negative impacts on health and wellbeing (physical, mental, and social). 3) Barriers to relationships, communication, and providing quality care. 4) Telehealth as a safe option to increase access with opportunities and challenges. 5) Discomfort practicing in an environment of misinformation, mistrust, and divisiveness. 6) New & pre-existing ethical issues in the COVID-19 context. CONCLUSIONS Results of this study indicate that physical therapists in the outpatient setting wrestled with critical questions regarding outpatient physical therapy practice during the COVID-19 pandemic: the role of touch in professional identity, challenges to the therapeutic alliance, effect of productivity and fiscal expectations and whether outpatient physical therapy is essential during public emergencies.
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Affiliation(s)
- Rebecca Edgeworth Ditwiler
- School of Physical Therapy and Rehabilitation Sciences, University of South Florida, USF Health Morsani College of Medicine, Tampa, FL, USA.
| | - Laura Lee Swisher
- School of Physical Therapy and Rehabilitation Sciences, University of South Florida, USF Health Morsani College of Medicine, Tampa, FL, USA
| | - Dustin Dean Hardwick
- School of Physical Therapy and Rehabilitation Sciences, University of South Florida, USF Health Morsani College of Medicine, Tampa, FL, USA,School of Physical Therapy, University of the Incarnate Word, San Antonio, TX, USA
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Jesus TS, Landry MD, Dussault G, Fronteira I. Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century. HUMAN RESOURCES FOR HEALTH 2017; 15:8. [PMID: 28114960 PMCID: PMC5259954 DOI: 10.1186/s12960-017-0182-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/12/2017] [Indexed: 05/26/2023]
Abstract
BACKGROUND People with disabilities face challenges accessing basic rehabilitation health care. In 2006, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) outlined the global necessity to meet the rehabilitation needs of people with disabilities, but this goal is often challenged by the undersupply and inequitable distribution of rehabilitation workers. While the aggregate study and monitoring of the physical rehabilitation workforce has been mostly ignored by researchers or policy-makers, this paper aims to present the 'challenges and opportunities' for guiding further long-term research and policies on developing the relatively neglected, highly heterogeneous physical rehabilitation workforce. METHODS The challenges were identified through a two-phased investigation. Phase 1: critical review of the rehabilitation workforce literature, organized by the availability, accessibility, acceptability and quality (AAAQ) framework. Phase 2: integrate reviewed data into a SWOT framework to identify the strengths and opportunities to be maximized and the weaknesses and threats to be overcome. RESULTS The critical review and SWOT analysis have identified the following global situation: (i) needs-based shortages and lack of access to rehabilitation workers, particularly in lower income countries and in rural/remote areas; (ii) deficiencies in the data sources and monitoring structures; and (iii) few exemplary innovations, of both national and international scope, that may help reduce supply-side shortages in underserved areas. DISCUSSION Based on the results, we have prioritized the following 'Six Rehab-Workforce Challenges': (1) monitoring supply requirements: accounting for rehabilitation needs and demand; (2) supply data sources: the need for structural improvements; (3) ensuring the study of a whole rehabilitation workforce (i.e. not focused on single professions), including across service levels; (4) staffing underserved locations: the rising of education, attractiveness and tele-service; (5) adapt policy options to different contexts (e.g. rural vs urban), even within a country; and (6) develop international solutions, within an interdependent world. CONCLUSIONS Concrete examples of feasible local, global and research action toward meeting the Six Rehab-Workforce Challenges are provided. Altogether, these may help advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs.
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Affiliation(s)
- Tiago S. Jesus
- Portuguese Ministry of Education, Aggregation of Schools of Escariz, 4540-320 Escariz, Portugal
| | - Michel D. Landry
- Doctor of Physical Therapy Division, Duke University Medical Center, Duke University, Box 104002, 27710 Durham, NC United States of America
- Duke Global Health Institute, Duke University, Durham, NC United States of America
| | - Gilles Dussault
- Global Health and Tropical Medicine (GHTM) & WHO Collaborating Center on Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal
| | - Inês Fronteira
- Global Health and Tropical Medicine (GHTM) & WHO Collaborating Center on Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, 1349-008 Lisbon, Portugal
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Gozalo PL, Resnik LJ, Silver B. Benchmarking Outpatient Rehabilitation Clinics Using Functional Status Outcomes. Health Serv Res 2015; 51:768-89. [PMID: 26251040 DOI: 10.1111/1475-6773.12344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To utilize functional status (FS) outcomes to benchmark outpatient therapy clinics. DATA SOURCES Outpatient therapy data from clinics using Focus on Therapeutic Outcomes (FOTO) assessments. STUDY DESIGN Retrospective analysis of 538 clinics, involving 2,040 therapists and 90,392 patients admitted July 2006-June 2008. FS at discharge was modeled using hierarchical regression methods with patients nested within therapists within clinics. Separate models were estimated for all patients, for those with lumbar, and for those with shoulder impairments. All models risk-adjusted for intake FS, age, gender, onset, surgery count, functional comorbidity index, fear-avoidance level, and payer type. Inverse probability weighting adjusted for censoring. DATA COLLECTION METHODS Functional status was captured using computer adaptive testing at intake and at discharge. PRINCIPAL FINDINGS Clinic and therapist effects explained 11.6 percent of variation in FS. Clinics ranked in the lowest quartile had significantly different outcomes than those in the highest quartile (p < .01). Clinics ranked similarly in lumbar and shoulder impairments (correlation = 0.54), but some clinics ranked in the highest quintile for one condition and in the lowest for the other. CONCLUSIONS Benchmarking models based on validated FS measures clearly separated high-quality from low-quality clinics, and they could be used to inform value-based-payment policies.
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Affiliation(s)
- Pedro L Gozalo
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Linda J Resnik
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI.,Providence Veterans Administration Medical Center, Health Services Research, Providence, RI
| | - Benjamin Silver
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
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Halfon P, Eggli Y, Morel Y, Taffé P. The effect of patient, provider and financing regulations on the intensity of ambulatory physical therapy episodes: a multilevel analysis based on routinely available data. BMC Health Serv Res 2015; 15:52. [PMID: 25889368 PMCID: PMC4325958 DOI: 10.1186/s12913-015-0686-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many studies have found considerable variations in the resource intensity of physical therapy episodes. Although they have identified several patient- and provider-related factors, few studies have examined their relative explanatory power. We sought to quantify the contribution of patients and providers to these differences and examine how effective Swiss regulations are (nine-session ceiling per prescription and bonus for first treatments). METHODS Our sample consisted of 87,866 first physical therapy episodes performed by 3,365 physiotherapists based on referrals by 6,131 physicians. We modeled the number of visits per episode using a multilevel log linear regression with crossed random effects for physiotherapists and physicians and with fixed effects for cantons. The three-level explanatory variables were patient, physiotherapist and physician characteristics. RESULTS The median number of sessions was nine (interquartile range 6-13). Physical therapy use increased with age, women, higher health care costs, lower deductibles, surgery and specific conditions. Use rose with the share of nine-session episodes among physiotherapists or physicians, but fell with the share of new treatments. Geographical area had no influence. Most of the variance was explained at the patient level, but the available factors explained only 4% thereof. Physiotherapists and physicians explained only 6% and 5% respectively of the variance, although the available factors explained most of this variance. Regulations were the most powerful factors. CONCLUSION Against the backdrop of abundant physical therapy supply, Swiss financial regulations did not restrict utilization. Given that patient-related factors explained most of the variance, this group should be subject to closer scrutiny. Moreover, further research is needed on the determinants of patient demand.
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Affiliation(s)
- Patricia Halfon
- Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland.
| | - Yves Eggli
- Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland.
| | - Yves Morel
- Institute of Health Economics and Management, University Hospital Center and University of Lausanne, Route de Chavannes 31, 1015, Lausanne, Switzerland.
| | - Patrick Taffé
- Institute of Social and Preventive Medicine (IUMSP), University Hospital Center and Faculty of Biology and Medicine, Biopole 2, Route de la Corniche 10, 1010, Lausanne, Switzerland.
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Resnik L, Gozalo P, Hart DL. Weighted index explained more variance in physical function than an additively scored functional comorbidity scale. J Clin Epidemiol 2010; 64:320-30. [PMID: 20719472 DOI: 10.1016/j.jclinepi.2010.02.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 02/10/2010] [Accepted: 02/13/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE 1) examine association between the Functional Comorbidity Index (FCI) and discharge functional status (FS); 2) examine impact of FCI on FS when added to comprehensive models; and 3) compare additive FCI with weighted FCI and list of condition variables (list). STUDY DESIGN AND SETTING Patients were drawn from Focus On Therapeutic Outcomes, Inc. (FOTO) database (1/1/06-12/31/07). FS collected using computer adaptive tests. Linear regression examined association between FCI and FS. Three methods of including functional comorbidities (FC) were compared. RESULTS Relationship between FCI and FS varied by group (range, 0.02-0.9). Models with weighted index or list had similar R². Weighted FCI or list increased R² of crude models by <0.01 for cervical, shoulder, and lumbar; by 0.01 for wrist/hand, knee, and foot/ankle; by 0.02 for hip; by 0.03 for elbow; and by 0.08 for neurological. Addition of FCI to comprehensive models added <0.01 to R² (all groups). Weighted FCI increased R² by <0.01 for cervical, lumbar, and shoulder; by 0.01 for wrist/hand, hip, knee, and foot/ankle; by 0.02 for elbow; and by 0.04 for neurological; whereas list increased R² by <0.01 for cervical, shoulder, and lumbar; by 0.01 for knee and foot/ankle; by 0.02 for elbow, wrist/hand, and hip; and by 0.05 for neurological. CONCLUSION List of comorbidities or weighted FCI is preferable to using additive FCI.
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Affiliation(s)
- Linda Resnik
- Providence VA Medical Center, Department of Community Health, Box G-S121(6), Brown University, Providence, RI 02908, USA.
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Resnik L, Liu D, Mor V, Hart DL. Predictors of physical therapy clinic performance in the treatment of patients with low back pain syndromes. Phys Ther 2008; 88:989-1004. [PMID: 18689610 PMCID: PMC2527215 DOI: 10.2522/ptj.20070110] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Accepted: 06/09/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE Little is known about organizational and service delivery factors related to quality of care in physical therapy. This study sought to identify characteristics related to differences in practice outcomes and service utilization. SUBJECTS The sample comprised 114 outpatient clinics and 1,058 therapists who treated 16,281 patients with low back pain syndromes during the period 2000-2001. Clinics participated with the Focus on Therapeutic Outcomes, Inc (FOTO) database. METHODS Hierarchical linear models were used to risk adjust treatment outcomes and number of visits per treatment episode. Aggregated residual scores from these models were used to classify each clinic into 1 of 3 categories in each of 3 types of performance groups: (1) effectiveness, (2) utilization, and (3) overall performance (ie, composite measure of effectiveness and utilization). Relationships between clinic classification and the following independent variables were examined by multinomial logistic regression: years of therapist experience, number of physical therapists, ratio of physical therapists to physical therapist assistants, proportion of patients with low back pain syndromes, number of new patients per physical therapist per month, utilization of physical therapist assistants, and setting. RESULTS Clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified in the low utilization group compared with the high utilization group, and 12.4 times more likely to be classified in the best performance group compared with the worst performance group. Serving a higher proportion of patients with low back pain syndromes was associated with an increased likelihood of being classified in the lowest or middle group. Years of physical therapist experience was inversely associated with being classified in the middle utilization group compared with the highest utilization group. DISCUSSION AND CONCLUSION These findings suggest that, in the treatment of patients with low back pain syndromes, clinics that are low utilizers of physical therapist assistants are more likely to provide superior care (ie, better patient outcomes and lower service use).
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Affiliation(s)
- Linda Resnik
- Providence VA Medical Center, Department of Community Health, Brown University, 2 Stimson Ave, Providence, RI 02912, USA.
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Benchmarking physical therapy clinic performance: statistical methods to enhance internal validity when using observational data. Phys Ther 2008; 88:1078-87. [PMID: 18689608 PMCID: PMC2527217 DOI: 10.2522/ptj.20070327] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Many clinics and payers are beginning programs to collect and interpret outcomes related to quality of care and provider performance (ie, benchmarking). OUTCOMES assessment is commonly done using observational research designs, which makes it important for those involved in these endeavors to appreciate the underlying challenges and limitations of these designs. This perspective article discusses the advantages and limitations of using observational research to evaluate quality of care and provider performance in order to inform clinicians, researchers, administrators, and policy makers who want to use data to guide practice and policy or critically appraise observational studies and benchmarking efforts. Threats to internal validity, including potential confounding, patient selection bias, and missing data, are discussed along with statistical methods commonly used to address these limitations. An example is given from a recent study comparing physical therapy clinic performance in terms of patient outcomes and service utilization with and without the use of these methods. The authors demonstrate that crude differences in clinic outcomes and service utilization tend to be inflated compared with the differences that are statistically adjusted for selected threats to internal validity. The authors conclude that quality of care measurement and ranking procedures that do not use similar methods may produce findings that may be misleading.
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Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with foot or ankle impairments produced valid and responsive measures of function. Qual Life Res 2008; 17:1081-91. [PMID: 18709546 DOI: 10.1007/s11136-008-9381-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We tested the item response theory (IRT) model assumptions of the original item bank, and evaluated the practical and psychometric adequacy, of a computerized adaptive test (CAT) for patients with foot or ankle impairments seeking rehabilitation in outpatient therapy clinics. METHODS Data from 10,287 patients with foot or ankle impairments receiving outpatient physical therapy were analyzed. We first examined the unidimensionality, fit, and invariance IRT assumptions of the CAT item bank. Then we evaluated the efficiency of the CAT administration and construct validity and sensitivity of change of the foot/ankle CAT measure of lower-extremity functional status (FS). RESULTS Results supported unidimensionality, model fit, and invariance of item parameters and patient ability estimates. On average, the CAT used seven items to produce precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Patients who were older, had more chronic symptoms, had more surgeries, had more comorbidities, and did not exercise prior to receiving rehabilitation reported worse discharge FS. Seventy-one percent of patients obtained statistically significant change at follow-up. Change of 8 FS units (scale 0-100) represented minimal clinically important improvement. CONCLUSIONS We concluded that the foot/ankle item bank met IRT assumptions and that the CAT FS measure was precise, valid, and responsive, supporting its use in routine clinical application.
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Affiliation(s)
- Dennis L Hart
- Focus on Therapeutic Outcomes, Inc., 551 Yopps Cove Road, White Stone, VA, 22578-2403, USA.
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Matheson L, Mayer J, Mooney V, Sarkin A, Dreisinger T, Verna J, Leggett S. A method to provide a more efficient and reliable measure of self-report physical work capacity for patients with spinal pain. JOURNAL OF OCCUPATIONAL REHABILITATION 2008; 18:46-57. [PMID: 18027077 DOI: 10.1007/s10926-007-9111-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2007] [Accepted: 10/29/2007] [Indexed: 05/25/2023]
Abstract
Self-report measures of functional ability are commonly used in occupational rehabilitation to measure the current status of an individual and his or her progress in response to intervention. Most of these measures have been developed using classical test theory that does not provide calibration of the items. Methods of test development that originated in the field of Education have been applied recently to healthcare measures, providing item calibration and allowing proportional evaluation of total scores. The purpose of this article is to demonstrate the application of these methods in the revision of an existing self-report measure. The potential value of these methods to improve established measures is demonstrated.
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