An interesting article came out in the British popular press last week that states some chronic low-back pain can be cured by antibiotics. The writing is fairly clear that only certain cases would benefit from this approach and it includes links to the two scientific abstracts the article is based on: http://link.springer.com/article/10.1007%2Fs00586-013-2674-z and http://link.springer.com/article/10.1007%2Fs00586-013-2675-y.
Articles like this can help patients become better-educated consumers of healthcare... but do they? In the United Kingdom, use of prescribed medications is regulated by the National Institute of Clinical Excellence (NICE) and doctors can't prescribe drugs not approved for a specific purpose. There is little chance of patients pestering their GPs for antibiotics. Here in the US, however, pharmaceutical companies bank on stories like this so that patients will pester their doctors for drugs. The potential for multi-resistant bacteria proliferation just got a bit bigger.
I have some issues with promotions for health-related products. Just yesterday, I saw a commercial for a particular knee replacement that replicates "normal" motion of joint as a pure hinge with no slide-glide components at all. Whether this works better or not, I object to the use of "normal" when the motion is absolutely not normal. You may have seen it -- the company uses oval-shaped wheels on cars and bikes to make its point about "abnormal" joint motions. How many patients will demand this type of joint just because of the advertising?
So the popular press and advertising may raise knowledge levels and create better consumer choices. It could also muddy the waters, resulting in poorer outcomes, unhappy patients and higher costs for everyone.
I learned this expression while working in England. It was a way of getting to the core of something, often a product, to determine the original intent and whether it was accomplished. I wonder that about continuing education requirements. Florida has had them (12 hours/year) since I've been practicing (a long time) while New York has only recently adopted them (same 12 hours/year).
Why have these requirements that we go and study for half of one day a year? What is the original intent behind them? From my public health perspective, I see it as ensuring patients are cared for by professionals, with the latest knowledge. From my professional perspective, I see it as a way to stimulate thought and encourage continued professional development. From my cynical perspective, I see it as another bureaucratic encumbrance where course developers have a captive clientele from which to make money.
What do you think? Have the states accomplished something worthwhile or simply created a burden for professionals? After all, wouldn't any professional naturally stay on top of his game with continuing growth? Wouldn't the free market weed out anyone who wasn't keeping up?
Is this the best way to credit us with compliance? My ADVANCE colleague, Lisa Mueller, writes often about her journal club activities. Shouldn't this count toward her continuing development? What about colleagues involved in research, shouldn't that count as well? Most times it doesn't.
Does your state offer alternatives to attending in person or online courses? Do you think it's a justifiable way of demonstrating continuing growth? It is in the UK. The Chartered Society of Physiotherapists expects its members to spend three to six hours a month on development, including things like journal clubs and research. Those activities are documented and kept in a portfolio, which needs to be presented on demand.
What would you choose?
So I'm back in the US about six months now and I've got a massive amount of continuing education to do. Before anyone starts wagging fingers about "serves you right" or anything else that sounds like your mother scolding, I had to do lots of CPD (continuous professional development) in the UK... none of it counts here. The UK accepts everything I've done here but New York doesn't even accept the poster presentation I did at the Chartered Society of Physiotherapy conference in Liverpool last year. They do give credit for presentations done in the US though.
I'm busy doing a bunch of online courses, some good, some lame. The descriptions rarely indicate which category they will fall into. New York has only a time requirement, but I'm also licensed in Florida, which requires 12 hours of in-person education. I'm off to a course in Fort Lauderdale in a few weeks on shoulder rehab. I purposely chose a course in an area that I haven't delved into for a while. I like to try to stay as well rounded as possible, even if I may not use the information on a day-to-day basis.
By the end of May, I'll have 36 hours under my belt. Some will have actually have been valuable. I'm glad that required CEU is now the norm. For way too long, PTs could go for decades without so much as reading an article. It's a step in the right direction. Now I propose investigating a different approach, like the one in the UK. I'll go into that next week.
Public health is a challenging field. It's an area focused on prevention so therefore not reimbursable by most third-party payers. It's primarily spearheaded by government bodies; therefore it is often not trusted or presented as too "nanny state" and interfering. The outcomes are that nothing bad happens; therefore it's difficult to demonstrate success or necessity.
It's not supported in the Constitution beyond "provide for the general welfare of the public" -- therefore it is subject to wide interpretation. It's such a varied field ranging from prevention of epidemics and response to natural disasters to ensuring zebra mussels don't wipe out the fish of the Great Lakes or that drug and food suppliers don't wipe out their customers. It's focused on groups rather than individuals so the WIIFM (What's in it for me?) factor is tough for people to appreciate. No wonder my colleagues think it's an unusual choice for a PT.
It is also small wonder that so many initiatives get shot down. For example, there has been much discussion on this blog site about flu shots. There is scientific evidence that they are safe and effective and the benefits outweigh the risks. Yet many refuse to accept the vaccination. My ADVANCE colleague, Janey Goude, posted last week very compelling reasons to question scientific evidence, particularly in regard to medications and research. In the face of such findings, it will only grow harder to convince people to trust pharmaceutical companies and their products. It's through the greed of corporations that the public well-being suffers.
However, without public health initiatives it would be much harder to find clean water for drinking, restaurants with clean kitchens, safe ways to dispose of medical sharps, safer cars to ride in, higher rates of live births and maternal health, and higher rates of life expectancy. They are simply, the right things to do for society as a whole, a way to look out for one another. As I drove to Philadelphia last weekend and was nearly wiped out by a texting driver, I was grateful for both my mandated seatbelt and the laws that hopefully will impact the distracted driver before he impacts someone else.
Finding the right balance between nanny state and public protection is no easy task. I'll keep trying though.
Last week I got to experience being a consumer in the US health system again. What fun!... not. I have a relative who was an emergent inpatient in a hospital in the southern part of the country. I traveled down to assist my relative at home and be present for the discharge.
It's easy to see how discharges are one of the most risky parts of the healthcare journey for a patient. In this particular state, where I'm licensed as well, all professionals are required to take a course every two years on "Prevention of Medical Errors," which focuses on errors during transitions. I don't think the discharge nurse had heard of this requirement.
The discharge instructions were mistyped, had misspellings and the primary doctor's name was incorrect. When I asked the nurse to go over the medications for discharge, she snarled at me, "Anything else I can go over for you?" My relative stopped her and informed her that she wanted me present and to ask any questions I felt relevant.
She then read the paper verbatim with no understanding of what she was reading (couldn't pronounce the medications) and no concern that we understood what she read. A pleasant volunteer then helped us to the billing department where my relative handed over a credit card to cover the 20 percent not covered by Medicare. We were then taken to the curb.
I reflected on how this experience stacked up against the experience a friend of mine had in the NHS (no private insurance) after a CVA. The rooms were better decorated in the US, but no cleaner. The rooms were private, but the equipment was the same. The staffing was lean in both locations. The specialists were remarkable in both locations. The real difference was needing to hand over a credit card at the conclusion in the US versus just walking out the door in the UK. What exactly is it that we're paying so much for? Prettier wallpaper? The luxury of a single room? (All rooms in this hospital are single rooms). Or is it the profit of the hospital systems?
Once again, I hear people say how much better our system is than the socialized medicine of the UK... I just don't see it.
New York state has made remarkable changes to the way it's administering Medicaid. The Medicaid Redesign Team has enacted changes that will completely alter the current practices and expectations of both providers and patients.
As of May 1, all long-term home health programs will cease to exist and patients must enroll in a managed long-term care (MLTC) plan. As of July 1, all participating providers must use the Universal Assessment System (UAS) for assessing their members. Starting next year, all dual-eligibles (Medicare and Medicaid) must enroll in a combination Medicare/Medicaid Advantage plan under Fully Integrated Dual Access (FIDA). That means most people who just enrolled in an MLTC will have to switch plans in a year. All providers will work on a per-member/per-month risk-adjusted reimbursement. They will bear the full brunt of the risk of caring for the most vulnerable in the state's population.
This means I have 18,000 patients and thousands of clinicians who need to be trained on these changes, which are immense in their breadth. Furthermore, the rules and guidelines evolve hourly (daily is a luxury).
In the end, I believe the state will benefit from better care and resource management, the patients will benefit from better coordinated care, and taxpayers will benefit from reduced burden of disease and the costs associated with it.
Its getting there that's the tough part.
I know I promised a post about experience in the US health system as a consumer, but that will be next week. I still need to think it through.
Last week my ADVANCE colleague, Janey Goude, wrote a piece about the Medicare plan to charge penalties to hospitals with excessive readmission rates. I had to reluctantly agree with her assessment... the plan isn't working the way it should.
This is one of the problems of public health. The field tries to ensure that the population is protected from harm in many ways, including from hospitals and other health providers. It's one of the reasons we're required to be licensed as professionals. Sometimes those actions have unintended repercussions. The New York Times has an article detailing how this can happen.
Janey pointed out how some institutions have figured out loopholes to work around the readmission, e.g. holding someone for "observation" is not considered a readmission. What about hospitals that serve poorer areas with populations that are sicker? There are hospitals on the Upper East Side of Manhattan that cater to a more educated population with better access to primary care than hospitals in the South Bronx, which is a poorer area with residents less likely to have regular primary care. It's likely that the facilities in the South Bronx will have a higher re-hospitalization rate than the Upper East Side. Why should those facilities treating the poor be penalized for reaching out to these communities? They shouldn't.
The article also points out that hospitals with higher mortality rates may actually receive better marks and fewer penalties. It's tough to readmit someone who is dead.
So we have a rule that was designed to curb abuse of the Medicare system (a noble thing), which the clever have designed a way to work around. The hospitals treating those most ill may be penalized for doing the work they do under the rule. Do I think the rule should be thrown away? No, I saw firsthand the abuse one institution did with unnecessary readmissions. I do think it needs to go back to the shop for an overhaul though.
Janey make note... I freely admit that you are right!
I read this article on NPR (National Public Radio) about how people of a certain age, which includes me, are less fit than their counterparts of two decades ago. How can this be? With all the advances in knowledge and availability of information, how can this group of people have missed the boat?
Actually, we haven't missed the boat on everything; incidence rates of COPD and lung cancer are less. Unfortunately, hypertension and diabetes have gone up! Why? We are less physically active than we were two decades ago. We sit in our cars, socialize via computer and are expected to email from our desks rather than walk down the hall to discuss something with a colleague.
Employers think that walking to actually talk to someone wastes time and therefore money. If their employees are getting rounder as a result with increased utilization of healthcare services and time off due to health issues, have they really saved anything in the long run?
I have a relative who circles the parking lot looking for a spot closest to the shop door. Some people have to do so for health reasons and rightfully have blue badges to park in designated spots. Sometimes it's pouring down rain and walking from the far end of the car park is really not fun. What about all those other days? What about parking the car at the furthest part of the lot and adding a few extra steps?
I work on the third floor of a large office tower. I use the stairs at least five times a day rather than the elevator. It isn't exactly a substitute for the gym, but it's something that helps maintain leg strength and some cardiac conditioning.
Modern conveniences can be a treat, but like ice cream, should be enjoyed in moderation. How can you encourage your patients to increase their activity in small, but perhaps meaningful ways? Imagine the impact on quality of life and health costs if everyone were as active as two decades ago.
In response to my blog from last week, one Facebook reader suggested that laws such as Mayor Bloomberg's ban on super-sized drinks started a slide down a slippery slope into a nanny state. Simultaneously fellow ADVANCE blogger, Toni Patt, DPT, reflected on the priorities patients choose when in rehab facilities. Both seem to focus on the idea of personal responsibility and/or accountability. This made me recall a lesson from my "Public Health Law and Ethics" course.
The question presented to us was whether or not motorcycle helmet laws should exist. My initial response was, "If people wanted to risk splattering their brains all over I-95, that was their choice, so long as they don't hurt anyone else." That last phrase was the key to my undoing. The professor rightly pointed out that I assumed said rider would die in the accident, but what if he didn't? What if he lived? What if in addition to multiple fractures, he suffered a TBI? What would that cost? Who would pay?
If the person had private insurance, that might cover for a while. What if he had no insurance? What if he was out of work for sufficient time to lose coverage? What about the cost of rehab, home care, adaptive devices and environmental adaptations required? What if this person never left a nursing home? The impact on those of us paying insurance premiums and taxes toward Medicaid would be significant as we pay this rider's bills.
Now multiply this incident times many more people. Now would you say it was in the public's best interest to have helmet laws? Should we just leave the rider in the middle of the high-occupancy vehicle lane to die like road kill because riding without a helmet was his choice? How should we penalize the family of this person who may or may not have advocated his riding without a helmet? This person's desire to feel the wind in his hair while riding actually hurts a lot of other people.
This is one reason why I believe PTs should play a role in the development of public health guidelines. Fellow blogger Dr. Patt works with brain-injured individuals. Who could be better to describe the potential impact of a TBI to lawmakers? Who could be better to voice opinions about whether legal influence or perhaps other public health measures could have an impact on this problem?
The decision to limit personal freedoms should never be "capricious and arbitrary" as Mayor Bloomberg's was. If it turns out to be necessary, it should only be when absolutely nothing else will work and all other options have been exhausted. PTs should be part of these discussions.
By now, many people have heard about New York City Mayor Michael Bloomberg's attempt to combat obesity by limiting the size of soft drinks containing sugar. There has been both an aggressive ad campaign and a new ban on beverages over 16 ounces. He has quite a few professional voices backing these decisions. Today, though, a state Supreme Court judge overturned this new law, saying the mayor reached beyond his authority in an "arbitrary and capricious" way.
Obesity is a growing problem in developed western nations. It also has huge potential financial implications on healthcare as the incidence of diabetes skyrockets. This is not to mention the probable growth of osteoarthritis and cardiac disease from being overweight. People will argue that it's their choice and their right to get fat from soda should they choose to. Well, that impacts Medicare and Medicaid utilization, as well as rising premiums for private insurance. Do people really have the right to increase others' costs for their own selfish behavior?
Wellness and prevention of arthritis, cardiac disease and diabetes can certainly fall under the scope of physical therapy patient education. What should the professional role be in this situation? Do you educate overweight patients, regardless of presentation, on the risks of being overweight or the options available in food choices?
This public health issue isn't going away anytime soon. Should government take steps like those Mr. Bloomberg has attempted to protect the entire public from those who make poor choices, or do we allow a level of personal freedom that could eventually impact all of our health costs?
What about the impact on the factory workers, distributors, shop keepers, advertising agencies and bottlers if these bans go into place? Will this action to protect the population actually hurt the economy and localities that depend on producing soda to make a living?
Nanny state or anarchy, we seem to be the ones paying in the end.
For most of my professional life, except when I worked in the NHS in England, either I was paid on a fee-for-service basis or the employer I worked for was reimbursed that way. Essentially, "make a visit, get paid" was the way it worked. That's a very expensive way to do things and one that promotes a practice of visiting more rather than figuring out how to achieve outcomes with fewer visits.
PTs aren't the only ones who get paid this way. This week, doctors are being shoved into the spotlight with a bunch of media attention from Time magazine, to Politico website and even New York state is advocating an end to this practice of reimbursement as evidenced in this report from Robert Wood Johnson Foundation.
If this is gaining so much momentum in the MD arena, I'd be willing to bet that it will affect how we are reimbursed as well. Are we as a profession ready for that? I know that in homecare this will take an attitude shift to accomplish. What about private practices? Will this make the therapy cap seem like the "good old days?"
Last week my colleague ADVANCE blogger, Janey Goude, advocated for advancing health maintenance and prevention rather than sick care. I've gone into the arena of public health with the same idea. Is the profession ready to move from mainly rehabilitative tertiary prevention to preventive primary prevention? We have an opportunity to be leaders in the health revolution. Let's not waste it.
A piece of research came out in the British Medical Journal at the end of last month regarding tele-physio. I've been a vocal critic of this practice "development" in this blog and to anyone who will listen. This is an important piece of research. If American PTs are inclined to brush it off as some silly NHS protocol, they'd be wise to contemplate whether or not managed care companies might pay close attention to it!
This is not a bad piece of research, but there are some areas that I think need addressing. The investigators used a large number of participants, but not ethnically diverse with more than 95 percent being Caucasian. The patients allocated to tele-physio were "invited" to call back after the initial telephonic consultation. No mention is made of how many failed to call back. Is it being assumed that they were fully managed with the one call?
The group allocated to tele-physio had 53 percent progress to some face-to-face intervention, with 43 percent being managed by telephone only. These two subgroups are lumped together in the analysis, when in truth, they are deserving of separate analysis! I would really like to see how these two subgroups compared to each other in addition to how the combination compared to "usual treatment."
There are also issues with the timeframe of measurements. If the initial follow-up was at six weeks post-referral, but some people still hadn't seen a physio at that point, then how can one measure impact? Yes, there's a problem with access to physio in the UK, but I don't believe this study truly supports tele-physio as a solution.
I do credit the investigators with a robust discussion on the strengths and limitations of the study. I can see a benefit to a telephonic triage prior to face-to-face interventions that could shorten wait times and initiate action sooner than is current practice. I can see this approach benefiting more rural settings where access is limited. I can't yet see the evidence for this becoming mainstream practice.
Lastly, having seen this practice in action in England, I take issue with practical applications. The study used senior physios to perform telephonic interventions. In practice I have seen Band 5, new graduates in the role who lack sufficient experience to ensure patient safety. I also question their investigation into adverse events (none?). I personally know of three people who performed a home exercise program that was mailed to them after telephonic consultation. All three performed their exercises incorrectly and two wound up aggravating their presenting conditions.
What are your reactions?
As many readers of this blog know, I'm fairly passionate about fall prevention and have been trying to incorporate my work in that arena into my public health work. The potential impact on our aging population, and cost the rest of us will bear as a result, is significant and deserves attention.
I was at a seminar last week about this very topic and the question of Vitamin D supplementation arose. The geriatric MD specialist was a brilliant speaker and among other things, she advocated supplementation for all people 65 and older. I raised my hand to question this, since the November 2012 Cochrane Review actually states vitamin D supplementation isn't recommended for fall prevention unless individuals are deficient to begin with.
My epidemiologic training kicked in and I inquired what the prevalence of Vitamin D deficiency actually was? The MD responded, "high" and another participant said it was 75 percent. I did some research on my own and found that in the US, overall prevalence is 42 percent in older adults with a prevalence of up to 82 percent in black subgroups! (Forrest, 2011). So it appears that actually vitamin D would benefit the older population.
The Office of Dietary Supplements (2013) provides a good overview of the implications of vitamin D deficiency and benefits of sufficiency and the risks of excessive intake. Deficits can bring about muscle weakness and osteoporosis, both of which are risk factors for falls. However, Cochrane and the UK's National Institute for Clinical Excellence (NICE) both insist that, "Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95 percent CI 0.90 to 1.11; 7 trials; 9324 participants) or risk of falling (RR 0.96, 95 percent CI 0.89 to 1.03; 13 trials; 26,747 participants)."
So the science says we should be supplementing older adults, but the evidence says no. I know what I'll be advocating. What would you do? What message should we send as a profession?
Forrest, K.Y., & Stuhldreher, W.L. 2011. Prevalence and correlates of vitamin D deficiency in US adults, Nutr Res. 2011 Jan; 31(1):48-54. DOI: 10.1016/j.nutres.2010.12.001. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21310306
Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M., & Lamb, S.E. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract;jsessionid=0B9BC6AB67C76CE012EB926BF231A165.d02t03?systemMessage=Wiley+Online+Library+will+be+disrupted+on+23+February+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essential+maintenance
NICE. (2011). Fall Prevention; Clinical Guideline 21. Department of Health. Retrieved from http://publications.nice.org.uk/falls-cg21/guidance#interventions-that-cannot-be-recommended-because-of-insufficient-evidence
Office of Dietary Supplements. (2011). Dietary Supplemental Fact Sheet, Vitamin D, National Institute of Health. Retrieved from http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
Who is Gretchen Reynolds, you may ask?
She's a columnist for The New York Times, and journalist for other publications as well, who writes about exercise and fitness.
She brings reports about studies on exercise, fitness and aging to the general public in a simple, easy-to-understand manner. She's not a physical therapist. The comments from readers after her columns are sometimes as interesting as the article itself. This week's comments come from a number of doctors.
Why should you care?
This is writing that could and should be done by a physical therapist. Is it any wonder that the public (and doctors!) don't associate physical therapy with many things we should be addressing, such as exercise and arthritis or weight loss? As a profession, we complain that other practitioners are pushing into "our" territory and infringing on what we do.
Small wonder that! How many times have we heard or told someone to not use "medical jargon?" We're so impressed with our body of knowledge that we use big words, words that have no meaning to the average consumer (yes, it's a business). But trainers speak the language people want to hear and are able to understand. They're accessible on paper, online and at most gyms.
What should we do?
Get out there! Approach your local paper about writing a column. Write a book. Give a seminar (to the public, not each other). Learn how to engage the public. Congratulations, most physical therapists have DPTs now. It's tragic that trainers may drive you into bankruptcy.
It has been just over three years since "Treat Me, but No Tricks Please" appeared in The New York Times. In this scathing piece about inconsistency in physical therapy, Gina Kolata roiled emotions and got a lot of people thinking about whether what we do actually works or not. It was of little help that the president of the orthopedic section of the APTA, James J. Irrgang, PhD, PT, ATC, repeatedly referred to the "voodoo" that physical therapists do for treatment, giving a sense of validity to her article.
Since then, we have graduated more DPT professionals, research has been done and many more patients have benefitted from the interventions applied by our colleagues. But what does the public know of it? Every October we don t-shirts and decorate our departments for Physical Therapy Month. We pat ourselves on the back in self-congratulations of the good work we do. But the only people who will see the message are those who already know it.
Go on to Amazon, Barnes & Noble, or any other online or marketplace bookseller and you'll find reams written by medical doctors, nurses, fitness trainers and dieticians, but how many by physical therapists? I did a search for journalists who are physical therapists. I came up with zero results.
We need to engage the public proactively, not wait for the Gina Kolatas of the world to write rubbish so we can respond with impotence. Why do people choose trainers or chiropractors first? Poor journalism and our own lethargy in engagement keep us in question, that's one reason why.