Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions? Jennifer Kreppein and Thomas D. Stewart PHYS THER. 2014; 94:1680-1682. doi: 10.2522/ptj.2014.94.11.1680.2
The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/94/11/1680.2 Collections
This article, along with others on similar topics, appears in the following collection(s): Clinical Decision Making Coordination, Communication, and Documentation Health and Wellness/Prevention Professional Issues Professional-Patient Relations
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Letters to the Editor 30 Baldry P. Management of myofascial trigger point pain. Acupunct Med. 2002;20:2–10. 31 Cagnie B, Dewitte V, Barbe T, et al. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013;17:348. 32 Roxas M. Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev. 2005;10:83–93. 33 Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172–175. 34 Wearing SC, Smeathers JE, Urry SR, et al. The pathomechanics of plantar fasciitis. Sports Med. 2006;36:585–611. 35 Ebrahim A, Ahmed G, Elsayed E, Sarhan R. Effect of electroacupuncture TENS, stretching exercises, and prefabricated insole in patients with plantar fasciits. The Scientific Journal of Al-Azhar Medical University. 2007;28:1–10. 36 Copay AG, Subach BR, Glassman SD, et al. Understanding the minimum clinically important difference: a review of concepts and methods. Spine J. 2007;7:541– 546. 37 Beaton DE, Bombardier C, Katz JN, et al. Looking for important change/differences in studies of responsiveness. OMERACT MCID Working Group. Outcome Measures in Rheumatology. Minimal Clinically Important Difference. J Rheumatol. 2001;28:400–405. 38 Beaton DE. Understanding the relevance of measured change through studies of responsiveness. Spine (Phila Pa 1976). 2000;25:3192–3199. [DOI: 10.2522/ptj.2014.94.11.1677]
Author Response
dling intervention outlined in our study. Just because a reliable and clinically usable method of trigger point examination is not yet available does not in any way indicate that current methods should not be evaluated for their effectiveness in robust randomized trials. Second, the optimal dose of trigger point dry needling for plantar heel pain is unknown. This is a conundrum of many musculoskeletal interventions at present and is not isolated to dry needling. With this in mind, we developed a pragmatic, consensus-driven dry needling treatment, using a recognized research method, which was supported by experts worldwide.3 We believe that the protocol we developed was an advance on what had been used previously. We again thank Dunning and colleagues for their comments. We hope that clinicians take note of our findings in light of the limitations we outlined and that other researchers use our trial to inform future trials on this intriguing intervention.
Thank you to Dunning and colleagues for their letter to the editor1 on our study.2 The comments primarily focused on the reliability of trigger point examination and the optimal dose of dry needling for plantar heel pain. We thank the authors for their comments and provide a broad response below.
Matthew P. Cotchett, Shannon E. Munteanu, Karl B. Landorf
First, and importantly, we clearly outlined that one of the limitations of our trial was that there was a lack of evidence for the reliability of trigger point examination. Although we accept this as a limitation, clinicians still use the method outlined in our work, and as such, our pragmatically designed trial is a worthwhile addition to the evidence relating to the dry nee-
S.E. Munteanu, PhD, Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University.
M.P. Cotchett, BPod, Department of Allied Health, La Trobe Rural Health School, La Trobe University, PO 199 Bendigo, Victoria, Australia 3552, and Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University, Bundoora, Melbourne, Victoria, Australia. Address all correspondence to Mr Cotchett at: m.cotchett@ latrobe.edu.au.
K.B. Landorf, PhD, Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University. This letter was posted as a Rapid Response on September 26, 2014. at ptjournal.apta.org.
References 1 Dunning J, Butts R, Perreault T. Letter to the editor on “Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial.” Phys Ther. 2014;94:1677–1680. 2 Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. 2014;94:1083– 1094. 3 Cotchett MP, Landorf KB, Munteanu SE, Raspovic AM. Consensus for dry needling for plantar heel pain (plantar fasciitis): a modified Delphi study. Acupunct Med. 2011;29:193–202. [DOI: 10.2522/ptj.2014.94.11.1680.1]
Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions? The voice of physical therapy is absent in the assessment of hospital Medicare readmission risk. Physical therapy functional assessments are involved in decisions to discharge to home or to inpatient rehabilitation, but physical therapy findings are missing for gauging readmission risk. Thirty-day readmissions are a vital factor in hospital reimbursement.1 Does omitting physical therapy information make a difference? What does physical therapy information offer to readmission risk assessment? Physical therapy provides a unique information-bearing relationship in the hospital setting.2 It involves hands-on, personal treatment often delivered by the same individual or team, which is an increasingly rare component in fragmented, technology-driven health care delivery. This often daily, personal care provides an anchoring bond in the setting of rapid, frequently remote, medical care. Physical therapy can offer a healing relationship in the context of acute loss as patients seek to restore function and self-esteem.
1680 ■ Physical Therapy Volume 94 Number 11 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
November 2014
Letters to the Editor Because this treatment involves the same small team of physical therapists, some patients will share their personal concerns regarding their efforts to adjust to their losses and related uncertainty. This shared information and insight gained by the physical therapy team could inform treatment planning and readmission risk. Who knows their risks better than the patients themselves? This understanding is not big data, but it is personal and actionable information. We reviewed the 2012–2014 medical literature using the search terms “physical therapy” and “patient readmission” both separately and together. We then searched the discovered articles for the descriptor “physical therapy” or “physical therapist.” These terms did not appear, except in one article written by a team of physical therapists in Toronto whose focus was discharge readiness, not readmission risk.3 To understand current tools used to monitor readmission risk, it is helpful to consider the Rothman index, a widely used quantitative measure of medical acuity.4 It involves 26 risk variables, such as temperature, pulse oximetry, and pulse rate, plus a 12-point nursing assessment. The Rothman index has predictive validity for readmission risk as well as transfer to a higher level of care.5 There is, however, no mention of physical therapy findings among these variables. The American College of Surgeons conducted a study to assess readmission risk after lower extremity bypass procedures.6 Again, there was no mention of physical therapy information in this study. A Cochrane Review published in 2013 reviewed the effectiveness of routine discharge planning versus individualized discharge plans as
November 2014
reflected in outcomes, including reduced readmissions.7 Twenty-four randomized studies were analyzed. Individualized plans provided superior results. Physical therapy findings were never mentioned in this review. What is missing when physical therapist input is left out? Of paramount importance is the insight into the patients’ experience shared with physical therapists that could inform discharge planning and readmission risk. To capture that information, a narrative from the physical therapy team might be useful. This narrative would focus on the patients’ perceptions of the dangers they face. Some of their concerns might be predictable, such as fear of falling or impending death. Others—such as despair, apprehension about an abusive relationship, or something as ordinary as tripping on the family pet— might be amenable to intervention, thus reducing readmission risk. Quantitative scores from screening tests cannot capture the patients’ experience as narratives can. In addition, physical therapy narratives could reveal patients’ views of what has meaning for their lives. These sources of meaning, such as family relationships, serve as a guide to what might motivate patients to maximize recovery and minimize readmission risk, whereas the fears could identify obstacles to optimal recovery. Physical therapists also could provide relevant information such as mobility and balance observations. Mobility is a potent predictor of readmission risk.8 This knowledge could aid discharge planning and related readmission risk reduction. There is heuristic value in studying how physical therapy information might be useful for reducing 30day readmissions. For example,
closely examining who gets physical therapy and who does not with given diagnoses might shed light regarding the impact of physical therapy actions and information on 30-day readmission. For purposes of systematic data collection, the physical therapy narrative might feature pull-down lists of structured texts to describe patient motivations and concerns. If so, what would the structured texts contain? Which components of those texts might be correlated with 30-day readmission risk? In addition, how might mobility and balance predict early readmission? The relevance of physical therapy information and involvement is not restricted to discharge. For example, socioeconomic status, diagnosis, and caregiver support influence early readmission risk and can be identified at admission. Might these factors point to early physical therapist involvement in these cases? If so, which aspects of physical therapy might be the most beneficial? The physical therapist perspective regarding patients can augment the Rothman index and similar quantitative tools designed to measure readmission risk. Not all patients receive physical therapy during their hospital admissions. Patients with cardiovascular disease, especially those with congestive heart failure and those who have undergone surgery for orthopedic conditions, do routinely receive physical therapy. They constitute groups known to have high readmission risk. There are quantitative tools to measure and mitigate readmission risk. The voice of physical therapy is missing in this process. Does this omission matter? We think it does. Physical therapy does contribute to patient education and discharge
Volume 94 Number 11 Physical Therapy ■ 1681 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
Letters to the Editor planning and can contribute to reducing readmission risk through narrative plus quantitative data such as mobility and balance. Jennifer Kreppein, Thomas D. Stewart J. Kreppein, PT, Physical Therapy, Stony Brook Medical Center, Stony Brook, New York. T.D. Stewart, MD, Psychiatry, Yale School of Medicine, 25 Kingsbridge Way, Madison, CT 06443 (USA). Address all correspondence to Dr Stewart at: [email protected].
References 1 Berenson RA, Paulus RA, Kalman NS. Medicare’s readmissions-reduction program: a positive alternative. N Engl J Med. 2012;366:1364–1366. 2 Stewart TD. Psychotherapy and physical therapy: common ground. Phys Ther. 1977;57:279–283. 3 Matmari L, Uyeno J, Heck CS. Physiotherapists’ perceptions of and experiences with the discharge planning process in acutecare general internal medicine units in Ontario. Physiother Can. 2014:66:254–263. 4 Rothman, MJ, Rothman SI, Beals J 4th. Development and validation of a continuous measure of patient condition using the electronic medical record. J Biomed Inform. 2013;46:837–848.
5 Bradley EH, Yakusheva O, Horwitz LI, et al. Identifying patients at increased risk for unplanned readmission. Med Care. 2013;51:761–766. 6 Zhang JQ, Curran T, McCallum JC, et al. Risk factors for readmission after lower extremity bypass in the American College of Surgeons national surgery quality improvement program. J Vasc Surg. 2014;59:1331–1339. 7 Shepperd S, Lannin NA, Clemson LM, et al. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013:1:CD000313. 8 Fisher SR, Kuo YF, Sharma G, et al. Mobility after discharge as a marker for 30-day readmission. J Gerontol A Biol Sci Med Sci. 2013;68:805–810. [DOI: 10.2522/ptj.2014.94.11.1680.2]
1682 ■ Physical Therapy Volume 94 Number 11 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
November 2014
Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions? Jennifer Kreppein and Thomas D. Stewart PHYS THER. 2014; 94:1680-1682. doi: 10.2522/ptj.2014.94.11.1680.2
References
This article cites 8 articles, 1 of which you can access for free at: http://ptjournal.apta.org/content/94/11/1680.2#BIBL
Subscription Information
http://ptjournal.apta.org/subscriptions/
Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml Information for Authors
http://ptjournal.apta.org/site/misc/ifora.xhtml
Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/94/11/1680.2 Collections
This article, along with others on similar topics, appears in the following collection(s): Clinical Decision Making Coordination, Communication, and Documentation Health and Wellness/Prevention Professional Issues Professional-Patient Relations
e-Letters
To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article.
E-mail alerts
Sign up here to receive free e-mail alerts
Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
Letters to the Editor 30 Baldry P. Management of myofascial trigger point pain. Acupunct Med. 2002;20:2–10. 31 Cagnie B, Dewitte V, Barbe T, et al. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013;17:348. 32 Roxas M. Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev. 2005;10:83–93. 33 Singh D, Angel J, Bentley G, Trevino SG. Fortnightly review: plantar fasciitis. BMJ. 1997;315:172–175. 34 Wearing SC, Smeathers JE, Urry SR, et al. The pathomechanics of plantar fasciitis. Sports Med. 2006;36:585–611. 35 Ebrahim A, Ahmed G, Elsayed E, Sarhan R. Effect of electroacupuncture TENS, stretching exercises, and prefabricated insole in patients with plantar fasciits. The Scientific Journal of Al-Azhar Medical University. 2007;28:1–10. 36 Copay AG, Subach BR, Glassman SD, et al. Understanding the minimum clinically important difference: a review of concepts and methods. Spine J. 2007;7:541– 546. 37 Beaton DE, Bombardier C, Katz JN, et al. Looking for important change/differences in studies of responsiveness. OMERACT MCID Working Group. Outcome Measures in Rheumatology. Minimal Clinically Important Difference. J Rheumatol. 2001;28:400–405. 38 Beaton DE. Understanding the relevance of measured change through studies of responsiveness. Spine (Phila Pa 1976). 2000;25:3192–3199. [DOI: 10.2522/ptj.2014.94.11.1677]
Author Response
dling intervention outlined in our study. Just because a reliable and clinically usable method of trigger point examination is not yet available does not in any way indicate that current methods should not be evaluated for their effectiveness in robust randomized trials. Second, the optimal dose of trigger point dry needling for plantar heel pain is unknown. This is a conundrum of many musculoskeletal interventions at present and is not isolated to dry needling. With this in mind, we developed a pragmatic, consensus-driven dry needling treatment, using a recognized research method, which was supported by experts worldwide.3 We believe that the protocol we developed was an advance on what had been used previously. We again thank Dunning and colleagues for their comments. We hope that clinicians take note of our findings in light of the limitations we outlined and that other researchers use our trial to inform future trials on this intriguing intervention.
Thank you to Dunning and colleagues for their letter to the editor1 on our study.2 The comments primarily focused on the reliability of trigger point examination and the optimal dose of dry needling for plantar heel pain. We thank the authors for their comments and provide a broad response below.
Matthew P. Cotchett, Shannon E. Munteanu, Karl B. Landorf
First, and importantly, we clearly outlined that one of the limitations of our trial was that there was a lack of evidence for the reliability of trigger point examination. Although we accept this as a limitation, clinicians still use the method outlined in our work, and as such, our pragmatically designed trial is a worthwhile addition to the evidence relating to the dry nee-
S.E. Munteanu, PhD, Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University.
M.P. Cotchett, BPod, Department of Allied Health, La Trobe Rural Health School, La Trobe University, PO 199 Bendigo, Victoria, Australia 3552, and Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University, Bundoora, Melbourne, Victoria, Australia. Address all correspondence to Mr Cotchett at: m.cotchett@ latrobe.edu.au.
K.B. Landorf, PhD, Department of Podiatry and Lower Extremity and Gait Studies Program, La Trobe University. This letter was posted as a Rapid Response on September 26, 2014. at ptjournal.apta.org.
References 1 Dunning J, Butts R, Perreault T. Letter to the editor on “Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial.” Phys Ther. 2014;94:1677–1680. 2 Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. 2014;94:1083– 1094. 3 Cotchett MP, Landorf KB, Munteanu SE, Raspovic AM. Consensus for dry needling for plantar heel pain (plantar fasciitis): a modified Delphi study. Acupunct Med. 2011;29:193–202. [DOI: 10.2522/ptj.2014.94.11.1680.1]
Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions? The voice of physical therapy is absent in the assessment of hospital Medicare readmission risk. Physical therapy functional assessments are involved in decisions to discharge to home or to inpatient rehabilitation, but physical therapy findings are missing for gauging readmission risk. Thirty-day readmissions are a vital factor in hospital reimbursement.1 Does omitting physical therapy information make a difference? What does physical therapy information offer to readmission risk assessment? Physical therapy provides a unique information-bearing relationship in the hospital setting.2 It involves hands-on, personal treatment often delivered by the same individual or team, which is an increasingly rare component in fragmented, technology-driven health care delivery. This often daily, personal care provides an anchoring bond in the setting of rapid, frequently remote, medical care. Physical therapy can offer a healing relationship in the context of acute loss as patients seek to restore function and self-esteem.
1680 ■ Physical Therapy Volume 94 Number 11 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
November 2014
Letters to the Editor Because this treatment involves the same small team of physical therapists, some patients will share their personal concerns regarding their efforts to adjust to their losses and related uncertainty. This shared information and insight gained by the physical therapy team could inform treatment planning and readmission risk. Who knows their risks better than the patients themselves? This understanding is not big data, but it is personal and actionable information. We reviewed the 2012–2014 medical literature using the search terms “physical therapy” and “patient readmission” both separately and together. We then searched the discovered articles for the descriptor “physical therapy” or “physical therapist.” These terms did not appear, except in one article written by a team of physical therapists in Toronto whose focus was discharge readiness, not readmission risk.3 To understand current tools used to monitor readmission risk, it is helpful to consider the Rothman index, a widely used quantitative measure of medical acuity.4 It involves 26 risk variables, such as temperature, pulse oximetry, and pulse rate, plus a 12-point nursing assessment. The Rothman index has predictive validity for readmission risk as well as transfer to a higher level of care.5 There is, however, no mention of physical therapy findings among these variables. The American College of Surgeons conducted a study to assess readmission risk after lower extremity bypass procedures.6 Again, there was no mention of physical therapy information in this study. A Cochrane Review published in 2013 reviewed the effectiveness of routine discharge planning versus individualized discharge plans as
November 2014
reflected in outcomes, including reduced readmissions.7 Twenty-four randomized studies were analyzed. Individualized plans provided superior results. Physical therapy findings were never mentioned in this review. What is missing when physical therapist input is left out? Of paramount importance is the insight into the patients’ experience shared with physical therapists that could inform discharge planning and readmission risk. To capture that information, a narrative from the physical therapy team might be useful. This narrative would focus on the patients’ perceptions of the dangers they face. Some of their concerns might be predictable, such as fear of falling or impending death. Others—such as despair, apprehension about an abusive relationship, or something as ordinary as tripping on the family pet— might be amenable to intervention, thus reducing readmission risk. Quantitative scores from screening tests cannot capture the patients’ experience as narratives can. In addition, physical therapy narratives could reveal patients’ views of what has meaning for their lives. These sources of meaning, such as family relationships, serve as a guide to what might motivate patients to maximize recovery and minimize readmission risk, whereas the fears could identify obstacles to optimal recovery. Physical therapists also could provide relevant information such as mobility and balance observations. Mobility is a potent predictor of readmission risk.8 This knowledge could aid discharge planning and related readmission risk reduction. There is heuristic value in studying how physical therapy information might be useful for reducing 30day readmissions. For example,
closely examining who gets physical therapy and who does not with given diagnoses might shed light regarding the impact of physical therapy actions and information on 30-day readmission. For purposes of systematic data collection, the physical therapy narrative might feature pull-down lists of structured texts to describe patient motivations and concerns. If so, what would the structured texts contain? Which components of those texts might be correlated with 30-day readmission risk? In addition, how might mobility and balance predict early readmission? The relevance of physical therapy information and involvement is not restricted to discharge. For example, socioeconomic status, diagnosis, and caregiver support influence early readmission risk and can be identified at admission. Might these factors point to early physical therapist involvement in these cases? If so, which aspects of physical therapy might be the most beneficial? The physical therapist perspective regarding patients can augment the Rothman index and similar quantitative tools designed to measure readmission risk. Not all patients receive physical therapy during their hospital admissions. Patients with cardiovascular disease, especially those with congestive heart failure and those who have undergone surgery for orthopedic conditions, do routinely receive physical therapy. They constitute groups known to have high readmission risk. There are quantitative tools to measure and mitigate readmission risk. The voice of physical therapy is missing in this process. Does this omission matter? We think it does. Physical therapy does contribute to patient education and discharge
Volume 94 Number 11 Physical Therapy ■ 1681 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
Letters to the Editor planning and can contribute to reducing readmission risk through narrative plus quantitative data such as mobility and balance. Jennifer Kreppein, Thomas D. Stewart J. Kreppein, PT, Physical Therapy, Stony Brook Medical Center, Stony Brook, New York. T.D. Stewart, MD, Psychiatry, Yale School of Medicine, 25 Kingsbridge Way, Madison, CT 06443 (USA). Address all correspondence to Dr Stewart at: [email protected].
References 1 Berenson RA, Paulus RA, Kalman NS. Medicare’s readmissions-reduction program: a positive alternative. N Engl J Med. 2012;366:1364–1366. 2 Stewart TD. Psychotherapy and physical therapy: common ground. Phys Ther. 1977;57:279–283. 3 Matmari L, Uyeno J, Heck CS. Physiotherapists’ perceptions of and experiences with the discharge planning process in acutecare general internal medicine units in Ontario. Physiother Can. 2014:66:254–263. 4 Rothman, MJ, Rothman SI, Beals J 4th. Development and validation of a continuous measure of patient condition using the electronic medical record. J Biomed Inform. 2013;46:837–848.
5 Bradley EH, Yakusheva O, Horwitz LI, et al. Identifying patients at increased risk for unplanned readmission. Med Care. 2013;51:761–766. 6 Zhang JQ, Curran T, McCallum JC, et al. Risk factors for readmission after lower extremity bypass in the American College of Surgeons national surgery quality improvement program. J Vasc Surg. 2014;59:1331–1339. 7 Shepperd S, Lannin NA, Clemson LM, et al. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013:1:CD000313. 8 Fisher SR, Kuo YF, Sharma G, et al. Mobility after discharge as a marker for 30-day readmission. J Gerontol A Biol Sci Med Sci. 2013;68:805–810. [DOI: 10.2522/ptj.2014.94.11.1680.2]
1682 ■ Physical Therapy Volume 94 Number 11 Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
November 2014
Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions? Jennifer Kreppein and Thomas D. Stewart PHYS THER. 2014; 94:1680-1682. doi: 10.2522/ptj.2014.94.11.1680.2
References
This article cites 8 articles, 1 of which you can access for free at: http://ptjournal.apta.org/content/94/11/1680.2#BIBL
Subscription Information
http://ptjournal.apta.org/subscriptions/
Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml Information for Authors
http://ptjournal.apta.org/site/misc/ifora.xhtml
Downloaded from http://ptjournal.apta.org/ by Dell Schramm on November 21, 2014
