Invited Commentary

The quality of health care provided to Americans has been receiving an increasing degree of scrutiny. Increased attention to quality, along with improved measurement methods, have raised concerns that the quality of health care provided for even the most common conditions is inconsistent, unpredictable, and often suboptimal.^1,2 With a larger proportion of health care costs being shifted to the consumer, concerns about quality of care are adversely affecting consumer satisfaction. Americans’ dissatisfaction with the health care system has doubled since 1998.³ Quality concerns also are influencing reimbursement and regulatory agencies. The Centers for Medicare and Medicaid Services and various state agencies are disseminating quality data and exploring value-based payment (ie, pay-for-performance) initiatives to encourage higher-quality care through financial incentives to providers. These initiatives will increasingly affect physical therapy. The quality of physical therapy care has not been scrutinized to the extent of the quality of care of other providers, which is why research such as the study by Resnik and colleagues⁴ is urgently needed. In the current health care environment, it is imperative that physical therapists become conversant with the language of quality, including how it is defined, how it is measured, and the factors that influence it.

Resnik and colleagues used the Institute of Medicine's (IOM) definition of health care quality as a framework for examining the associations of various structural and staffing factors in outpatient physical therapy clinics and the quality of care provided to individuals with low back pain syndromes (LBPS). The IOM defines quality of care as “the degree to which health services for individuals or populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”¹ An important aspect of this definition is that it grounds health care quality in the experience of individual health care consumers, not just aggregate patient populations.⁵ The desired health outcomes of individual patients includes the clinical outcomes of care (eg, changes in pain, disability); however, individuals also desire value. Value in health care is a combination of high quality and low price.⁶ Resnik and colleagues considered both clinical outcomes (FOTO overall health status [OHS] score at discharge) and costs (number of visits) as aspects of the quality of physical therapy care and categorized physical therapy clinics based on each of these factors individually (effectiveness and utilization) and in combination (overall performance). This is an important consideration when moving research from quality monitoring to quality improvement, as improvement in quality can occur by achieving better clinical outcomes without substantially increasing costs or by reducing costs while achieving a similar clinical outcome.

Resnik and colleagues examined the associations between various aspects of staffing and organizational structure and the quality measures (effectiveness, utilization, and overall performance). Specifically, the authors considered factors related to the practice environment (clinic setting, average number of new patients per physical therapist per month, and proportion of patients with LBPS) and the physical therapy professional staff (number of full-time–equivalent physical therapists, average years of clinical experience, ratio of full-time–equivalent physical therapists to physical therapist assistants, and utilization of physical therapist assistants (based on the percentage of time spent with the patient).

The results of this study are interesting with respect to what was, and what was not, associated with higher-quality physical therapy care. First, years of clinical experience of the physical therapists did not equate to higher-quality care. In fact, the only association identified based on therapists’ years of experience was that more experienced physical therapy staffs were somewhat more likely to have high service utilization. While apparently counterintuitive, the lack of a positive relationship between greater clinical experience and increased quality of care has been well documented within physical therapy.⁷ Similar to the findings by Resnik and colleagues, studies examining physicians have shown that if any association exists between years of clinical experience and quality of care, it is an inverse relationship.⁸ This may reflect a reluctance among more experienced clinicians to adapt to new information or change practice patterns.⁹ These findings serve as an important reminder that experience is not a guarantor of quality, and more experienced physical therapists need to be a focus of quality-improvement initiatives.

Several studies in medicine have reported a volume-outcomes relationship, where physicians or facilities with a higher volume of patients with a certain condition tend to get better clinical outcomes.¹⁰ This study is the first to examine the volume-outcomes relationship for physical therapists managing patients with LBPS. Although higher-volume clinics had lower utilization, Resnik and colleagues did not find an association with effectiveness or overall performance. Although further exploration of this relationship is needed, the medical literature has reported a greater association between volume and outcomes for conditions or procedures that are relatively uncommon.¹¹ Low back pain syndromes are typically the most common conditions managed in outpatient physical therapy clinics, which may partially explain the lack of association between volume and clinical outcomes.

Recent studies have shown that the practice setting and health care delivery system affect the quality of care that is delivered. For example, patients receiving care in the Veterans Health Administration system are reported to be more likely to receive high-quality care than patients seeking care in other health care systems in the United States.¹² Explanations for these findings have focused on structural aspects of the Veterans Health Administration system, including the use of integrated information systems (including electronic medical records) and an administrative commitment to quality management and measurement.¹³ Resnik and colleagues categorized physical therapy clinic settings as hospital-based or “other” and did not find a substantial relationship between setting and quality of care. This basic dichotomy likely failed to capture the critical elements of a practice setting that are related to quality such as electronic record keeping, ongoing performance monitoring, administrative accountability for performance, and the overall culture of the clinic.

The most notable finding of the study by Resnik and colleagues was the association between utilization of physical therapist assistants and all aspects of quality of care. Higher utilization of physical therapist assistants was associated with higher utilization, decreased effectiveness, and lower overall performance. The observational design of this study does not permit determination of the cause of these associations, but encourages the formation of hypotheses. The strength of the associations between quality of care and physical therapist assistant utilization reflected in the odds ratios suggests that further examination may yield important insights on the determinants of the quality of physical therapy care.

The association between physical therapist assistant utilization and quality of care may be a reflection of an additional aspect of the IOM's definition of quality that was not directly assessed in this study—that quality of care must be “consistent with current professional knowledge.”¹ Quality of care requires that patients receive care that is supported with research evidence and is consistent with professional standards. Resnik and colleagues examined clinical outcomes as a measure of quality, but they did not assess the process of care. Without process measures, it is not possible to examine the type of care provided by physical therapist assistants to determine whether it was less likely to be consistent with current professional knowledge than care provided by physical therapists.

Quality standards being established by regulatory agencies typically focus their determination of quality on care process measures instead of clinical outcomes. This is done by defining “quality indicators” for common conditions, then basing quality assessments on the proportion of patients receiving these quality indicators during the process of care.¹⁴ For example, the 2008 Physician Quality Reporting Initiative from the Centers for Medicare and Medicaid Services includes a quality indicator specifying that individuals 65 of age or older who have experienced at least 2 falls in the past year should be screened for future fall risk.¹⁵ Quality of care for these patients, therefore, would require that providers ask about a patient's fall history and perform appropriate screening for individuals at risk.

Quality indicators for physical therapy provided to individuals with LBPS have not been formally established. However, evidence supports the provision of advice to stay active, avoidance of passive modalities, provision of exercise, and spinal manipulation for suitable patients.¹⁶ Our previous research¹⁷ showed that physical therapy care adherent to these care process indicators is associated with higher quality (ie, better clinical outcomes at lower cost). Furthermore, it appears that providing physical therapy adherent to these care process quality indicators has implications extending beyond the physical therapy episode of care. For patients with acute LBPS, we have found that high-quality physical therapy care is associated with lower subsequent health care costs due to prescription medication, diagnostic imaging, specialty visits, and so forth in the year following discharge from physical therapy.¹⁸ It appears that the IOM definition of quality of care holds true for physical therapy care provided to patients with LBPS. When care is consistent with current professional knowledge, it leads to a higher likelihood of the outcomes individual patient's desire—better clinical outcomes at lower costs. The application of physical therapy care that is current with professional knowledge requires training in clinical decision making and specific clinical skills (ie, spinal manipulation). It is not surprising that when a high proportion of care is provided by professionals whose training does not include these key components, quality may be compromised.

The study by Resnik and colleagues is an important contribution to the study of quality of care in the context of physical therapy provided to individuals with LBPS. Health care consumers, payers, and regulators are placing more and more emphasis on the quality of care they consume, reimburse, or regulate. Physical therapists also must focus on the quality of care they are providing, and more research is needed to report the quality of care being provided by physical therapists and factors that enhance quality of care.

• American Physical Therapy Association