Dijkers and colleagues are to be congratulated on the development of a rehabilitation treatment taxonomy framework that has the potential to improve the way that physical therapists and other rehabilitation professionals describe the care that they provide to patients.1,2 Additionally, the authors are to be commended for their efforts to engage relevant stakeholders in a broad discussion to help refine and accurately describe the model in ways that should enhance its utility and applicability.
An effective classification system for interventions has potential value for physical therapist clinicians, researchers, and educators. Such a system also may be useful for those involved in health policy and payment determination because it should help to clarify and demonstrate the value of specific rehabilitation services and interventions. Despite obvious implementation challenges, the taxonomy framework proposed by the researchers merits discussion and consideration.
Physical therapists typically know whether their patients show functional improvement throughout an episode of care. What they often do not know is which treatment was responsible for the improvement and why the change occurred. A treatment taxonomy framework that requires a disciplined consideration of the clinical target (the problem), the active ingredient (treatment) that is intended to bring about change, and the hypothesized mechanism of action has the potential to standardize and improve care.
The value of this taxonomy framework for research is even more apparent. Researchers and clinicians alike are continually frustrated by research articles that report the effectiveness, or lack thereof, of “physical therapy” without offering any description of the actual treatment that was provided or its intended purpose.3 A framework for research studies that includes a description of what was done, the hypothesized mechanism of action, and the effect on the clinical target should lead to research that is more useful to both researchers and clinicians.
The lack of specificity of treatment descriptions in research studies makes it difficult to conduct comparative effectiveness studies to determine whether certain treatments are more or less effective than surgery, medication, or other more costly or invasive interventions. A comparative effectiveness study that simply looks at the effectiveness of “physical therapy” as compared with surgery for a specific condition does not offer much useful information.
Clinical practice guidelines have become a preferred mechanism for helping health care professionals in all disciplines integrate the most current evidence into practice. The development of clinical practice guidelines in physical therapy is hindered because of otherwise valuable studies that fail to provide sufficient information about actual treatments that were investigated. Consequently, the development of meaningful guidelines that inform evidence-based physical therapist practice is more difficult.
Despite the need for specificity in describing and classifying treatments, the various rehabilitation professions have a need to retain a clear identity. Research articles that attribute change in patient status to specific treatments (ie, exercise or gait training) and not to the training or the profession of the person who provided the treatment (ie, physical therapy) may limit that profession's ability to measure and communicate its value within the health care delivery system. This paradox is beyond the scope of this commentary but warrants consideration and further dialogue among stakeholders.
A taxonomy framework such as the one described has potential value for physical therapist education and warrants a review by experts. A framework that teaches students to consider the specific clinical target, purpose, and active ingredient when designing a plan of care could promote a more disciplined and evidence-based approach to clinical decision making.
Payers and policy makers also are limited by the lack of information about specific treatments in physical therapy. Consequently, decisions are made about how much physical therapy should be provided without regard for which aspects of rehabilitation have value—and which aspects do not. Decisions are made about the total costs, number of hours, days, or sessions of therapy that will be approved for payment but rarely about the type of treatment or its specific purpose. Knowledge about the intent and mechanism of action of interventions could help payers and policy makers understand which therapy treatments are of highest value for specific patient conditions and subsequently lead to better decision making regarding payment.
A new classification model, no matter how well designed and elegant, must be integrated into our existing system of documentation, coding, quality measurement, and functional reporting. For physical therapists in 2014, the payment and regulatory environment is already considered to be unduly burdensome, especially with Medicare's recent implementation of functional limitation reporting requirements and Physician Quality Reporting System (PQRS) penalties.4 Despite the potential value of such a taxonomy, it will be difficult to facilitate such reporting without sufficient incentives and penalties.
Additionally, both private and government payers appear to be moving away from procedure-based payment for physical therapist services and toward either a per-visit or episodic payment model.5 Some private insurers already pay physical therapists using a per-visit model, and several report plans for episodic or bundled payment in the near future. The American Physical Therapy Association is currently involved in formal discussions with the American Medical Association's Common Procedural Terminology workgroup on a revision of the coding and payment system for rehabilitation services. This revision involves a transition from a procedure-based system to a per-session payment model based upon patient severity and the intensity of the service. A transition from the procedure-based payment model could decrease the emphasis on documentation to describe the clinical decision making behind the selection of interventions and the evaluation of the effectiveness of specific treatments. Whether these changes in payment will lead to changes in clinical practice is unknown.
In recent years, physical therapists have focused increasingly on outcome measurement as a way of determining the impact of selected interventions in the aggregate. This focus has resulted in broad efforts to encourage the use of outcome measurement tools.6 These tools do not consider the interventions that are provided, nor do they consider the intended clinical targets or mechanisms of action. Attempting to alter this trend of outcome reporting or to insert an additional requirement for classifying and describing specific treatments will be challenging.
For the same reason that interprofessional collaboration and consensus are important to the success of a taxonomy, it is essential that there be similar collaboration internationally. The authors are to be commended for reaching out to individuals and groups involved with development of international classification systems, including the International Classification of Functioning, Disability and Health. A classification system that has acceptance both interprofessionally and internationally will have a greater chance of adoption and an even greater chance of providing useful knowledge about the effectiveness of the treatments we provide.
The essence of a science-based profession is knowledge of which treatments work for which conditions and why. A taxonomy framework such as the one developed by the authors has the potential to help answer the many questions that remain about the effectiveness of our treatment. The authors have challenged us to respond to their model with questions, recommendations, and debate. Despite the challenges of implementation into current practice, research, and educational models, the rehabilitation treatment taxonomy is worthy of continued dialogue.
- © 2014 American Physical Therapy Association
