Health Services Research: Physical Therapy Has Arrived!

Health services research (HSR) and health policy topics are critically important to the future of the physical therapy profession, but they are included only rarely in physical therapy journals—until now. We are pleased to introduce the first of a 3-part special series on physical therapy–relevant HSR and health policy in rehabilitation.

According to the Agency for Health Care Research and Quality, HSR is a “multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately, our health and well-being.”¹ HSR provides data, evidence, and tools to help make health care affordable, safe, effective, equitable, accessible, and patient centered. Products derived from HSR inform health policy—defined as “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society”²—at all levels, from individual providers (eg, physical therapists), to health care organizations and systems, to payers and government. At one end of the spectrum, HSR can enable providers and patients to make better decisions about their individual health care; at the other end, HSR can inform decisions about payment policy and health care coverage for populations.

Health services research has never been more important than it is now, as health systems struggle to control costs and provide high-quality, high-value care. Desperately needed to demonstrate both the necessity and the value of physical therapy, this domain of research will provide data to inform the organization and delivery of physical therapy care, payment policies related to physical therapy, and future state and federal health care regulations.

In physical therapy, HSR was first promoted within APTA's Health Policy Administration (HPA) Section and presented through HPA platform and poster presentations. In 2005, the section initiated an HSR small-grant program that is still active today, and several of the authors published in this special series were fostered by the program. Over the past decade, the urgent need for HSR was recognized by APTA's Board of Directors and the Foundation for Physical Therapy. There also was recognition that few individuals or teams of investigators were positioned to conduct this type of research.

The interdisciplinary nature of HSR draws on methods and data sources that are common to a variety of other disciplines (eg, economics, epidemiology, psychology, sociology, management) but that are not typically taught in rehabilitation science graduate degree programs. Most physical therapist researchers lack the background and skills to design and conduct HSR and to compete for the federal funding required to conduct large scale research projects. The physical therapy community coalesced to address this gap.

In 2015, the Foundation for Physical Therapy made a major investment by funding the Center on Health Services Training and Research (CoHSTAR), a $2.5 million multi-institutional training center for physical therapy HSR (APTA was a major donor to the Foundation campaign).³ A collaboration of Brown University, Boston University, and University of Pittsburgh, CoHSTAR will train postdoctoral and faculty fellows, host visiting scientists, sponsor HSR summer institutes, and fund pilot studies.

The timing of this special series is ideal. When we began planning this series, our expectations were modest. Typically, PTJ publishes a handful of HSR papers each year, and the number of HSR abstracts submitted to APTA conferences is small, so we expected to publish manuscripts in 1 or at best 2 PTJ issues. We searched the literature for authors who were conducting relevant research but were not necessarily publishing in rehabilitation journals, and we invited colleagues from inside and outside the profession. We also issued an open call for papers. The strong response was gratifying; we discovered a wealth of high-quality and relevant research.

This issue contains 8 scholarly papers representing a range of HSR topics. The 6 research reports are excellent examples of research using large secondary data sources, with the first 3 addressing particularly important and timely policy-relevant questions:

• Amico et al⁴ used Medicare claims data to simulate alternative cap payment policies and illustrate how these different cap policies are more or less favorable for Medicare beneficiaries depending on their needs and whether they require care from more than one discipline. They also explored how beneficiary need for physical therapy (as measured by diagnosis and mobility) could be used to risk-adjust therapy caps. Although they show that risk adjustment is indeed important when considering therapy payment models, they also found that much of the variation in therapy expenditures was not explained by their risk adjustment methods.

• Jette et al⁵ examined the validity of CMS G-code severity modifiers in detecting change in a validated measure of functional status, the Activity Measure for Post-Acute Care (AM-PAC). Their analyses demonstrated that the severity modifiers were limited in detecting change in function, particularly when the patient's baseline AM-PAC scores were at the lower end of the range of scores of a particular functional limitation code modifier. These findings challenge the usefulness of the current system of data collection for examining change in function over time.

• Andrews and colleagues⁶ examined hospital discharge data from 2 states and provide compelling evidence that therapy intensity in the inpatient setting is associated with a decrease in the risk of 30-day readmission. This article highlights an area that would benefit from further research: the potential value of physical therapists in reducing readmissions and improving care transitions.

The next 2 papers examine use and costs associated with ambulatory physical therapy:

• Fritz et al⁷ used Medicaid claims data from Utah to examine health care entry setting, utilization, and timing of physical therapy care and subsequent cost over a 1-year period for patients with a new consultation for low back pain (LBP). They found that only 20% of patients received any physical therapy, and, of these, only 16% entered physical therapy care directly. However, direct entry was associated with lower total costs for LBP. This important finding demonstrates the value of direct access to physical therapy and suggests that greater efforts are needed to improve access to physical therapy for Medicaid patients with LBP.

• Chevan et al⁸ used nationally representative data from the Medical Expenditure Panel Survey to examine the burden of out-of-pocket costs for physical therapy as well as factors associated with these costs. They found that 54% of people who had physical therapy also had out-of-pocket costs, and they identified predictors of cost. These findings, particularly valuable in informing fair copay legislative efforts, demonstrate substantial differences by geographic region and urban and rural areas and potential barriers to access to care for some patients.

Another paper addresses a methodological issue that is common when conducting HSR:

• Yen et al⁹ examined how to account for the clustering or non-independence of measures within a provider (eg, patients seen by the same provider) or an organization (eg, patients within a practice). Understanding HSR methods and approaches for examining observational data (eg, claims or registry data) is important to advance the field.

This month's installment of the series ends with a perspective on high-value care and a case report on the implementation of a quality improvement (QI) initiative to improve high-value care. Rundell et al¹⁰ offer a comprehensive framework for understanding HSR; discuss comparative effectiveness research, patient-centered outcomes research, and health economic assessment; and discuss how data from these types of studies can be used for decision making and health policy. Karlen et al¹¹ illustrate the ultimate goal of HSR, which is to inform policies and practice that improve the care and health of our patients. They describe their approach to implementing a QI strategy, informed by current evidence, within their health care system—and provide convincing data that their approach increased the value of physical therapy for their patients with LBP.

We hope that the HSR special series not only exposes readers to HSR, but also stimulates interest in collaborations and training opportunities and expands the dialogue on how the profession can advance the field and ultimately improve the health and well-being of the patients and clients we treat. The physical therapy profession “has arrived”—we have a critical mass of investigators, clinicians, and physical therapist leaders who are interested in HSR, and we have a training center to help foster growth in physical therapy–relevant HSR. We look forward to the progress that will be made as the profession embraces this field of research.

We thank Editor-in-Chief Rebecca Craik, who heartily supported the development of this series. We also thank the manuscript reviewers (see here) who devoted their valuable time and invaluable expertise to make this landmark series a success.

• © 2015 American Physical Therapy Association