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Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect

Sheng-Che Yen, Marie B. Corkery, Kevin K. Chui, Justin Manjourides, Ying-Chih Wang, Linda J. Resnik
DOI: 10.2522/ptj.20140444 Published 1 December 2015
Sheng-Che Yen
S-C. Yen, PT, PhD, Department of Physical Therapy, Movement and Rehabilitation Sciences, Bouvé College of Health Sciences, Northeastern University, 308G Robinson Hall, 360 Huntington Ave, Boston, MA 02115 (USA).
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Marie B. Corkery
M.B. Corkery, PT, DPT, MHS, FAAOMPT, Department of Physical Therapy, Movement and Rehabilitation Sciences, Bouvé College of Health Sciences, Northeastern University.
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Kevin K. Chui
K.K. Chui, PT, DPT, PhD, GCS, OCS, FAAOMPT, Department of Physical Therapy, College of Health Professions, Sacred Heart University, Fairfield, Connecticut.
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Justin Manjourides
J. Manjourides, PhD, Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University.
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Ying-Chih Wang
Y-C. Wang, PhD, OTR/L, Occupational Science and Technology Department, College of Health Sciences, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin.
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Linda J. Resnik
L.J. Resnik, PT, PhD, Providence VA Medical Center and Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island.
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Abstract

Background Valid comparison of patient outcomes of physical therapy care requires risk adjustment for patient characteristics using statistical models. Because patients are clustered within clinics, results of risk adjustment models are likely to be biased by random, unobserved between-clinic differences. Such bias could lead to inaccurate prediction and interpretation of outcomes.

Purpose The purpose of this study was to determine if including between-clinic variation as a random effect would improve the performance of a risk adjustment model for patient outcomes following physical therapy for low back dysfunction.

Design This was a secondary analysis of data from a longitudinal cohort of 147,623 patients with lumbar dysfunction receiving physical therapy in 1,470 clinics in 48 states of the United States.

Methods Three linear mixed models predicting patients' functional status (FS) at discharge, controlling for FS at intake, age, sex, number of comorbidities, surgical history, and health care payer, were developed. Models were: (1) a fixed-effect model, (2) a random-intercept model that allowed clinics to have different intercepts, and (3) a random-slope model that allowed different intercepts and slopes for each clinic. Goodness of fit, residual error, and coefficient estimates were compared across the models.

Results The random-effect model fit the data better and explained an additional 11% to 12% of the between-patient differences compared with the fixed-effect model. Effects of payer, acuity, and number of comorbidities were confounded by random clinic effects.

Limitations Models may not have included some variables associated with FS at discharge. The clinics studied may not be representative of all US physical therapy clinics.

Conclusions Risk adjustment models for functional outcome of patients with lumbar dysfunction that control for between-clinic variation performed better than a model that does not.

Footnotes

  • Dr Yen, Dr Chui, Dr Wang, and Dr Resnik provided concept/idea/research design. Dr Yen, Dr Corkery, Dr Chui, Dr Wang, and Dr Resnik provided writing. Dr Yen, Dr Chui, and Dr Manjourides provided data analysis. Dr Yen provided project management. Dr Wang provided participants. Dr Yen, Dr Corkery, Dr Manjourides, Dr Wang, and Dr Resnik provided consultation (including review of manuscript before submission).

  • The authors thank Focus On Therapeutic Outcomes, Inc (FOTO) for providing the patient data set.

  • Received October 14, 2014.
  • Accepted April 13, 2015.
  • © 2015 American Physical Therapy Association
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Vol 95 Issue 12 Table of Contents
Physical Therapy: 95 (12)

Issue highlights

  • Physical Activity and Sedentary Behavior in Children With Cerebral Palsy
  • Whole-Body Vibration in Stroke
  • Implementing Quality Improvement for Higher-Value Low Back Pain Care
  • Role of Health Services Research
  • Risk Adjustment for Lumbar Dysfunction
  • Out-of-Pocket Spending for Ambulatory Services: National Panel Survey
  • Physical Therapy for Medicaid Enrollees
  • Association of Rehabilitation Intensity and Risk of Hospital Readmission
  • CMS G-Code Functional Limitation Severity Modifiers
  • Refinements of Medicare Outpatient Therapy
  • Self-Reported Disability in Older Adults
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Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect
Sheng-Che Yen, Marie B. Corkery, Kevin K. Chui, Justin Manjourides, Ying-Chih Wang, Linda J. Resnik
Physical Therapy Dec 2015, 95 (12) 1692-1702; DOI: 10.2522/ptj.20140444

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Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect
Sheng-Che Yen, Marie B. Corkery, Kevin K. Chui, Justin Manjourides, Ying-Chih Wang, Linda J. Resnik
Physical Therapy Dec 2015, 95 (12) 1692-1702; DOI: 10.2522/ptj.20140444
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Subjects

  • Musculoskeletal System/Orthopedic
    • Injuries and Conditions: Low Back
  • Outcomes Measurement
  • Special Series and Special Issues
    • Health Services Research Special Series
  • Health Services Research

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