Abstract
Background and Purpose The current state of health care demands higher-value care. Due to many barriers, clinicians routinely do not implement evidence-based care even though it is known to improve quality and reduce cost of care. The purpose of this case report is to describe a theory-based, multitactic implementation of a quality improvement process aimed to deliver higher-value physical therapy for patients with low back pain.
Case Description Patients were treated from January 2010 through December 2014 in 1 of 32 outpatient physical therapy clinics within an academic health care system. Data were examined from 47,755 patients (mean age=50.3 years) entering outpatient physical therapy for management of nonspecific low back pain, with or without radicular pain. Development and implementation tactics were constructed from adult learning and change management theory to enhance adherence to best practice care among 130 physical therapists. A quality improvement team implemented 4 tactics: establish care delivery expectations, facilitate peer-led clinical and operational teams, foster a learning environment focused on meeting a population's needs, and continuously collect and analyze outcomes data. Physical therapy utilization and change in functional disability were measured to assess relative cost and quality of care. Secondarily, charge data assessed change in physical therapists' application of evidence-based care.
Outcomes Implementation of a quality improvement process was measured by year-over-year improved clinical outcomes, decreased utilization, and increased adherence to evidence-based physical therapy, which was associated with higher-value care.
Discussion When adult learning and change management theory are combined in quality improvement efforts, common barriers to implementing evidence-based care can be overcome, creating an environment supportive of delivering higher-value physical therapy for patients with low back pain.
In any given year, 1 in 5 people will experience low back pain (LBP), and 15% of all people will receive medical treatment for LBP.1 Low back pain is the leading cause of disability in people under 45 years of age.2 It is also a very costly health care condition; 10 years ago, the annual US management was estimated at $86 billion.3 Aiming to reduce pain and restore function, patients with LBP commonly seek physical therapy; consequently, it is one of the largest patient volumes for these providers.4 Despite many evidence-based LBP treatments, such as reassurance, education, exercise, and manipulation, being low cost, the costs to manage LBP have continued to rise.5,6 As physical therapists can deliver these treatments, they can become high-value providers for LBP management, with value being defined as quality/cost.7 Although physical therapists are trained to deliver evidence-based treatments for LBP, there is considerable lack of consistency in doing so.8 Fewer than half of physical therapists report using guidelines frequently or very frequently.8 Specifically for LBP, the commitment to deliver evidence-based care among physical therapists varies from 13% to 62%.8–10
Researchers have explored barriers to using evidence-based care. In a self-reported survey of clinic-based physical therapists, 96% agreed that it is important to use treatment guidelines, but only one third said they were aware of the guidelines, and fewer than 10% could easily find them at work.8 Barriers to using evidence-based care include lacking time to critically review the literature, making sense of how to apply the guideline, and lacking self-efficacy in delivering the care.8,11
Studies also have explored the effectiveness of various implementation strategies for evidence-based care. It is largely accepted, regardless of the type of clinician, that active approaches to integrating evidence-based care are more effective than passive approaches.12–14 According to theory-based learning, clinicians first change their knowledge, which drives change in attitudes and beliefs, and finally changes behavior.13–16 In a review of the implementation of physical therapy guidelines for LBP care, one study demonstrated that a theory-based, multicomponent intervention modestly improved physical therapists' knowledge of, access to, and use of guidelines, but the study did not assess patient outcomes.8 Additionally, a systematic review of multifaceted strategies demonstrated effectiveness in some outcomes but not patient health or costs.12 The purpose of this case report is to describe a theory-based, multifaceted implementation of a quality improvement process aimed to deliver higher-value physical therapy for patients with LBP.
Setting
Fairview Health Services (Fairview), a 7-hospital, academic health system in Minnesota, launched a quality improvement process to improve the outcomes for patients with LBP and reduce the cost of care. Fairview also has many freestanding entities delivering care across an urban and suburban environment, including 32 outpatient physical therapy clinics with approximately 130 physical therapists. In 2010, Fairview solidified its commitment to delivering high-value care by becoming one of Medicare's 32 Pioneer Accountable Care Organizations. This commitment holds Fairview accountable to care for a population of patients enrolled in Medicare at a lower than expected cost while maintaining quality standards. With the intention to deliver higher-value care, Fairview aligned its strategic priorities under the Triple Aim. The Triple Aim, first defined by the Institute for Healthcare Improvement, focuses on delivering better-quality care and population health at a lower cost to that population.17
In order to achieve the Triple Aim, Fairview prioritized redesigning care for patient populations that were more expensive to manage. Due to the high volume of patients affected and the high cost to manage surgical and nonsurgical care, patients with LBP became a clear choice. Fairview's outpatient physical therapy clinics treat approximately 12,000 patients with LBP every year, comprising 25% of its total outpatient physical therapy population. In 2010, internal care model redesigns for this population in primary care were anticipated to increase physical therapy referrals. It became critical for physical therapists across the system to more consistently deliver high-value care. Higher-value care can be achieved by demonstrating increased quality at the same or lower cost or the same quality at a lower cost.
This case report summarizes data collected from January 2010 through December 2014 on patients with nonspecific LBP, with or without radicular symptoms (defined in Appendix 1), seeking care at an outpatient physical therapy clinic. The electronic database included 47,755 unique patient episodes (Fig. 1). Patients had a mean age of 50.3 years (range=6–100; age distribution: 6–17 years of age=4.8%, 18–64 years of age=71.0%, 65–100 years of age=24.2%). Approximately 60% of the patients were women.
Patients with low back pain (LBP) entering outpatient physical therapy from 2010 through 2014. ODI=Oswestry Disability Index, KSBT=Keele STarT Back Tool.
Development of Quality Improvement Process
Determining how to launch a quality improvement effort for LBP is challenging due to the inherent complexity of LBP. In the fall of 2010, the orthopedic service line executive dedicated project management and quality improvement staff to improve the value of physical therapy for patients with LBP. Primarily, this quality improvement team (QIT), well versed in change management and adult learning techniques, leveraged the system's vision to deliver higher-value care, and the urgency to do so. Both of these factors are critical for effective change management, especially when working with multiple stakeholders.18
To further the system vision, the QIT developed the Spine Guidance Team. The Spine Guidance Team, facilitated by the dedicated project manager, included senior directors and multidisciplinary representation from each hospital, discipline, and provider group (the orthopedic service line executive, a service line quality director, 2 senior directors overseeing inpatient spine care, 3 orthopedic surgeons, 2 neurosurgeons, a primary care sports medicine physician, a physiatrist, a clinical psychologist, a physical therapist, a chiropractor, a primary care provider, and 2 pain management specialists). Change management theory suggests that change is best driven when opportunities are collectively identified by multiple stakeholders.19 Clinicians on the team devoted at least half of their practice to caring for patients with LBP, which helped to ensure enough influence to serve as a guiding coalition within their specialties.18
As LBP population experts, the Spine Guidance Team's initial task was to identify quality improvement priorities for meeting this population's needs. The Spine Guidance Team, validating their Triple Aim commitment, established 3 priorities: getting patients to the right place at the right time for the right care, early identification and intervention for those anticipated to have chronic back pain, and disciplined quality data collection. This foundational input fostered collaboration and guided the quality improvement process.19
Finally, the QIT, with executive support, conveyed both the system vision and the Spine Guidance Team priorities to the physical therapists. Once the design of the quality improvement project began, barriers were assessed and multifactorial implementation strategies were developed. An executive-led communication strategy promoted program support and a sense of urgency for outpatient physical therapy to align care with the system vision and Triple Aim.18 Consistent and timely communication through formal and informal channels helped mitigate the implementation barriers often reported in the literature.16,18,20,21
Addressing common barriers for physical therapists to use evidence-based care, the QIT developed peer teams, knowing that learning theory states adults will more readily accept change coming from well-respected peers than from administration.8,14,16,18,20,22 Peer design groups were leveraged to work on behalf of all physical therapists to remove the barriers of lack of time and inability to critically review the literature.8
Effective implementation strategies focus on appealing to clinician knowledge, attitudes, and behaviors, as well as creating an enabling environment through operational and resource support.13–16 The QIT based the curriculum on the principles of progressing learners through those stages. Accepting that knowledge of best practice guidelines does not automatically translate into clinical change, the QIT created learning opportunities delivered by peers that could progress their colleagues from a level of “competence,” what someone is capable of doing, to “performance,” what someone actually does in clinical practice.13,14 Active learning more effectively changes behaviors than passive learning approaches, such as a single lecture.12–14,20 In total, the QIT created 4 theory-based, active tactics to support the implementation of evidence-based care: establish care delivery expectations, facilitate peer-led clinical and operational teams, foster a learning environment focused on meeting a population's needs, and continuously collect and analyze outcomes data. The QIT theorized that by using these tactics within the quality improvement process, the value of physical therapy could improve.
Application of the Quality Improvement Process
Beginning in 2011, the 4 tactics were developed and implemented in less than 2 years; the tactics were then modified and reinforced based on feedback over the following 2 years of the quality improvement project (Tab. 1).
Strategic Time Linea
Establish Care Delivery Expectations
The first tactic in the quality improvement process was to establish common care delivery expectations. Paralleling the Triple Aim, stakeholders established expectations for the initiative, specifically use of evidence-based physical therapy. To begin, a mandatory online module was assigned to physical therapists to support evidence-based practice, which included a physical evaluation, “red flag” screen, and neurological assessment. This expectation and the Spine Guidance Team priorities were revisited in quarterly all-staff meetings and lunch meetings at individual clinics beginning in 2012. Physical therapists and stakeholders were routinely informed of the physical therapists' objective progress toward meeting the care expectations and Spine Guidance Team's priorities (Appendix 2).
Facilitate Peer-Led Clinical and Operational Teams
The second tactic to deliver higher-value physical therapy was to facilitate peer-led clinical and operational teams. In order to support the quality-of-care expectations within the initiative, a pragmatic, evidence-based guide was created by the Best Practice Committee. This committee, comprising volunteer physical therapists and chiropractors, was charged to review the current literature, develop a 2-page treatment recommendation guide consisting of preferred pathways of care for managing LBP, and introduce the guide to their colleagues during clinic lunch meetings. This peer-led process, supported by the clinic directors, provided accessible, easily applied, consistent standards for delivering evidence-based physical therapy.
Another peer-led group, the Low Back Pain Champions, was formed to operationalize the spread of evidence-based practice. The Champions, one representing each clinic, served as liaisons between the frontline staff and the QIT to facilitate operational changes necessary to support the clinical initiatives. The QIT called upon the Champions approximately once every other month through email or conference calls, asking them to share updates with their peers or soliciting feedback needed to inform design groups. Semiannually, the Champions met in-person. This approach reinforced the importance of their role and provided an opportunity for team dynamics and synergy development.
The QIT organized additional clinical design groups to further deliver on the Spine Guidance Team's population priorities and to help support the work of the Best Practice Committee (Fig. 2). These groups integrated feedback delivered by the Champions to improve processes supporting evidence-based care. The first design group undertook the Spine Guidance Team's priority to more immediately identify patients at risk for chronic LBP. Another work group focused on integrating directional preference treatment with psychosocial risk factors in order to deliver more efficient care. Yet another group helped physical therapists better understand how to optimize care for patients at low risk for disabling back pain. The development of these peer-led teams flattened the organizational hierarchy, involving more frontline clinicians directly in change efforts.
Operational structure of low back pain programming depicting accountabilities (solid line) and collaborations (dotted line).
Foster a Learning Environment Focused on Meeting a Population's Needs
The third tactic to deliver higher value physical therapy concentrated on continuing education curricula to support evidence-based care. The Best Practice Guide served as the foundation for continuing education curricula for both quality and cost of LBP care. Rather than promoting individual physical therapists' continuing education preferences, the physical therapy directors agreed to support a curriculum based on the identified population needs and the physical therapists' gaps in meeting those needs. Semiannually and before clinic hours, a QIT member dedicated to staff education and training hosted interactive, multidisciplinary case discussions to support physical therapists in acquiring knowledge. A population-specific online forum, accessible through the system Intranet, provided a centralized location for supportive resources that reinforced new knowledge and dialogue. Physical therapy skills-based classes, such as lumbar manipulation, directional preference, and motivational interviewing, enhanced physical therapists' competence and performance. Internal experts provided much of the curriculum at no additional cost to the system, and they hosted multiple refresher opportunities to further enhance the original and developmental learning processes. This theory-based, active approach created many options for acquiring best practice knowledge and skills while facilitating clinician engagement in the programming.
Continuously Collect and Analyze Outcomes Data
The fourth tactic used in this quality improvement effort addressed the Spine Guidance Team's priority for disciplined outcome data collection and reporting. The QIT built an LBP patient database in order to internally share provider-level progress toward delivering higher-value care. Responding to a local payer initiative in 2010, the outpatient physical therapy clinics collected first and last visit Oswestry Disability Index (ODI) scores on all patients with LBP. Literature notes subgrouping patients with LBP may be helpful to better understand the heterogeneous LBP population.13,23–26 Therefore, to also address the goal of identifying those at risk for chronic LBP, the QIT decided to have all patients with LBP complete a Keele STarT Back Tool (KSBT) starting in 2012.25 This 9-question survey assesses functional and psychosocial status and subgroup patients based on risk for long-term disability resulting from their back pain.25
In order to meaningfully share quality and cost data directly with physical therapists, the QIT created Clinician Profiles (Appendix 2). The Clinician Profiles presented value data by clinician, volume of various KSBT subgroups, mean change in ODI scores by risk level, and mean number of physical therapy visits per episode of LBP. Foremost, the Clinician Profiles were created to help physical therapists better understand their individual LBP practice, illuminating opportunities to improve their practice and gauge individual progress in effectively and efficiently treating this population. Twice a year, the Champions, rather than clinic directors or supervisors, shared and discussed the Clinician Profiles with their colleagues. For administration and the QIT, the Clinician Profiles provided a means to quickly identify and spread best practice, as well as target the use of continuing education funds. The Clinician Profiles were not used to financially incentivize or punish physical therapists.
The Clinician Profiles evolved based on frontline feedback from the Champions. Although programming targeted implementation of evidence-based care, some physical therapists believed the principal focus was reducing patient visits, which prompted the QIT to add a new metric to the Clinician Profiles: mean percentage of improvement in ODI scores per visit. This new metric helped physical therapists understand that value also can be improved through achieving better outcomes while maintaining the same number of visits.
Outcomes
Although the common health care definition of Value=Quality/Cost7 can be applied to any specialty, physical therapy lacks a standardized metric for the value of LBP care. The QIT decided to collect data that served as proxies for quality and cost in order to reflect both the numerator and denominator of the value equation. The primary quality measurement for this initiative was the change in functional disability between the first and last physical therapy visits as measured with the ODI. A visit is a single, in-person interaction between a physical therapist and a patient. The primary cost measurement was the number of physical therapy visits per LBP episode. An episode is the care from the initial physical therapy evaluation through physical therapy discharge.
Later in the project, in order to account for variations in the amount of therapy delivered in each visit, the QIT introduced physical therapy charges as a cost variable. Charges are the price of therapy to the payer before any contractual discounts. Charge data allowed the QIT to understand the impact of the programming efforts on the quality of care. Itemized charge data lists the types of therapy delivered and can measure change in application of guideline-adherent care (Appendix 3). As charge data are captured on all patients, changes in value can be measured for the whole population, not just for those patients completing first and last ODIs.
After applying the 4 theory-based tactics, the physical therapy clinics trended year-over-year improvement in the mean functional outcomes of patients with LBP (Fig. 3, graph A). The mean percentage of functional improvement for patients increased from the 2010 baseline of 25.2% per episode to 31.5% in 2014. Additionally, the efficiency of care improved as measured by the mean number of visits for all patients with LBP, which decreased from 6.7 visits per episode in 2010 to 5.4 visits per episode in 2014. The primary value metric of mean percentage of ODI improvement per visit improved from 3.8% per visit in 2010 to 5.8% in 2014 (Fig. 3, graph B). The KSBT subgrouping demonstrated that Fairview's patients with LBP responded differently to interventions, as evidenced by differing rates of clinical outcome improvement and utilization and overall value (Tab. 2).
Graphs demonstrating increased value in the physical therapy (PT) delivered. Data included for patients who completed a first visit Oswestry Disability Index (ODI) and a last visit ODI (n=17,078). (A) Change in disability, as measured with the ODI, and mean number of PT visits by year. (B) Mean percentage of change in ODI score per PT visit by year.
Yearly Patient-Reported Outcomes and Utilization Dataa
The secondary measurement of physical therapy charges aligning to evidence-based care demonstrated quality improvement. Physical therapists increased their application of guideline-adherent care from 66.2% of all LBP episodes in 2010 to 89.6% in 2014 (Tab. 3). Fairview used Fritz and colleagues' definition of guideline-adherent care: in patients with more than one visit of physical therapy, at least 75% of physical therapy charges represent active care (Appendix 3).26 This improvement serves as a proxy for improved patient outcomes.6 During this same time, the increase in physical therapy charges per LBP episode was 40% lower than the observed rate of inflation for individual units of physical therapy at Fairview.
Number of Patients Entering Physical Therapy for Management of Low Back Paina
Discussion
This administrative case report shows that the described theory-based, multitactic implementation of a quality improvement process demonstrated higher value care for patients with LBP, as measured by percentage of ODI improvement per visit. Unlike studies focusing on guideline implementation,8,12,20 this case report shows that an active, varied approach improved patient outcomes and reduced physical therapy utilization. Although these tactics are based on adult learning theory and change management practice, using them collectively to implement evidence-based care to improve the value of care is potentially unique. Unfortunately, given the design of this quality improvement project, it is not possible to determine which individual tactic or combination of tactics was the most effective.
Along the way, there were challenges in advancing this project. Not surprisingly, physical therapists and directors had many competing priorities. In addition to delivering high-quality care, physical therapists managed increased documentation and coding demands, various payer requirements, and electronic medical record updates. These requirements reduced physical therapists' ability to attend fully to a quality improvement effort. In order to optimize the ability to deliver in all of these competing areas, the clinic directors limited the amount of change to which the physical therapists were exposed at any one time. This approach resulted in a prolonged implementation cycle, nearing 2 years, with another 2 years of modification and reinforcement (Tab. 1). During these required breaks, the QIT leveraged the data to discover opportunities to optimize existing processes or lead smaller design groups to further support the overall programming and Spine Guidance Team priorities.
Throughout the first couple of years, the QIT also encountered resistance because many physical therapists treating patients with LBP found it to be a very challenging population; many physical therapists preferred to focus their skill and knowledge development on sport-related conditions. Feedback from physical therapists revealed that, as they learned more about the population they were treating through shared data, developed their knowledge through the Best Practice Guide, and improved their treatment skills through the LBP continuing education courses, their enjoyment for and confidence in delivering care for these patients increased. Celebrating year-over-year improvements, having a consistent and dedicated QIT team, and reinforcing a consistent long-term commitment to this quality improvement effort helped overcome this challenge.
Another challenge was difficulty securing the desired technology resources. Ideally, the Best Practice Guide would be integrated into the electronic medical record to guide care rather than only being available in print. Preferably, the Clinician Profiles would be refreshed monthly or on-demand to allow more time-sensitive provider and patient feedback. The QIT and directors overcame these challenges by moving forward with options that were better than previously available methods and not getting held back by waiting for the best option. For example, original data extraction from the electronic medical record began on a manual spreadsheet before securing additional IT resources to create an automated process.
Although the executive and directors fully embraced delivering better outcomes more efficiently, increased efficiency meant less revenue per episode for the clinics. This challenge is very real across all of health care as the US transitions from traditional fee-for-service to value-based payments. This challenge was overcome through consistent executive reinforcement and the belief that the discipline acquired through this project will serve as a foundation for future alternative payment models, such as bundled payments.
Despite the large number of patients and clinics involved in this quality improvement project, there are limitations. Only clinics within an integrated academic health system participated, although the change management and learning theories supporting the tactics can be applied in various environments. Although only 35.8% of patients had first and final ODI scores, all patients had charge data, which allowed the QIT to assess change in value for the whole population.
Going forward, the demand for higher-value physical therapy will continue, especially for the high-volume, high-cost populations. For clinicians, it will be important to understand how application of evidence-based care can affect the overall value of care experienced by patients with LBP. Similarly, it is important for policy makers to consider limiting reimbursement for guideline-nonadherent physical therapy, such as passive modalities, which do not improve value for patients with LBP. Administrators may glean practical applications from this case report, including effective program development and implementation tactics and pragmatic measurements of value.
Appendix 1.
ICD-9 Diagnosis Codes Used to Define Population With Low Back Pain
Appendix 2.
Sample of Clinician Profilesa
a LBP=low back pain, ODI=Oswestry Disability Index, OPPT=outpatient physical therapy, KSBT=Keele STarT Back Tool.
Appendix 3.
Treatment Codes Used to Define Guideline-Adherent Physical Therapy for Low Back Pain
Footnotes
Both authors provided concept/idea/project design, writing, data analysis, and project management. Ms McCathie provided data collection.
- Received January 20, 2015.
- Accepted September 9, 2015.
- © 2015 American Physical Therapy Association
References
Issue highlights
