Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the effectiveness of physical therapy for the treatment of acute ambulatory and shoulder, hand, and finger injuries following an accident and/or surgery? (Question 1)

How do various physical therapy treatment modalities compare in terms of effectiveness? What is the amount of time / sessions needed to achieve maximum therapeutic value? We are particularly interested in physical therapy for acute shoulders, hands, fingers, and ambulatory conditions as follows:

• Carpel Tunnel Surgery
• Knee Surgery (tendon tears)
• Rotator cuff injuries
• Motor vehicle accident injuries, and strains, and falls resulting in broken limbs, joint strains, and ankle and knee injuries.

We are interested in a review of the evidence related to physical therapy assessment tools applicable to the above acute conditions. (Question 2) (See question 8 below for additional information related to assessment)

We are also interested in whether or not there is a maximum number of visits where therapeutic value is achieved and/or when therapy ceases to have a therapeutic value. (Question 3). (See Question 8 below for additional information related to this question related to medical necessity and maintenance care.)

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Different physical therapy treatment modalities. Is one modality, e.g., home vs. outpatient, more effective than another?

We are specifically interested in the following modalities represented in these (CPT) codes used frequently by physical therapists in our state: -97115 gait training (includes stair climbing) -97113 aquatic therapies and therapeutic exercises -97530 therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes -97535 self care/home management training direct one-on-one contact by provider, each 15 minutes

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

• Young adults (men and women), age 20-30, who have experienced an injury/trauma as a result of an accident and/or overuse injuries.
• Older adults (men and women), age 50-60+, who have experienced surgery/acute condition and/or are being treated for a chronic condition, such as arthritis, who are not ambulatory or require temporary assistive devices to be ambulatory, and who may have other co-morbidities such as diabetes, obesity, and arthritis.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

No

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Decrease in pain Increase in strength

Increase in ambulation Return to baseline activity level (pre injury or condition) and ability to return to normal activities, e.g., work. Maximum function of treated condition post injury or surgery (e.g. carpal tunnel surgery)

Describe any health-related risks, side effects, or harms that you are concerned about.

We are interested in knowing what, if any, specific risks and harms are as a result of therapy, e.g., permanent injuries or worsening of initial condition. Additionally we are interested in knowing if there are risks or potential adverse effects associated with some treatment modalities over others.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Functional limitations and disability

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Other

Importance

Describe why this topic is important.

Physical therapy (PT) is a significant cost burden for this state’s Fee for Service Medicaid program (92,000 members). PT is often prescribed/requested for 2-3 sessions a week for months (averaging 6-12 weeks). It is difficult for the state Medicaid program to determine medical necessity. The State pays for PT as long as the patient’s condition shows improvement, but they do not pay for maintenance care, but it is difficult to determine when therapeutic value ends and maintenance begins. It is also a challenge to gauge the value of care during the medical review solely based on the notes of the Physical Therapist. Consistency between PT reports vary greatly as there are no standardized PT therapy reports. This increases the difficulty in making coverage decisions. Three examples of recent reports provided by a PT justifying and requesting additional services are provided below –

• “Right arm strength improving”
• “Right arm strength 5 over 10”
• “Right arm strength over 5 lbs”

It is difficult for states to measure or assess treatment success, or to determine necessary length of treatment to return a patient to functionality. There is a need for established guidelines to assess physical therapy treatment (similar to what is available for assessing hemoglobin A1c levels in diabetics) including information on what treatments work best. There exists no standardized way to interpret or measure improvement. One scale, the Berg Balance Scale is used to assess functionality for some types of activities, e.g., sitting, picking up objects, standing on one leg, etc. and is seen as helpful but there is practice variation in its application and it is not applicable to all conditions or populations of interest. It is also not known what the evidence is for this scale.

We are interested in what assessments and/or metrics are available to assess and measure improvement in indicated conditions, what the evidence is for these assessments and whether or not they have been validated for the indicated conditions and populations.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

See above question 8. The state is looking at developing more objective methods for determining level of care needed based on medical necessity. A report on this topic would assist greatly in providing more objective information to support the development of policies to guide coverage decisions. Physical therapy is a high expense area for states. As such we are interested in learning about the available evidence so that we can ensure that we are making the best use of limited Medicaid resources and targeting them towards modalities and tools that are the most effective and produce the best outcomes for patients.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

See 8 and 9 above. We essentially want to know what physical therapy treatments work for these conditions and how best to assess treatments to enable us to make evidence-based coverage decisions.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

See 9 above.

Describe the timeframe in which an answer to your question is needed.

As soon as possible

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

A specific population of interest for this state is the Native American community, although this nomination applies to all populations enrolled in Medicaid. This state has a large Native American population that is covered by the State Medicaid Fee for Service program (92,000 members). The Native American population has a higher proportion of injuries and accidents as described above than the general population of the state resulting in higher utilization of PT services. The population is served both by the Indian Health Services (IHS) PT’s and private outpatient non-IHS providers. Most patients are seen in non-IHS outpatient settings.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

See 9 above.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program