From the 2018 HVPAA National Conference
Sarah Rosenberg-Wohl (University of California San Francisco), Raymond Gylys (University of California San Francisco), Christopher Holland (University of California San Francisco), L. Maurine Coco (University of California San Francisco), Ari Hoffman (University of California San Francisco)
Unnecessary referrals to physical therapy (PT) limit skilled therapists’ capacity to evaluate and treat the patients who most need their services.
- Define and describe unnecessary utilization of PT
- Reduce unnecessary utilization of PT
This program is based at an 800-bed academic teaching hospital in an urban setting and utilized electronic health record (EHR) data. We identified all hospitalized adult patients referred for PT between October 2016 and March 2017 (n=3,714). The annualized direct costs associated with inpatient adult PT evaluations totals $9.8 million. Our institution uses a mobility score as an objective measure of patient mobility, assessed on a scale of 0 (no activity) to 10 (able to walk >400 feet without assistance). We defined potentially unnecessary referral volume by the percentage of initial PT evaluations with a mobility score of 10 (16% in the study period). We changed the electronic order for PT referrals such that nonspecific indications were replaced with language specifically targeting appropriate reasons for referral, aiming to change behavior through clinical decision support embedded in the order itself. The new order was launched on March 16, 2017.
The primary outcome is the percentage of total PT referrals that are potentially unnecessary. We targeted a reduction from 16% to less than 10% using unpublished data from other academic medical centers as a benchmark. Secondary outcomes include total referral volume and the percentage of patients not seen due to staffing limitations (18% in the 12-month period prior to our intervention). Our balance measure is the rate of falls per 1,000 patient-days.
During the 6-months post-intervention, the average percentage of patients receiving an initial mobility score of 10 was 15.2%, a non-significant reduction from our pre-intervention number. However, when we refined our criteria to those patients for whom a PT referral was most likely to be unnecessary—those with an initial mobility score of 10 who were only seen once and who were discharged home, we did see a statistically significant reduction after our intervention, from an average of 27 per month to 7.25 per month (p < 0.001 by two-sided Student’s t-test). The total visit volume, percentage of patients not seen due to staffing limitations, and rate of falls were not statistically changed.
Passive clinical decision support was insufficient to change our primary or secondary outcomes, but post-hoc analysis showed a significant decrease in a subset of the potentially unnecessary PT referrals. Even if total volume of PT evaluations does not change, improved operational efficiency for rehab services allows therapists to see the patients most in need. This is the value proposition of our work. Gap analysis revealed many root causes of PT overuse—including culture, knowledge gaps, and others–that are not addressed by informatics interventions like ours.
Implications for the Patient
Critical first steps to optimize efficient use of skilled PT were accomplished. In the process of engaging key stakeholders to address this problem, the hospital created a Safe Mobilization Committee committed to changing the culture of mobility system-wide by facilitating safe patient handling, patient mobility, and falls prevention.