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To the Editor:
In their article, Leung et al1 conducted a retrospective analysis of workers’ compensation claims from one large Texas-based insurance company in an effort to assess the relationship between the amount of delivered physical therapy services and the totals for medical costs, indemnity costs, and lost-time from work. Following a thorough review of the article, we would like to point out a few areas of concern about how “Physical Therapy” is defined, methodology, and conclusions by the authors.
First, this article defines Physical Therapy (PT) by “the unique number of service dates associated with at least one PT code.” This definition is problematic and misleading because the codes analyzed are not billed solely by physical therapy professionals. The current procedural terminology (CPT) Codes that are referenced in Supplementary Appendix A (http://links.lww.com/JOM/A569) are primarily from the 97,000 series of CPT codes that are billed by multiple provider types including physicians, chiropractors, physical therapists, and occupational therapists. To validate the type of billing practitioner in large claims based studies, additional procedures are needed such as using practitioner identifiers (ie, national provider identifier number) or practitioner only codes (ie, PT evaluation or reevaluation codes). As the authors did not use additional methods to ascertain the identity of the practitioners billing the CPT, it does not seem appropriate to label the treatment delivered as “Physical Therapy (PT).”
In addition, by categorizing the first group of visits as zero to three, the authors combined two important categories into one, those whom no CPTs had billed in the 97,000 or no rehabilitation-type services from those who had one to three visits. As this category included the largest percentage of claims in both the indemnity and medical only claims groups, the reader is left wondering how many of these claims were never provided therapy services (zero visits) or only a small number of visits (one to three visits). Moreover, it is unclear as to the effect of not having therapy services on costs and, probably more important, outcomes.
Another problematic aspect of this study methodology was the author's use of combining multiple diagnoses within the indemnity and medical-only claims analysis. Combining unlike conditions like rotator cuff sprain and displacement of the lumbar intervertebral disc without myelopathy and generalizing on their episodic costs and rehabilitation needs fails to consider the potential variations expected in care, the important differences in the effects of comorbidities and effect of time to initial care.
This retrospective study design is inadequate to substantiate its conclusion that “repeated, professionally delivered treatments of 15 or more may actually impede the return-to-work process.” Guideline-based physical therapy is a safe and effective treatment for musculoskeletal conditions such as low back pain.2 The effectiveness of guideline based physical therapy is further substantiated by high quality studies cited in clinical practice guidelines for specific musculoskeletal conditions by the Academy of Orthopaedic Physical Therapy (https://www.orthopt.org/content/practice/clinical-practice-guidelines) and the American College of Occupational and Environmental Medicine (https://www.dir.ca.gov/dwc/MTUS/MTUS-Guidelines.html). In addition, well-designed studies have shown decreased cost and utilization of health care services including opioid use for patients with low back pain.3,4 In fact, research suggests that despite well-established evidence-based clinical practice guidelines, physical therapy services are significantly underutilized as compared with pharmacological therapies.5 We are not suggesting that over 15 visits is appropriate, however we believe that the answer lies in studies that use an health condition-specific, outcomes-based, and patient-centered approach to safely manage symptoms and address work participation barriers.
In terms of work-related conditions, evidence from a preponderance of high quality studies demonstrates that implementing an active approach to work rehabilitation improves the work status, work absence, and productivity of persons with work limiting or work restricting conditions. This has been accomplished using a variety of approaches such as functional restoration programs for patients with soft tissue injuries or low back pain,6,7 multidisciplinary integrated care,8 graded activity programs,9–11 workplace interventions,12 and a comprehensive rehabilitation program focused on self-regulation.13 Studies show reduced or equal cost comparing work rehabilitation to usual care.
Finally, we welcome health economic based studies that promote accountability for medical and indemnity costs in the workers’ compensation system. It is important to clearly define populations, conditions, interventions, and outcome measures that reflect more than just costs. Review of claims should consider the influence of other key variables that impact recovery, such as coordination of care, the skills and abilities of the therapy service provider, physical demands of the job, and availability of transitional duty to expedite recovery and reduce the need for additional therapy visits.14 Exceeding a certain threshold for number of visits for therapy should not be viewed as a cost driver, but rather as a prompt to further assess whether care is consistent with clinical practice guidelines and best practices to expedite safe and timely return to work.
1. Leung N, Tao XG, Bernacki EJ. The relationship of the amount of physical therapy to time lost from work and costs in the workers’ compensation system. J Occup Environ Med
2. Fritz JM, Cleland JA, Speckman M, Brennan GP, Hunter SJ. Physical therapy for acute low back pain: associations with subsequent healthcare costs. Spine (Phila Pa 1976)
3. Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Serv Res
4. Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Serv Res
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6. Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial injury. A prospective study with comparison group and one-year follow-up. Spine (Phila Pa 1976)
7. Corey DT, Koepfler LE, Etlin D, Day HI. A limited functional restoration program for injured workers: a randomized trial. J Occup Rehabil
8. Lambeek LC, Bosmans JE, Van Royen BJ, Van Tulder MW, Van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. BMJ
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11. Staal JB, Hlobil H, Twisk JWR, Smid T, Köke AJA, van Mechelen W. Graded activity for low back pain in occupational health care: a randomized, controlled trial. Ann Intern Med
12. Steenstra IA, Anema JR, van Tulder MW, Bongers PM, de Vet HCW, van Mechelen W. Economic evaluation of a multi-stage return to work program for workers on sick-leave due to low back pain. J Occup Rehabil
13. Gottlieb HJ, Koller R, Alperson BL. Low back pain comprehensive rehabilitation program: a follow-up study. Arch Phys Med Rehabil
14. Perry T, Cheung A, Asumbrado A, McBee K. Current concepts in occupational health: managing an acute injury that limits work participation. Orthop Phys Ther Pract