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Delivery of Physical Therapy in the Acute Care

Setting: A Population-Based Study


Janet K. Freburger, Kendra Heatwole Shank, Stefanie R.
Knauer and Richard M. Montmeny
PHYS THER. 2012; 92:251-265.
Originally published online November 3, 2011
doi: 10.2522/ptj.20100337

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/92/2/251

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Research Report

Delivery of Physical Therapy


in the Acute Care Setting:
A Population-Based Study
Janet K. Freburger, Kendra Heatwole Shank, Stefanie R. Knauer,
Richard M. Montmeny
J.K. Freburger, PT, PhD, Cecil G.
Sheps Center for Health Services
Background. Population-based studies on physical therapy use in acute care are Research and Institute on Aging,
lacking. University of North Carolina at
Chapel Hill, 725 Airport Rd, CB
Objectives. The purpose of this study was to examine population-based, hospital 7590, Chapel Hill, NC 27599-
discharge data from North Carolina to describe the demographic and diagnostic 7590 (USA). Address all corre-
spondence to Dr Freburger at:
characteristics of individuals who receive physical therapy and, for common diag-
janet_freburger@unc.edu.
nostic subgroups, to identify factors associated with the receipt of and intensity of
physical therapy use. K. Heatwole Shank, MS, OTR/L,
Department of Allied Health Sci-
ences, University of North Caro-
Design. This was a cross-sectional, descriptive study. lina at Chapel Hill.

Methods. Hospital discharge data for 2006 2007 from the 128 acute care hospi- S.R. Knauer, MA, Department of
Sociology, University of North
tals in the state were examined to identify the most common diagnoses that receive Carolina at Chapel Hill.
physical therapy and to describe the characteristics of physical therapy users. For 2
of the most common diagnoses, logistic and linear regression analyses were con- R.M. Montmeny, PT, PhD, CHT,
CEA, Northern New England Spine
ducted to identify factors associated with the receipt and intensity of physical Center, Wentworth-Douglass Hos-
therapy. pital, Dover, New Hampshire.

[Freburger JK, Heatwole Shank K,


Results. Of the more than 2 million people treated in acute care hospitals, 22.5% Knauer SR, Montmeny RM. Deliv-
received physical therapy (mean age66 years; 58% female). Individuals with osteo- ery of physical therapy in the
arthritis (admitted for joint replacement) and stroke were 2 of the most common acute care setting: a population-
patient types to receive physical therapy. Almost all individuals admitted for a joint based study. Phys Ther. 2012;92:
replacement received physical therapy, with little between-hospital variation. 251265.]
Between-hospital variation in physical therapy use for stroke was greater. Demo- 2012 American Physical Therapy
graphic and hospital-related factors were associated with physical therapy use and Association
physical therapy intensity for both diagnoses, after controlling for illness severity and Published Ahead of Print:
comorbidities. November 3, 2011
Accepted: August 15, 2011
Limitations. Data from only one state were examined, and the studied variables Submitted: October 15, 2010
were limited.

Conclusions. The use and intensity of physical therapy for stroke and joint
replacement in acute care hospitals in North Carolina vary by clinical and nonclinical
factors. Reasons behind the association of hospital characteristics and physical ther-
apy use need further investigation.

Post a Rapid Response to


this article at:
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February 2012 Volume 92 Number 2 Physical Therapy f 251


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Delivery of Physical Therapy in the Acute Care Setting

I
n the past 2 decades, population- nership sponsored by the Agency for third-party payers due to the inclu-
based databases, patient registries, Healthcare Research and Quality sion of information on patients with-
and administrative health care (AHRQ).10 The HCUP databases can out insurance; they cover entire pop-
databases have become much more be used to research a broad range of ulations (ie, all acute care admissions
common. These databases, which health policy issues, including the in a state); and they often can be
often are quite large, also have cost and quality of health care, pat- linked to other databases to gather
become more accessible. Advances terns of health care use, access to additional information that may be
in computer technology and more health care, and outcomes of health useful. Studies also support the valid-
robust statistical software packages care. The Nationwide Inpatient Sam- ity of hospital discharge data for
have significantly decreased the cost ple (NIS), one of several HCUP data- accurately identifying diagnoses,
and computational time needed to bases, is the largest all-payer inpa- procedures (eg, joint replacement),
analyze these large databases. tient care database in the United and patient comorbidities.1316
States. Although the NIS is a power-
Despite the growth in and access to ful database for examining national Population-based databases, such as
large health care databases, use of trends in access to, use of, and qual- the NIS and SIDs, can be used to
these databases to conduct research ity of hospital inpatient care, its data answer basic questions about the
relevant to physical therapy has been are currently not detailed enough to prevalence of diseases and condi-
modest. Much of the work has examine physical therapy use in tions that are treated by physical
focused on the delivery of physical particular. therapists. For example, one could
therapy in the outpatient setting.1 4 determine the number of hospital
Some studies also have focused on The State Inpatient Databases (SIDs), admissions with diagnoses com-
physical therapy use by Medicare another set of HCUP databases, do monly treated by physical therapists
beneficiaries5,6 and patients in have the detail needed to examine (eg, stroke, hip fracture) and exam-
skilled nursing facilities.7 Few stud- physical therapy use. The SIDs con- ine changes over time to better
ies have been conducted on physical sist of state-specific hospital data- understand current and future work-
therapy use in the acute care setting. bases from 40 states.11 Each state force needs. Population-based data-
database contains all inpatient dis- bases also can be examined to iden-
We found 2 studies that examined charge abstracts from community tify the proportion of and types of
University HealthSystem Consortium hospitals in the state, essentially individuals receiving physical ther-
(UHC) data from 1996 to determine making the database population- apy for a given diagnosis, condition,
the relationship between physical based. The SIDs contain clinical and or disability to determine if there are
therapy use in the acute care setting nonclinical variables, including: diag- variations in care (eg, by hospital, by
and outcomes of care for stroke and noses, procedures, admission and state, over time), if patients are
joint replacement.8,9 One limitation discharge status, patient demograph- receiving appropriate care (eg, Are
of these 2 studies is that the data ics, insurance information, length of current practice guidelines being
were limited to academic health cen- stay (LOS), and total charges. Many followed?), and whether there are
ter hospitals that were members of of the SIDs also include detailed potential problems with access to
the UHC. Findings from these studies information on hospital charges, care (eg, Are people who are under-
may not be generalizable to other which allows for the examination of insured and minority populations
types of acute care hospitals. Data physical therapy use and intensity. less likely to receive physical ther-
from these studies also are outdated Some SIDs contain hospital, county, apy?). Information garnered from
considering the dramatic changes in and ZIP code identifiers that allow examinations of population-based
Medicare and other health insurance linkage to other data.11 health care databases can be used to
plan payment policies over the past identify areas that need improve-
15 years. The SIDs have a number of ment and to inform the development
strengths.12 They are relatively inex- of initiatives or interventions to
Current data on hospital inpatient pensive to obtain and use when com- improve the delivery and quality of
stays in the United States are avail- pared with the cost of similar data health care.
able to researchers through the collected through surveys or medical
Healthcare Cost and Utilization Proj- record abstraction; they are more This study examined 2006 and 2007
ect (HCUP). The HCUP is a family of reliable than other sources of data, data from the North Carolina SID to
health care databases, software tools, such as patient self-reporting of med- describe the demographic and diag-
and other products developed ical expenditures or diagnosis; they nostic characteristics of individuals
through a federal-state-industry part- are superior to data obtained from who receive physical therapy in

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Delivery of Physical Therapy in the Acute Care Setting

North Carolina community hospitals, POS Files. CMS POS files are cre- Final Analytic Data Set
to identify common diagnostic sub- ated quarterly from the Online Sur- Our final analytic data set, created by
groups, and to identify factors asso- vey and Certification Reporting Sys- merging the North Carolina SID data
ciated with the receipt of and inten- tem (OSCAR) database. The OSCAR and the hospital-level data, consisted
sity of physical therapy use. database is maintained by CMS in of 2,285,793 discharge records from
cooperation with state surveying 128 hospitals. Because this data set
Method agencies. State surveying agencies was a different subset for each study
North Carolina State Inpatient gather information from Medicare- objective and because results of our
Database and Medicaid-certified institutional analyses for objective 1 guided the
Our primary source of data was the providers (eg, hospitals, skilled nurs- analyses for objective 2, we present
North Carolina SID (2006 2007), ing facilities, home health agencies) the remainder of the methods by
which contains discharge abstracts via survey and standard CMS forms, study objective.
from the universe of all inpatient every 1 to 3 years, depending on
stays at short-term, acute care hospi- institution type.20 Data collected Objective 1: Demographic and
tals (N128) in North Carolina. Data include information on staffing, num- Diagnostic Characteristics of
were retrieved from the UB-92 (Uni- ber of beds, type of facility, and ser- Patients Who Received Physical
form/Universal Billing) claim form, vices provided. These data are Therapy
which is used by hospitals and health entered electronically into the We first identified all records that
care centers when submitting bills to OSCAR database by the state survey- had one or more physical therapy
Medicare and other third-party pay- ing agency and are used by CMS to charges associated with them
ers for reimbursement of health care certify or maintain certification of (n512,018) (Fig. 1). Because there
services.11 The database contains institutional providers. Data ele- were more than 500 primary ICD-
one record for each hospital dis- ments are checked during data entry 9-CM diagnostic codes associated
charge. Data include the following for extreme values or extreme with these records, we used AHRQs
sociodemographic information: age, changes in values from the previous Single-Level Clinical Classification
race, sex; insurance information; data collection year.20 The POS file Software (CCS)23 to group these
geographic information: patient (last quarter of 2006) was used to codes into broader diagnostic cate-
county, patient zip code, hospital obtain data on hospital size (ie, num- gories. These diagnostic categories
county, hospital zip code; clinical ber of beds), for-profit status, medi- may be more useful for conducting
information: diagnoses, procedures, cal school affiliation, and physical descriptive and other types of anal-
LOS, source of admission (eg, home, therapist full-time equivalents (FTEs). yses, particularly when examining
emergency department, nursing a diverse clinical group. The spe-
home), discharge status (eg, home, Hospital Cost Reports. Hospital cific ICD-9-CM codes associated
skilled nursing facility); and charge Cost Report data are obtained from with each CCS diagnostic category
data: revenue codes and charges the Healthcare Cost Report Informa- are presented in the CCS users
for services provided (eg, intensive tion System (HCRIS) database main- manual.23
care unit charges, physical therapy tained by CMS. Information in the
charges), and total charges. Hospital HCRIS database are collected and Once the diagnostic categories were
identification numbers (ie, Centers supplied by Medicare fiscal interme- assigned, we tabulated these catego-
for Medicare and Medicaid Services diaries.21 Data from 2006 were used ries overall and by age categories.
IDs; American Hospital Association to determine whether the hospital We also conducted descriptive anal-
IDs), as well as the county and zip used contract physical therapists and yses of the demographic and
code information, allow linkage to had an affiliated inpatient rehabilita- hospital-related characteristics of the
other data sets. tion facility. sample. All analyses were conducted
using Stata version 10.1 (StataCorp,
Hospital-Level Data Area Resource File. The ARF is a College Station, Texas).
Data on hospital characteristics were national, county-level health resource
obtained from the Centers for Medi- information database supported by Objective 2: Factors Associated
care and Medicaid Services (CMS) the Department of Health and With Use and Intensity of
Provider of Services (POS) Files,17 Human Services.22 We used data Physical Therapy for Common
CMS Hospital Cost Reports,18 and from the 2006 2007 ARF19 to indi- Diagnostic Subgroups
the Area Resource File (ARF).19 cate whether the hospitals county Based on our analyses for objective
was located in a metropolitan or non- 1, the 3 most common diagnostic
metropolitan area. categories for individuals who

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Delivery of Physical Therapy in the Acute Care Setting

Figure 1.
Sample development. PTphysical therapy.

received physical therapy were fitting of prostheses and rehabilita- Study variables. Based on clinical
osteoarthritis (OA), rehabilitation tion care use. The V-codes are sup- experience and the body of litera-
care, and acute cerebrovascular dis- plementary and intended to indicate ture on health care utilization, we
ease (Tab. 1). Because almost all indi- a reason for care in patients who hypothesized that individual and
viduals with a primary diagnosis of have already been treated for a dis- hospital-level factors would affect
OA were in the hospital for a lower- ease or injury not currently present, whether and the extent to which
extremity joint replacement, our first who have residual impairments, or individuals received physical therapy
common diagnostic subgroup com- who may be receiving care to pre- in the acute care setting. For each
prised patients with lower-extremity vent recurrence.24 Because individu- diagnostic subgroup, we generated 2
joint replacement. Any individual als in this category represent a het- dependent variables: (1) a dichoto-
record with a diagnostic category of erogeneous group in regard to mous variable to indicate whether
OA and a primary procedure of a hip underlying diagnosis, we chose car- the individual received any physical
or knee joint replacement or revision diovascular accident (CVA) (the next therapy and (2) a measure of phys-
(ICD-9-CM procedure codes: 81.51 most common diagnostic subgroup) ical therapy intensity for those
81.55) was placed in this subgroup as our second diagnostic subgroup. who did receive physical therapy.
(n49,653). Because information on number of
Sample. To conduct analyses visits was not available, we used data
Rehabilitation care was the second examining factors associated with on physical therapy charges to cre-
most common diagnostic category physical therapy use, we needed to ate our measure. In preliminary anal-
(Tab. 1). Individuals in this diagnostic include participants in the same yses we found that charging prac-
category had one of the following pri- diagnostic categories who did not tices varied across hospitals and that
mary ICD-9-CM codes: V52.0, V52.1, receive physical therapy. Our final hospitals with high total charges also
V52.4, V52.8, V52.9, V53.8, V57.0, samples for the joint replacement had high physical therapy charges.
V57.1, V57.2, V57.21, V57.22, V57.3, and stroke subgroups were n49,653 We, therefore, chose to standardize
V57.4, V57.81, V57.89, V57.9, and and n26,422, respectively (Fig. 1). our measure of physical therapy
V58.82, which are associated with the intensity by dividing physical ther-

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Delivery of Physical Therapy in the Acute Care Setting

apy charges by total charges. This those that were related to our out- comes and incentives at for-profit
measure also accounts for the fact comes in preliminary analyses. For hospitals differ from those at other
that charges often are not reflective the joint replacement data, we hospitals.36,42
of true costs (eg, what is paid by included the following indicators
the insurer or what it costs the hos- (0no, 1yes): diabetes (with or Data Analysis. For both the stroke
pital to deliver the care). Because without complications), obesity, and joint replacement samples, we
our measure of physical therapy chronic pulmonary disease, rheuma- conducted multivariable logistic
intensity (total physical therapy toid arthritis, neurological disorder regression analyses to identify deter-
charges/total charges) was derived, or paralysis, and congestive heart minants of physical therapy use and
we conducted sensitivity analyses to failure2729; and for the stroke data: multivariable linear regression analy-
determine how our results changed congestive heart failure, diabetes ses to identify factors associated with
using total physical therapy charges with complications, depression, psy- physical therapy intensity (physical
and physical therapy charges per day choses, renal failure, and chronic therapy charges/total charges), con-
as measures of physical therapy obstructive pulmonary disease.30 33 ditional on receiving physical ther-
intensity. apy. Due to the skewed distribution
We also included condition-specific of physical therapy charges/total
Independent variables included variables for both data sets. For the charges, we transformed this vari-
patient-level demographic character- joint replacement data set, we cre- able by taking its natural log. Our
istics: age, sex, race (white, non- ated dichotomous variables to indi- multivariable analyses were limited
white, missing), and insurance cate whether the procedure was a to individuals who survived their
(Medicare/private/other, Medicaid, revision or a hip replacement (versus inpatient stay and to hospitals that
or uninsured); and measures of ill- knee replacement) and whether the had at least 10 admissions for stroke
ness severity: admission through the individual had a hip fracture.34 For or joint replacement over the 2-year
emergency department, LOS (cate- the stroke data set, we created period (n32,139 for the stroke
gorized by tertiles because of the dichotomous variables to indicate sample; n49,684 for the joint
skewed nature of the data), and whether the stroke was hemorrhagic replacement sample). When con-
comorbidities. We created our and whether the individual had atrial ducting our multivariable analyses,
comorbidity measures based on the fibrillation.31,35 The condition- we used the cluster option in Stata to
work of Elixhauser et al,25 who specific variables were created by account for the fact that measures
developed a comprehensive set of examining the ICD-9-CM procedure from the same hospital were not
30 comorbidity measures for use and diagnostic codes. independent and were likely more
with large administrative inpatient highly correlated than measures
databases. These measures were cre- Hospital variables included hospital from different hospitals.43 The clus-
ated using secondary ICD-9-CM diag- bed size (categorized by tertiles), ter option uses the Huber-White
nostic codes and include comorbidi- which served as an indirect measure sandwich estimator of variance to
ties such as diabetes, hypertension, of procedure or diagnosis volume correct the standard errors of the
congestive heart failure, and so on. A (both stroke and joint replacement parameter estimates (eg, the odds
table of the codes associated with volume have been shown to be pos- ratio in the logistic regression analy-
each of the comorbidity measures is itively associated with higher quality sis or the beta coefficient in the lin-
available on AHRQs Web site.26 of care36 39); whether the hospital ear regression analysis), which may
Because Elixhauser and colleagues had a major medical school affilia- be smaller due to the correlation of
found the independent effects of tion, an additional indicator of measures within hospitals. Not cor-
each of the comorbidity measures higher-quality care40,41; urban or recting the standard errors can lead
varied by patient population, they rural location of hospital; whether to the conclusion that findings are
suggested using the comorbidity the hospital had an affiliated rehabil- statistically significant when they are
measures as separate indicators in itation facility; the use of contract not.
analyses, rather than creating a physical therapists; and physical
count. therapist FTEs per 1,000 admissions Less than 0.1% of the records
(categorized by tertiles). The latter 2 (n907 for joint replacement sam-
Rather than including all 30 comor- variables represented measures of ple; n511 for stroke sample) had
bidities, we limited our list to those physical therapist supply. We also missing insurance data. These
that had support for inclusion based included a variable to indicate the records were dropped from the mul-
on the literature, those that occurred for-profit status of the hospital, as tivariable analyses. Because a large
with a frequency of at least 2%, and literature suggests that patient out- percentage of race data were miss-

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256
Table 1.

f
Top 15 Agency for Healthcare Research and Quality Single-Level Clinical Classification Software (CCS) Diagnostic Categories Associated With Receipt of Physical Therapy,
Overall and by Age Groupa
Overall (n512,018) <1 y 118 y 1945 y 4664 y >65 y
(% of Sample) (0.7%) (1.9%) (10.5%) (25.7%) (61.1%)

CCS Category % CCS Category % CCS Category % CCS Category % CCS Category % CCS Category %

Osteoarthritis 8.4 Liveborn 56.1 Leg fractures 14.03 Leg fractures 9.2 Osteoarthritis 12.7 Osteoarthritis 7.9

Physical Therapy
Rehabilitation 5.8 Low birth weight 8.8 Other bone/MSK 6.3 Back problems 8.6 Back problems 6.3 CVA 5.7
(V codes) disease

CVA 5.3 Other perinatal 6.1 Rehabilitation 6.0 Rehabilitation 5.8 Rehabilitation 6.3 Rehabilitation (V 5.6
conditions (V codes) (V codes) (V codes) codes)

Back problem 4.2 Cardiac congenital 5.3 Intracranial Injury 5.3 Other fractures 3.4 CVA 5.6 Hip fracture 5.1
anomalies

Pneumonia 3.8 Respiratory distress 2.3 Pneumonia 4.4 Device 3.2 Device 4.1 CHF, 5.0
syndrome complications complications nonhypertensive

Volume 92 Number 2
CHF 3.7 Bronchitis 1.6 Crushing/internal 3.7 Osteoarthritis 3.1 Leg fractures 3.2 Pneumonia 4.9
injury

Hip fracture 3.6 Other nutrition, 1.5 Other fractures 3.5 Acute CVD 2.9 Diabetes with 2.6 Back problems 2.7
endocrine, complications
metabolic disorders

Leg fracture 2.9 Other congenital 1.3 Other congenital 3.2 Crushing/internal 2.8 Respiratory failure 2.3 Septicemia 2.7
Delivery of Physical Therapy in the Acute Care Setting

anomalies anomalies injury

Device 2.8 Respiratory failure 1.1 Device 2.7 Intracranial Injury 2.7 CHF, 2.3 UTI 2.4
complications complications nonhypertensive

Septicemia 2.3 Pneumonia 1.0 Burns 2.6 Skin/subcutaneous 2.7 Pneumonia 2.2 COPD 2.3
infections

Respiratory failure 2.0 Device complications 1.0 Other acquired 1.9 Other bone/MSK 2.7 Septicemia 2.0 Acute MI 2.3
deformities disease

Acute MI 2.0 Nervous system 0.9 Skin/subcutaneous 1.8 Diabetes with 2.1 Procedure 2.0 Device 2.3
congenital infections complications complications complications
anomalies

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COPD 1.9 Rehabilitation 0.8 Open wound, 1.8 Device 2.0 Acute MI 1.8 Respiratory failure 2.0
extremities complications

Other fracture 1.7 Esophageal disorders 0.7 Infective arthritis, 1.6 Septicemia 1.5 Other heart 1.6 Fluid/electrolyte 2.0
osteomyelitis disease disorders

UTI 1.7 Immunity disorders 0.7 Other nervous 1.6 Other nervous 1.4 Skin/subcutaneous 1.6 Acute renal failure 2.0
system system infections
disorders disorders

Other 48.1 Other 10.9 Other 39.7 Other 46.1 Other 43.4 Other 45.3
a
MSKmusculoskeletal, CVAcerebrovascular accident, CHFcongestive heart failure, CVDcardiovascular disease, UTIurinary tract infection, COPDchronic obstructive pulmonary disease,
MImyocardial infarction.

February 2012
Delivery of Physical Therapy in the Acute Care Setting

Table 2.
Sample Characteristicsa

PT Users Stroke Arthroplasty


(n512,018) (n35,803b) (n50,141b)
Demographic characteristics

Mean (SD) age (y), [IQR] 66.1 (18.8) [5680] 69.1 (15.2) [5981] 67.6 (11.9) [5976]
Age category (%)
1y 0.7 0.0 0.0

118 y 1.9 0.3 0.0

1944 y 10.5 6.8 3.4

4564 y 25.7 29.3 36.7

65 y and older 61.1 63.6 59.9

Female (%) 57.7 52.8 65.3


Race (%)
White 42.1 40.5 50.3

Black 9.9 13.7 7.4

Other 2.3 2.1 1.8

Missing 45.8 43.7 40.5


Insurance (%)
Medicare 65.4 64.0 60.7

Private 12.2 14.7 20.9

Medicaid 7.4 6.6 2.9

Other 7.3 7.6 10.1

Self-pay/uninsured 3.9 5.7 1.0

CHAMPUS/government 2.7 1.3 3.6

Workers compensation 1.0 0.1 0.9


Hospital-related characteristics
Emergency department admission (%) 48.1 73.5 11.0

Mean (SD) length of stay (d) [IQR] 8.50 (9.49) [310] 6.4 (7.3) [37] 4.3 (5.5) [35]
Discharge status (%)
Home 38.3 34.0 12.9

Home health 25.8 13.4 47.2

Skilled nursing facility 22.7 19.3 27.9

Other short-term hospital 1.80 3.1 0.5

Rehabilitation facility 5.54 14.8 9.7

Expired 2.46 10.4 0.9

Other institutionc 2.05 2.4 0.8

Unknown 1.19 2.4 0.1

Left against medical advice 0.18 0.4 0.0


Received PT (%) 100 73.8 99.0

Median total charges,d [IQR] $20,773 [$11,808$36,218] $15,394 [$10,300$25,134] $30,850 [$25,038$37,790]

Median total PT charges,d [IQR] $1,121 [$274$1,023] $634 [$188$1,253] $912 [$656$1,240]

Median PT charges/day,d [IQR] $145 [$50.40$189] $176 [$103$274] $243 [$180$328]


d
Median PT charges/total charges (%), [IQR] 4.9 [1.44.8] 4.9 [2.87.8] 3.0 [2.24.0]
No. of hospitals 122 112 93
a
PTphysical therapy, IQRinterquartile range.
b
Includes individuals who did and did not receive PT.
c
Federal, intermediate care, psychiatric, or long-term care.
d
Conditional on receiving PT.

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Delivery of Physical Therapy in the Acute Care Setting

approximately 5% of the total


charges. Almost 50% of the sample
was admitted to the hospital through
the emergency department, and
more than half of the sample was
discharged to post-acute care (ie,
home health, rehabilitation facility,
skilled nursing facility). Differences
in demographic and hospital-related
characteristics by diagnosis were
present.

Variation of Physical Therapy Use


by Hospital
Figure 2 presents data on variation in
physical therapy use by hospital for
the stroke and joint replacement
Figure 2. samples. There was considerable
Percentage of patients receiving physical therapy (PT) by hospital. Each circle represents between-hospital variation in use of
a hospital. physical therapy for stroke. The
mean (SD) and median (interquartile
range [IQR]) percentages of patients
ing, we created a dummy variable to the second or third most common with stroke who received physical
identify those records with missing category overall and for all age therapy at each hospital (n122)
data. This variable allowed us to categories. were 71% (12%) and 73% (66%
retain those records, which other- 79%), respectively. In contrast, there
wise would have been dropped in The 5 most common secondary diag- was very little between-hospital vari-
the multivariable analyses. No other noses associated with individuals ation in the use of physical therapy
variables had missing values. who had rehabilitation as the pri- for joint replacement. The mean
mary diagnostic category were: (SD) and median (IQR) percentages
Role of the Funding Source V54.81 aftercare after joint replace- of patients who received physical
This study was funded, in part, by ment, V599.0 urinary tract infection, therapy at each hospital (n93)
the Division of Physical Therapy, V427.31 atrial fibrillation, V438.20 were 98% (2%) and 99% (99%
University of North Carolina at Cha- late effects of cerebrovascular dis- 100%), respectively. Hospitals with
pel Hill. ease, and V428.0 congestive heart percentages lower than 90 (n7)
failure. These 5 diagnoses accounted had fewer admissions overall. Three
Results for 20% of the records. of these hospitals had 10 or fewer
Of the more than 2 million patients joint replacement admissions over
discharged from short-term, acute Characteristics of Physical the 2-year period.
care hospitals in North Carolina in Therapy Users
2006 2007, 22.4% received physical Demographic and hospital-related Factors Associated With the
therapy during their inpatient stay. characteristics for physical therapy Receipt and Intensity of Physical
users and for individuals who had a Therapy
Common Diagnostic Categories stroke or joint replacement are pre- Table 3 presents results of our mul-
Table 1 presents the 15 most com- sented in Table 2. Physical therapy tivariable regression analyses on
mon diagnostic categories associated users had a mean age of 66 years, physical therapy use for stroke. Fac-
with physical therapy use for the 58% were female, and 42% were tors positively associated with phys-
entire sample and by age category. white, although race data were miss- ical therapy use (odds ratios signifi-
Osteoarthritis was the most common ing for almost half of the sample. A cantly greater than 1.00) included
category overall and for individuals majority of the sample was 65 years older age, being on Medicaid insur-
older than 45 years of age. Leg frac- or older and had Medicare insurance. ance relative to Medicare/private/
tures were the most common diag- Median total physical therapy other, being uninsured relative to
nostic category for individuals 1 to charges were $1,121 for all physical Medicare/private/other, having an
45 years of age. Rehabilitation was therapy users, which represented emergency department admission,

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Delivery of Physical Therapy in the Acute Care Setting

Table 3.
Factors Associated With Use of Physical Therapy for Strokea

Any PT Useb Intensity of PT Usec


Odds Beta
Ratio 95% CI P Coefficient 95% CI P

Demographic characteristics

White (ref) 1.00 .00

Non-white 1.14* 0.98 1.34 .091 .01 0.06 0.07 .83

Race missing 1.08 0.85 1.38 .513 .06 0.10 0.21 .47

Age/10 d
1.17*** 1.13 1.22 .001 .09*** 0.07 0.11 .001

Female 0.95 0.90 1.01 .094 .03** 0.05 0.00 .02

Medicare/private/other (ref) 1.00 .00

Medicaid 1.31*** 1.13 1.51 .001 .14*** 0.10 0.19 .001

No insurance 1.15** 1.02 1.31 .03 .02 0.03 0.07 .36

Illness severity/comorbidities

Emergency department admission 1.27*** 1.12 1.45 .001 .09 0.22 0.04 .18

LOS4 days (ref) 1.00 .00

LOS 46 days 3.02*** 2.82 3.23 .001 .10*** 0.06 0.14 .001

LOS6 days 6.03*** 5.20 6.99 .001 .05 0.07 0.17 .38

Atrial fibrillation 0.88*** 0.81 0.96 .005 .02 0.05 0.01 .18

Hemorrhagic stroke 0.41*** 0.36 0.46 .001 .38*** 0.42 0.15 .001

Congestive heart failure 0.89** 0.80 0.98 .02 .04* 0.08 0.00 .05

Diabetes with complications 1.13* 0.99 1.28 .07 .01 0.05 0.04 .68

Psychoses 1.06 0.82 1.37 .66 .01 0.09 0.06 .73

Depression 1.38 0.52 3.66 .52 .42** 0.16 0.67 .002

Renal failure 0.94 0.80 1.11 .45 .14*** 0.20 0.08 .001

COPD 1.08 0.97 1.19 .15 .04** 0.08 0.01 .005

Hospital characteristics

Urban location 1.10 0.83 1.46 .52 .14 0.04 0.32 .13

No. of bedslow (ref) 1.00 .00

No. of bedsmedium 1.26 0.83 1.90 .28 .20 0.70 0.30 .43

No. of bedshigh 1.16 0.72 1.87 .53 .36 0.94 0.21 .21

Major medical school affiliation 1.51*** 1.20 1.90 .001 .11 0.34 0.13 .36

For-profit hospital 1.01 0.72 1.41 .96 .20** 0.37 0.03 .03

PT FTEslow (ref) 1.00 .00

PT FTEsmedium 1.24 0.95 1.62 .12 .02 0.17 0.20 .87

PT FTEshigh 1.14 0.82 1.57 .43 .12 0.12 0.35 .33

Uses contract physical therapists 0.72* 0.51 1.01 .06 .07 0.24 0.10 .42

Affiliated rehabilitation unit or facility 0.94 0.73 1.21 .63 .02 0.14 0.18 .83

R .10
2

a
PTphysical therapy, CIconfidence interval, refreference, LOSlength of stay, COPDchronic obstructive pulmonary disease, FTEfull-time equivalent.
* P.10, ** P.05, *** P.01. Significant values are shown in bold type.
b
n31,628.
c
Conditional on receiving PT (n25,016), dependent variable: natural logarithm of PT charges/total charges.
d
Age/10 is age divided by 10; therefore, the effect (ie, odds ratio) is based on a 10-year change in age.

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Delivery of Physical Therapy in the Acute Care Setting

having an LOS greater than 4 days, or procedure, or having a hip replace- lems. Joint replacement often is an
being seen at a hospital with a major ment was associated with a lower elective procedure, with patients
medical school affiliation. Having intensity of physical therapy. Individ- having a choice of physicians and
congestive heart failure, atrial fibril- uals seen in urban hospitals received hospitals. Stroke, on the other hand,
lation, or a hemorrhagic stroke was higher-intensity physical therapy, is an event that occurs unexpect-
negatively associated with physical whereas those in for-profit hospitals edly. Where the patient is (ie, geo-
therapy use (odds ratios significantly or hospitals that used contract phys- graphically) at the time of the stroke
less than 1.00). ical therapists received lower- will greatly affect where he or she is
intensity physical therapy. admitted.
Of those who received physical ther-
apy, intensity of physical therapy use Sensitivity Analyses On average, 98% of individuals who
was higher (beta coefficients posi- Findings of our multivariable linear were admitted for a joint replace-
tive and significantly greater than 0) regression analyses using physical ment procedure in North Carolina
for older individuals, individuals on therapy charges or physical therapy hospitals received physical therapy.
Medicaid relative to Medicare/pri- charges per day (rather than physical There also was little variation in
vate/other, individuals with an LOS therapy charges/total charges) were physical therapy use across hospi-
from 4 to 6 days, relative to those similar, with the exception of one tals. Although we do not understand
with an LOS less than 4 days, and variable: urban location of the hospi- fully the effectiveness of physical
individuals with depression. Inten- tal. In the stroke models, urban loca- therapy in the acute care of patients
sity of physical therapy use was tion became significant. In the joint after joint replacement, particularly
lower (ie, beta coefficients signifi- replacement models, urban location in regard to longer-term outcomes,
cantly less than 0) for females and became nonsignificant. some studies suggest that starting
individuals with hemorrhagic stroke, rehabilitation as soon as possible
renal failure, or chronic obstructive Discussion after surgery leads to better out-
pulmonary disease. To our knowledge, this is one of the comes.47 49 Most current guidelines
first population-based studies exam- for postoperative, acute care after
Factors positively associated with ining physical therapy use in acute joint replacement also recommend
physical therapy use for joint care. We have reported on a number physical therapy.50 In addition,
replacement (Tab. 4) included lon- of findings related to the characteris- patients and health care providers
ger LOS, being seen at larger hospi- tics of patients who receive physical believe physical therapy is useful in
tals, and being seen at hospitals with therapy in acute care settings, as the acute care setting.51 The fact that
major medical school affiliations. well as determinants of physical most individuals who undergo joint
Factors negatively associated with therapy use and intensity for individ- replacement in North Carolina hos-
physical therapy use were having a uals with stroke or lower-extremity pitals receive physical therapy is
revision procedure, hip fracture, or joint replacement. Approximately consistent with current best evi-
hip replacement (relative to knee); one quarter of patients admitted to dence and guidelines.
and being seen at a hospital that used short-term, acute care hospitals in
contract physical therapists. Of par- North Carolina receive physical ther- On average, 70% of patients admitted
ticular note is the imprecision of apy. These users are older, with a to North Carolina hospitals for treat-
some parameter estimates (ie, LOS majority insured by Medicare. Osteo- ment of stroke received physical
variables, medical school affiliation arthritis and stroke were 2 of the therapy. Between-hospital variation
variable). This imprecision was most common diagnostic categories in the percentage of patients who
because most people received phys- to receive physical therapy, which received physical therapy was
ical therapy, which led to small cell is consistent with the literature on greater than for joint replacement.
sizes for some of the cross tabula- the growth in joint replacement Although a shorter LOS was associ-
tions (eg, physical therapy use by procedures44,45 and the incidence of ated with a decreased likelihood of
medical school affiliation). stroke.46 Both are common reasons physical therapy use, even when we
for acute care hospitalizations. limited our sample to individuals
Of those who received physical ther- who survived their inpatient stay
apy, older individuals, females, and Our analyses of determinants of and were in the hospital for at least
those with a longer LOS received a physical therapy use for joint 3 days, only 85% of the sample
higher intensity of physical therapy. replacement and stroke provide an received any physical therapy. When
The presence of comorbidities, hav- opportunity to compare and contrast looking at the percentage of individ-
ing a hip fracture, having a revision findings on 2 very different prob- uals who received physical therapy

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Delivery of Physical Therapy in the Acute Care Setting

Table 4.
Factors Associated With Use of Physical Therapy for Joint Replacementa

Any PT Useb Intensity of PT Usec


Odds Beta
Ratio 95% CI P Coefficient 95% CI P

Demographic characteristics

White (ref) 1.00 .00

Non-white 0.44* 0.19 1.03 .06 .02 0.05 0.02 .45

Race missing 1.54 0.78 3.01 .21 .14* 0.00 0.27 .05

Age/10 d
0.95 0.79 1.14 .56 .02*** 0.01 0.03 .001

Female 1.00 0.75 1.32 .99 .03*** 0.02 0.05 .001

Medicare/private/other (ref) 1.00 .00

Medicaid 2.02 0.61 6.71 .25 .00 0.04 0.04 .99

No insurance 1.07 0.32 3.50 .92 .02 0.08 0.05 .61

Illness severity/comorbidities

Emergency department admission 0.81 0.34 1.93 .64 .07* 0.14 0.00 .06

LOS 3 days (ref) 1.00 .00

LOS 34 days 8.03*** 1.85 34.88 .005 .39*** 0.31 0.46 .01

LOS 4 days 14.78*** 2.33 93.86 .004 .57*** 0.48 0.66 .01

Hip fracture 0.28** 0.09 0.86 .03 .12*** 0.19 0.04 .003

Hip replacement 0.75** 0.59 0.95 .02 .07*** 0.12 0.02 .008

Revision procedure 0.29*** 0.14 0.60 .001 .26*** 0.37 0.15 .001

Diabetes 1.03 0.63 1.70 .90 .01 0.03 0.05 .64

Obesity 1.54 0.70 3.37 .29 .03 0.02 0.07 .25

COPD 0.83 0.52 1.32 .42 .02** 0.03 0.00 .03

Rheumatoid arthritis 1.70* 0.98 2.96 .06 .03* 0.06 0.00 .08

Neurological conditions 1.16 0.53 2.56 .71 .03** 0.06 0.00 .03

CHF 0.60 0.29 1.24 .17 .07*** 0.10 0.05 .001

Hospital characteristics

Urban location 0.44 0.15 1.22 .12 .18** 0.02 0.33 .03

No. of bedslow (ref) 1.00 .00

No. of bedsmedium 1.12 0.53 2.37 .77 .16* 0.00 0.32 .06

No. of bedshigh 4.62*** 1.97 10.86 .001 .05 0.23 0.13 .56

Major medical school affiliation 6.52** 1.39 30.70 .02 .03 0.23 0.17 .74

For-profit hospital 0.40 0.12 1.34 .14 .19** 0.37 0.01 .04

PT FTEslow (ref) 1.00 .00

PT FTEsmedium 1.57 0.63 3.93 .34 .06 0.22 0.10 .45

PT FTEshigh 0.82 0.29 2.33 .72 .01 0.13 0.11 .84

Uses contract PTs 0.28*** 0.13 0.62 .002 .13** 0.25 0.01 .04

Affiliated rehabilitation unit or facility 1.12 0.54 2.31 .76 .07 0.10 0.25 .41

R2.12
a
PTphysical therapy, CIconfidence interval, refreference, LOSlength of stay, COPDchronic obstructive pulmonary disease, CHFcongestive heart
failure, FTEfull-time equivalent. * P.10, ** P.05, *** P.01. Significant values are shown in bold type.
b
n48,777.
c
Conditional on receiving PT (n48,288), dependent variable: natural logarithm of PT charges/total charges.
d
Age/10 is age divided by 10; therefore, the effect (ie, odds ratio) is based on a 10-year change in age.

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Delivery of Physical Therapy in the Acute Care Setting

by hospital, 5 of the hospitals had were less likely to receive physical The reasons for this finding are
proportions below 70%. therapy. These 2 variables are prox- unclear. Further exploration of the
ies for greater illness severity.34,62 accuracy of the measure may pro-
As with joint replacement, our vide some insight. Although there is
understanding of the effectiveness of With respect to hospital characteris- a growing body of literature on the
physical therapy for the acute care of tics, we found that individuals who relationship between higher nurse
patients with stroke is limited. Sev- were seen at hospitals with major staffing and better quality of
eral current stroke guidelines recom- medical school affiliations (ie, aca- care,63,64 little has been done in the
mend mobilization and assessment demic health centers) were more area of rehabilitation staffing. Such
by rehabilitation professionals as likely to receive physical therapy for information would be useful for
soon as possible after an acute care stroke and joint replacement. Assum- determining optimal staffing levels
admission.5255 Recommendations of ing the receipt of physical therapy for physical therapy.
the Northeast Cerebrovascular Con- for these conditions is appropriate
sortium are that all patients admitted and necessary (considering current In the models that examine factors
to the hospital for stroke be evalu- evidence and guidelines), this find- associated with the intensity of
ated by a physical therapist and an ing supports other literature that sug- physical therapy use, females with
occupational therapist.56 Incorporat- gests, at least for some aspects of stroke received lower-intensity
ing rehabilitation into stroke unit care, academic health centers deliver physical therapy, whereas females
care also has been shown to be one higher-quality care.40,41 with joint replacement received
of the key components in disability higher-intensity physical therapy.
reduction after stroke.57 Considering We also found that hospital size was These findings need further explora-
current evidence and guidelines, associated with use of physical ther- tion to determine whether these dif-
variation in the use of physical ther- apy for joint replacement. The rea- ferences are indicative of sex dispar-
apy in the acute care setting needs sons for this finding are unclear. ities or potential confounding. For
further exploration and may be Although imprecise, hospital size example, data suggest that females
indicative of suboptimal care. may be a proxy measure for joint delay joint replacement and, there-
replacement procedure volume. fore, are more disabled than males
Although demographic characteris- Larger hospitals are likely to perform preoperatively.65
tics were not associated with physi- more procedures than smaller hospi-
cal therapy use for joint replace- tals. In some of our work with other In both models, for-profit status of
ment, we found older age, being on hospital databases, we found joint the hospitals was associated with
Medicaid, and being uninsured asso- procedure volume and hospital size lower-intensity physical therapy use.
ciated with physical therapy use for were moderately correlated (r.60). This finding also warrants further
stroke. One explanation for these Studies have shown a positive rela- exploration to determine whether it
findings is these variables are captur- tionship between joint replacement is indicative of differences in care
ing unmeasured illness severity. Indi- procedure volume and quality of delivery or differences in patient
viduals who are older have more care.37,38 Whether use of physical populations (eg, patients at for-profit
comorbidities, complications, and therapy is more likely at hospitals hospitals tend to be healthier).
problems in response to a CVA and with higher procedure volumes
have greater functional limita- needs further exploration, along Although urban location was not
tions.58,59 People with Medicaid cov- with the relationship between phys- associated with physical therapy
erage or no insurance, proxies for ical therapy use and quality of care intensity for the stroke sample, it
lower socioeconomic status, have for joint replacement. was for the joint replacement sam-
poorer health relative to individuals ple. In our sensitivity analyses using
of higher socioeconomic status.60 62 In both the stroke and joint replace- other measures of physical therapy
ment models, individuals seen at hos- intensity, we found the effect of
In both the stroke and joint replace- pitals who used contract physical urban location changed, suggesting
ment models, several of the illness therapists were less likely to receive that charging practices at urban and
severity and comorbidity measures physical therapy. This may suggest nonurban hospitals may vary. These
were associated with physical ther- potential physical therapy supply findings also lend support to our
apy use in the expected directions. issues. Physical therapy FTEs per choice of physical therapy charges/
For example, individuals with a hem- admissions, however, were not sig- total charges as our measure of phys-
orrhagic stroke and those who had a nificantly associated with physical ical therapy intensity.
joint replacement after hip fracture therapy use in any of the models.

262 f Physical Therapy Volume 92 Number 2 February 2012


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Delivery of Physical Therapy in the Acute Care Setting

Limitations they are the best way to help a with little between-hospital varia-
This study has several limitations. patient)70 or underuse of care (ie, tion. Use of physical therapy for
First, it is based on data from one instances in which evidence-based, patients with stroke was more var-
state, which limits its external valid- effective health care practices are ied. Both clinical and nonclinical fac-
ity. The analyses also were limited by not used).70 Our findings suggest tors were associated with the use
the type and availability of data. We that hospital characteristics influ- and intensity of physical therapy for
did not have measures of function. ence whether individuals receive joint replacement and stroke.
Instead, we used proxy measures of physical therapy and the intensity of
illness severity and comorbidities. their physical therapy, particularly
Dr Freburger and Dr Montmeny provided
Other measures of illness severity, for patients with joint replacement. concept/idea/research design and writing.
such as intensive care unit use66 or Future investigations should focus Dr Freburger provided data collection, proj-
APR-DRG (all patient refined diagno- on a better understanding of the rea- ect management, fund procurement, and
sis related groups) measures of sever- sons for this variation and the influ- institutional liaisons. All authors provided
data analysis. Ms Knauer provided clerical
ity and mortality, may have been use- ence of hospital characteristics.
support. Ms Heatwole Shank and Ms Knauer
ful. The APR-DRGs expand the provided consultation (including review of
traditional diagnosis related group Although hospital discharge data manuscript before submission).
classification by adding a 4-level mea- have been used in numerous studies
This research, in part, was presented orally at
sure of illness severity and a 4-level examining health care use and out- the Combined Sections Meeting of the
measure of mortality risk.67 In addi- comes of care,12 little has been done American Physical Therapy Association; Feb-
tion, race data were missing for with these data in the area of reha- ruary 1720, 2010; San Diego, California.
almost 50% of the sample, which bilitation care. State Inpatient Data- This study was funded, in part, by the Divi-
may have been the reason for the bases from several other states are sion of Physical Therapy, University of North
generally nonsignificant findings on available for minimal to moderate Carolina at Chapel Hill.
race. National efforts are under way fees through HCUP. Although not all 10.2522/ptj.20100337
to improve the reporting of race/eth- SIDs have detailed information on
nicity data in health care databases physical therapy use, efforts are
such as the SIDs.68 Another limita- under way to improve this situation. References
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February 2012 Volume 92 Number 2 Physical Therapy f 265


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Delivery of Physical Therapy in the Acute Care
Setting: A Population-Based Study
Janet K. Freburger, Kendra Heatwole Shank, Stefanie R.
Knauer and Richard M. Montmeny
PHYS THER. 2012; 92:251-265.
Originally published online November 3, 2011
doi: 10.2522/ptj.20100337

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