Monday, October 24, 2011

Yoga more effective for patients with chronic low back pain at reducing symptoms and improving function


Yoga classes were found to be more effective than a self-care book for patients with chronic low back pain at reducing symptoms and improving function, but they were not more effective than stretching classes, according to a study published Online First by the Archives of Internal Medicine.

"Despite the availability of numerous treatments for chronic back pain, none have proven highly effective, and few have been evaluated for cost-effectiveness," the authors provide as background information. "Self-management strategies, like exercise, are particularly appealing because they are relatively safe, inexpensive, and accessible and may have beneficial effects on health beyond those for back pain. One form of exercise with at least 'fair' evidence for effectiveness for back pain is yoga, which might be an especially promising form of exercise because it includes a mental component that could enhance the benefits of its physical components."

Karen J. Sherman, Ph.D., M.P.H., from Group Health Research Institute, Seattle, and colleagues designed a study to determine whether yoga is more effective than conventional stretching exercises or a self-care book for primary care patients with chronic low back pain. A total of 228 adults with chronic low back pain were randomized to 12 weekly yoga classes (92 patients) or conventional stretching exercise classes (91 patients), or a self-care book that provided information on causes of back pain and advice on exercising, lifestyle modifications and managing flare-ups (45 patients). The main outcomes measured were back-related functional status and how much the back pain was bothering the patients. Telephone interviews were conducted at baseline, and at six, 12, and 26 weeks after randomization.

"Back-related dysfunction declined over time in all groups," the authors report. Compared with the self-care group, the yoga group reported superior function at 12 and 26 weeks (average difference, -2.5 and -1.8, respectively) and the stretching group reported superior function at six, 12 and 26 weeks (-1.7, -2.2, -1.5, respectively). "There were no statistically or clinically significant differences between the yoga and stretching groups" at any time point, the authors note.

"We found that physical activity involving stretching, regardless of whether it is achieved using yoga or more conventional exercises, has moderate benefits in individuals with moderately impairing low back pain. Finding similar effects for both approaches suggests that yoga's benefits were largely attributable to the physical benefits of stretching and strengthening the muscles and not to its mental components." The benefits of these approaches may last several months, the authors conclude.

Commentary: Comparative Effectiveness Studies in Chronic Low Back Pain

In an accompanying commentary, Timothy S. Carey, M.D., M.P.H., from Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, writes, "The study by Sherman et al in this issue is an excellent example of a pragmatic comparative effectiveness trial."

"This research now represents best evidence for stretching therapies. Support by payers for these therapies will be very helpful through partial financial support for the classes. Such support will encourage patients to utilize the classes, representing a value-based reimbursement policy."

"We physicians should refer our patients for exercise, practitioners should work to standardize treatments, and payers should encourage these treatments through minimization of copayments for therapies that have both effectiveness and modest cost. Comparative effectiveness research, when well conducted, can assist us in making these clinical and policy recommendations."

Friday, October 14, 2011

Direct access to physical therapists associated with lower costs and fewer visits


A new study suggesting that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases" could have significant implications for the US health care system, says the American Physical Therapy Association (APTA).

The study, published ahead of print September 23 in the journal Health Services Research (HSR), reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.

The study is noteworthy because services delivered by physical therapists account for "a significant portion" of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists, some of them nonetheless impose restrictions if patients have not been referred by a physician.

"Physical therapists have long known that direct access to our services is safe and effective," said APTA President R. Scott Ward, PT, PhD. "The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care."

"When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care," added Thomas DiAngelis, PT, DPT, president of APTA's Private Practice Section. "We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it."

Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. A total of nearly 63,000 outpatient physical therapy episodes of care were analyzed – more than 45,000 were classified as physician-referred and more than 17,000 were classified as "self-referred" to physical therapists. Physical therapy episodes began with the initial physical therapist evaluation and ended on the last date of services before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of physical therapy. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use – or care related to the problem for which physical therapy was received, but not physical therapy treatment – was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing. Potential differences in functional status and outcomes of care were not addressed.

"Health care use did not increase in the self-referred group, nor was continuity of care hindered," the researchers write. "The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overstated."

According to Rick Gawenda, PT, president of APTA's Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services. "Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs," says Gawenda. "It's time to end the physician referral requirement in every state, and it's time for all payers to embrace direct access to physical therapists."

Earlier research has supported direct access to physical therapists, but the new HSR study is the most comprehensive to date. A 1994 study analyzed 4 years of Blue Cross Blue Shield of Maryland claims data and found that total paid claims for physician referral episodes to physical therapists were 2.2 times higher than the paid claims for direct access episodes. In addition, physician referral episodes were 65% longer in duration than direct access episodes and generated 67% more physical therapy claims and 60% more office visits. The HSR study looked at a far more extensive number of episodes than the previous study, and also controlled for illness severity and other factors that could have affected the patients' outcomes.

"In summary," the researchers write, "our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards."


Tuesday, October 11, 2011

Ginger Root Supplement Reduced Colon Inflammation Markers


Ginger supplements reduced markers of colon inflammation in a select group of patients, suggesting that this supplement may have potential as a colon cancer prevention agent, according to a study published in Cancer Prevention Research, a journal of the American Association for Cancer Research.

Suzanna M. Zick, N.D., M.P.H., a research assistant professor at the University of Michigan Medical School, and colleagues enrolled 30 patients and randomly assigned them to two grams of ginger root supplements per day or placebo for 28 days.
After 28 days, the researchers measured standard levels of colon inflammation and found statistically significant reductions in most of these markers, and trends toward significant reductions in others.

Inflammation has been implicated in prior studies as a precursor to colon cancer, but another trial would be needed to see how ginger root affects that risk, Zick said.
“We need to apply the same rigor to the sorts of questions about the effect of ginger root that we apply to other clinical trial research,” she said. “Interest in this is only going to increase as people look for ways to prevent cancer that are nontoxic, and improve their quality of life in a cost-effective way.”

Zick is a naturopathic doctor (N.D.), which is a four-year degree that supplements a traditional medical education with instruction on the proper use of natural therapies, diet, nutrition and other alternative treatments. Her program is one of eight in the country, compared with about 135 traditional medical schools.