Differences Among Health Care Settings in Utilization and Type of Physical Rehabilitation Administered to Patients Receiving Workers’ Compensation for Musculoskeletal Disorders

Our goal was to determine if the utilization and type of physical rehabilitation care for injured workers differed based upon the setting in which the care was provided. In the present study, numerous significance differences were identified. Utilization of physical rehabilitation treatment was significantly different among settings regardless of ICD-9-CM classification, body-part treated, surgical or non-surgical intervention, and geographic area in which treatment was provided. Patients receiving care in corporate physical therapy clinics and private physical therapy practices consistently had more visits and overall units of treatment during their episode of care than did the other practice settings addressed in this study. The exact reasons for this observation are unknown. One possible explanation is that these facilities may have typically treated patients who required more care, i.e., those with more complex and prognostically unfavorable conditions than those seen in other settings. In our sample, corporate physical therapy clinics and private physical therapy practices treated higher than expected frequencies of patients who had surgical intervention, and would likely require substantial care, compared to other settings. However, these subjects only accounted for 24.1 % of the total number of subjects treated by corporate physical therapy clinics and 25.3 % of the total number of subjects treated by private physical therapy practices. There were no meaningful between-group changes in our findings after the analysis was adjusted for surgical intervention. The remainder of between-setting frequencies of potential predictor variables (Table 2) recorded at the inception of care did not reflect meaningful differences between corporate physical therapy clinics and private physical therapy practices compared to other settings. It is not known if other patient-specific characteristics such as job description and the presence of bio-behavioral factors or other co-morbidities, that were not addressed in this study could explain the between-setting differences in physical rehabilitation utilization.

A second possible explanation for the higher number of visits and units utilized by corporate physical therapy clinics and private physical therapy practices is that more total treatment provides a more effective outcome than less overall treatment. This contention could be addressed by a comparison of outcome measures reflecting important status changes such as functional recovery and/or return to work. Unfortunately, these data were not available; therefore, no judgments may be made on the overall “value” of care between settings.

The treatment emphasis was also significantly different between settings. Occupational medicine clinics and physician offices had higher proportions of physical agents to total units than did other settings. This finding remained consistent after the analyses were adjusted for body-part treated, surgical or non-surgical intervention and geographic area in which treatment was provided. The reason for this difference is unknown. Although the body of supporting evidence is limited, physical agents have been primarily advocated as a means to control pain in people with acute injuries [22]. The majority of patients seen in occupational medicine clinics (68.2 %) received care within 30 days of injury, which may explain the higher usage of physical agents in this setting. However, physician offices had a predominance of patients with more chronic conditions, i.e., greater than 90 days from injury to start of care (Table 2), and these settings had significantly higher proportions of physical agents to total units compared to corporate physical therapy clinics and private physical therapy practices. Another argument for the high usage of physical agents in occupational medicine clinics and physician offices is that these settings may use more non-physical therapist “care-extenders” to provide treatment than do corporate physical therapy clinics or physical therapy private practices [14]. We are unable to address the issue from our dataset. Further study is needed to determine the relationship between the specific person delivering care and the type of treatment delivered.

Corporate physical therapy clinics and private physical therapy practices had significantly lower proportions of physical agents to total units compared to other settings, indicating a higher usage of therapeutic procedures that are supported by evidence-based treatment guidelines [24‐34]. This finding is important because recent evidence has suggested that the early and sustained involvement of injured workers in the active process of their care, i.e., performing exercises and activities that encourage patients to move injured body-parts, may have both physiological and psychological benefits that exceed those provided by physical agents [35].

An unexpected finding was the large difference in treatment utilization between geographic regions regardless of practice setting, diagnosis, body-part treated or surgical intervention. The reason for this finding is unknown, but may reflect variations in local reimbursement policies.

The implications of our findings are that, regardless of ICD-9-CM code classification, body-part treated, and the presence of surgical or non-surgical intervention, there are likely to be significant differences in physical rehabilitation utilization and treatment emphasis for injured workers between practice settings. Patients treated in corporate physical therapy clinics and private physical therapy practices are likely to receive more care than those treated in occupational medicine clinics, physician offices or hospital-based outpatient clinics. Physical rehabilitation care provided in corporate physical therapy clinics and private physical therapy practices is likely to have the greatest emphasis on exercise- and manual therapy-based treatments, while care provided in occupational medicine clinics and physician offices will have a greater emphasis on the use of physical agents. These findings, although preliminary, suggest the need for stakeholders to further investigate the role of practice setting on overall cost-effectiveness of physical rehabilitation provided to injured workers [2‐4, 19, 36‐38].

This study examined a large dataset representing urban, suburban and rural physical rehabilitation delivery to injured workers throughout the United States. The analysis was adequately powered to detect between-setting differences; however, there was an imbalance in frequency of subjects from different clinical settings. The majority (84.4 %) of the subjects received care from private physical therapy practices and corporate physical therapy clinics. Although definitive data are missing, we believe that this distribution of care is likely to be similar to actual clinical practice. The age, gender mix and other demographic characteristics of our sample are similar to other studies assessing care for injured workers; however, our findings can only be generalized to the population of people receiving physical rehabilitation for a musculoskeletal problem associated with a workers’ compensation claim.