Patient Advantage. (2009). Proposal for a pilot study to identify cost saving measures in management of muskuloskeletal conditions. Patient Advantage.
The proposal gives details the methodology, objectives and expected outcomes of a pilot project aimed at identifying the opportunities for saving cost in the management of musculoskeletal problems, with a particular focus on myofascial pain. The literature reviewed in the proposal identifies myofascial pain as a major underlying factor in many cases of chronic musculoskeletal pain and yet it is grossly under diagnosed and under treated. This justifies the need for the study using the action research modality. The proposal identifies different methods used to measure the cost of healthcare which include direct costs, indirect costs, claims cost and goes on to give the statistics of the average cost for the treatment and management of musculoskeletal problems. The proposal identifies the gaps in research regarding reducing the cost for the treatment of musculoskeletal pains as (1) The lack of consensus on the key components the treatment and management of musculoskeletal problems- making costing a difficult task and hence the variations in the cost presented by different scholars (2) Effectiveness of some treatment strategies despite their low cost (3) Access to the appropriate treatment (4) If imaging should be ordered or not and in what time frame (5) The timing of referral therapy. The study proposes a comprehensive and integrated program that considers the unexplored potential cost saving measures such as identifying the most effective treatment early (low tech and low cost), teaching high risk patients in weight management and fitness and managing the chronic problems. Employing this integrated approach was projected to save the overall cost by 5% .
The strength of this reference is in the integrated approach which will be used in the proposed study. This is the principal source that will be used in the formulation of the study because it is the actual pilot study for the proposed AR. It will form the basis of the study and provide baseline data for comparison. In addition, the literature review in the proposal gives sufficient evidence of the need for action and the gaps to be addressed and the researcher will work with PA in the proposed study. The weakness of the study is that it relies on 2009 data and thus the need to review other more recent studies for data on the most recent costs.
Fritz, J., Childs, J., Wainner, R., & Flynn, T. (2012). Primary Care Referral of Patients with Low Back Pain to Physical Therapy: Impact on Future Healthcare Utilization and Costs. Spine , 37 (25), 2114-21.
This was a retrospective cohort study aimed at describing the utilization of physical therapy (PT) after primary care consultation for low back pain (LBT). The study also evaluated the link between the content of physical and timing of physical therapy and subsequent healthcare costs and utilization. A sample of 32,070 patients identified from a national database of employer-sponsored health plans with a new primary care LBT consultation were categorized based on how they used physical therapy within ninety days. They were categorized as early (within 14 days) or delayed users of physical therapy and based on the content of the therapy (guideline adherent or nonadehrent). The cost of healthcare and utilization in 18-months after the primary care consultation were evaluated. The study established that early physical therapy decreased the need/risk for advanced imaging, additional visits to the physician, injections, opioid medication and surgery (all associated with increased costs) when compared with delayed physical therapy. Generally, early PT was linked to reduced risk of subsequent healthcare. As a result, the costs of LBP were decreased by $2336.23 for the patients who received early PT. The researchers recommended further study to establish the patients with LBP to be referred to PT.
The strength of the study was in the sample selection criteria and size. Getting a big sample from a national database increased the chances of better population representation. The study was chosen because it provides a good basis for supporting non-invasive and non-pharmacological managements as more cost effective. The weakness of the study was in the design; a longitudinal study spanning over a longer period than 18 months could have yielded more valid results.
Andersson, S., Sundberg, T., Johansson, E., & Falkenberg, T. (2012). Patients’ experiences and perceptions of integrative care for back and neck pain. Alternative Therapies in Health Medicine , 18 (3), 25-32.
The study sought to explore the experiences and perceptions of patients when they received integrative care in back and neck pain management. The authors begin by acknowledging that despite the conventional guidelines in Sweden recommending primary care management for neck and back pain a vast of patients mostly prefer to use complementary/alternative therapies. According to the authors there are very few studied defining and evaluating the models of integrative care despite the recent growth in integrative medicine (IM). The pragmatic qualitative randomized clinical pilot trial was carried out within a larger intervention study and assessed a model of integrative medicine that combined conventional therapies and emerging and evidence based complementary therapies for patients with nonspecific neck and back pain. This was compared with patients undergoing conventional primary care. The data was collected through 11 focus-group discussions (5 for integrative care and 5 conventional care). The discussions were transcribed and content analysis used to evaluate the data. Participants said that they found conventional management to lack guidance, accessibility, to be reductionistic and focus on disease. On the other hand they reported integrative care was holistic, facilitated increased treatment response and empowered patient but had additional costs.
The strength of this study is the study design (randomized clinical trial) which is the best research design in terms of getting valid data in terms of causation and effect. In addition, it took the action research approach which is the best approach for achieving change and will also be employed in the proposed study. This reference will be useful because it employs the same approach (AR) as the proposed study and it addresses the issue of complementary medicine which is a low tech, low tech and effective modality. In addition, the integrative medicine which incorporates different components will be applied (tested); this integrative approach increases the chance of better outcome. However, the cost effectiveness of the integrated approaches needs to be investigated and which components could be combined to ensure both efficacy and cost effectiveness. The weakness of the study is that integrated medicine is very broad field with very many diverse combinations and thus generalization of the results of this study can be difficult and controversial. It is also difficult to measure expectations and perception.
Lubeck, D. P. (2003). The costs of musculoskeletal disease: Health needs assessment and Health economics. Best Practice & Research Clinical Rheumatology , 17 (3), 529–539.
This study was basically a literature review of other references that described the costs of musculoskeletal diseases. The author categorized the costs into three broad classes, namely: direct costs (those associated with inpatient medical care and ambulatory care), indirect costs (the paid or unpaid services resulting from the disability/incapacitation associated with the musculoskeletal diseases such as employment, home making and schooling) and intangible costs (such as pain, worry, emotional, psychological and other effects on the patient’s quality of life). While accurately measuring all the components of costs is necessary in order to get the complete picture of the economic burden of the condition, the latter two categories are difficult to measure. The author then described how musculoskeletal diseases affect an individual and the society. The author went ahead to give the actual figures for the three costs from different studies. While the direct costs were given as a range of between US$2299 and US$8500, the indirect and intangible costs were given as a percentage of the total cost. This further indicates the difficulty of measuring the last two costs.
The strengths of this study is that it gives costs from different studies and thus a range or an average of these costs is more valid than costs as estimated by a single study. In addition, the study breaks down the costs into different components thus giving a clearer picture. The reference will be useful because it will help in determining the actual cost of musculoskeletal diseases which the proposed study aims to reduce. The weakness of the study is that it considers costs from different parts of the world where the inflation rates are different and the costs are extracted from studies conducted at different times and hence may not be up to date because costs vary with time.
Kobelt, G., Eberhardt, K., Jönsson, L., & Jönsson, B. (1999). Economic consequences of the progression of rheumatoid arthritis in Sweden. Arthritis & Rheumatism , 42 (2), 347–356.
The study sought to develop a simulation model that could be employed in evaluating the cost-effectiveness of different treatments aimed at changing the progression of rheumatoid arthritis (RA). A cohort of 116 Swedish patients with early RA was followed for 5 years. The Markov model was developed to determine different severity states and treatment interventions were stimulated to illustrate the model. The study established that with increasing severity the costs increased and that at the end of the five years the total costs of patients who were in a more severe state at diagnosis were higher.
The strength of the study is that it is longitudinal study where the participants/patients were followed of a prolonged time which is a component of validating the data. The weakness of the study is in its small sample size which may not be representative of the study population. However, despite the study being old the findings of the study give an indication of a useful trend; that costs increase with disease progression. As such, in the long run and particularly for chronic diseases, interventions that slow disease progression could save costs. It also supports the hypothesis that early diagnosis and treatment can save cost which is an important hypothesis in the proposed study.
Meenan, R., Callahan, L., & Helmick, C. (1999). The national arthritis plan: a public health strategy for a looming crisis. Arthitis care research , 79-81.
The study was an extract from the National arthritis action plan prepared jointly by the Arthritis foundation association, CDC and health officials. It clearly indicates that arthritis is a major public health concern that may become a crisis because it is grossly ignored. The paper, increases awareness on arthritis as the key cause of disability, prevention strategies, recommends early diagnosis and access to appropriate treatment/management, emphasizes on support (both emotional and financial) and minimizing preventable pain and disability due to arthritis.
The strength of the study is that it not only addresses the cost of arthritis as a musculoskeletal disease but also emphasizes on prevention and out of hospital management. The self/family management, early diagnosis and access to appropriate management are vital cost saving measures that will be explored in the proposed study hence the choice of the reference. The weakness of the study is that it is a purely descriptive study which is not very reliable.
Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., et al. (2007). The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and community Health , 61 (3), 254-261.
The study aimed at determining the clinical and cost effectiveness of a lay-led care support program that aims at improving the patients’ self care skills. The study involved 629 patients in England with a wide range of log term conditions. The study also involved 6-weekly sessions of teaching self care skills. The parameters that were evaluated were reported energy, self-efficacy, routine health services utilization and cost-effectiveness for a period of 6 months. The study established that there was significant self-efficacy and energy but no statistically significant reduction in routine services utilization in patients that underwent the training. The training also resulted in considerable reported better quality of life and reduced costs.
The strength of the study was the design which was a pragmatic randomized controlled trial, which enhances the validity of the data. The weakness of the study is in the small sample size and the short follow-up period which could compromise the data validity. The study was chosen because it addresses self-management/care as cost saving measure which will be explored in the proposed study.
Stano, M. (1993). A comparison of health care costs for chiropractic and medical patients. Journal of Manipulative and Physiological Therapeutics , 16 (5), 291-299.
As indicated by the topic, this was a comparative study to compare the healthcare costs of chiropractic treatment and conventional treatment of neuromusculoskeletal (NM) disorders. The study was basically a retrospective analysis of two years claims data on different insurance payments and classes of utilization for a large national sample patients. The study analyzed the data of 395,641 patients with 1 or more of 493 NM conditions. The study established that the almost one quarter patients that were treated by chiropractors had a significantly lower health care cost. The cost was found to be lower by an average of $ 1,000 in the 2-year period and was mainly attributed to lower inpatient utilization.
The strength of the study is in its large national sample which is very representative. In addition, the varied sample with 493 different NM conditions enhances the generalization of the data to different conditions. The study was chosen because it addressed the cost of one of the most commonly used complementary/alternative treatments and the same will be considered in the proposed study. The weakness of the study is in the design; generally retrospective studies are criticized because they rely on secondary data whose validity can’t be established.
Pendergast, J., Kliethermes, S., Freburger, J., & Duffy, P. ( 2011). A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research. journal Health Services Research .
The study was a retrospective analysis of 5 years claims data of a private Midwest insurance. The researchers reviewed 62,707 episodes of physical therapy (PT). 27% of the patients visiting the physical therapist for outpatient directly (self-referred) and the rest only visiting the physical therapist after a physician’s referral. The study established that the “self-referred patients” had lower average overall costs and fewer visits.
The strength of the study was in the large sample size and the fact that it followed data over a prolonged data. The study was chosen on the basis that the proposed study will review direct access to PT as cost saving measure. The weakness of the study was in the retrospective approach.
Patterson, K. C., & Patterson, R. A. (2013). Direct Access to Physical Therapy in Michigan is Overdue. Medical Student Research Journal , 3 (fall ), 052-055.
The study is more of an argument for a legislative, system and policy framework to facilitate direct access to physical therapists without requiring physician referral. The authors review the current framework in Michigan, which require physician referral, and show its weakness while clearly stating that there is no evidence or rational indicating that the physician’s referral adds value. The authors indicate that while other states have shifted the paradigm to self referral, Oklahoma and Michigan remain in the traditional paradigm of physician referral. The researchers then present research evidence on the benefits of quick direct access to PT.
The strength of the study is that it has presented extensive evidence in arguing for direct access to PT. It was chosen on the basis that PT is one of the key strategies and treatment component that will be considered as a cost saving measure. Unfortunately the study is pure descriptive.
References
Andersson, S., Sundberg, T., Johansson, E., & Falkenberg, T. (2012). Patients’ experiences and perceptions of integrative care for back and neck pain. Alternative Therapies in Health Medicine , 18 (3), 25-32.
Fritz, J., Childs, J., Wainner, R., & Flynn, T. (2012). Primary Care Referral of Patients with Low Back Pain to Physical Therapy: Impact on Future Healthcare Utilization and Costs. Spine , 37 (25), 2114-21.
Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., et al. (2007). The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and community Health , 61 (3), 254-261.
Kobelt, G., Eberhardt, K., Jönsson, L., & Jönsson, B. (1999). Economic consequences of the progression of rheumatoid arthritis in Sweden. Arthritis & Rheumatism , 42 (2), 347–356.
Lubeck, D. P. (2003). The costs of musculoskeletal disease: health needs assessment and health economics. Best Practice & Research Clinical Rheumatology , 17 (3), 529–539.
Meenan, R., Callahan, L., & Helmick, C. (1999). The national arthritis plan: a public health strategy for a looming crisis. Arthitis care research , 79-81.
Patient Advantage. (2013). Proposal for a pilot study to identify cost saving measures in management of muskuloskeletal conditions. Patient Advantage.
Patterson, K. C., & Patterson, R. A. (2013). Direct Access to Physical Therapy in Michigan is Overdue. Medical Student Research Journal , 3 (fall ), 052-055.
Pendergast, J., Kliethermes, S., Freburger, J., & Duffy, P. ( 2011). A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research. journal Health Services Research .
Stano, M. (1993). A comparison of health care costs for chiropractic and medical patients. Journal of Manipulative and Physiological Therapeutics , 16 (5), 291-299.
