MSK3 – Patients Suffering From a Back Injury who Improve Physical Function

Measure Title: Patients Suffering From a Back Injury who Improve Physical Function

Measure Description Percentage of patients 18 years or older suffering from a back injury who achieve the Minimal Clinically Important Difference (MCID) in the MDQ or PROMIS Pain Interference, or like mapped measure during the performance year.

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.

This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in MDQ/PROMIS Pain Interference/or like mapped measure.

Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or start of care with a back injury evaluated and treated by a Physical Therapist (PT), Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.

Numerator: The total number of patients with back injuries to achieve an MCID in their MDQ change score (> or = to -6) or (> or = -2) in PROMIS Pain Interference change score or like mapped measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the performance year.

Denominator Exclusions: Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15

Denominator Exceptions: Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress or follow a standard care pathway. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions: None

Published Specialty: Physical Therapy/Occupational Therapy

High Priority Measure: Yes

Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)

Include Telehealth: Yes

Inverse Measure: No

Proportional Measure: Yes

Continuous Variable Measure: No

Ratio Measure: No

Score Range: N/A

Number of Performance Rates: 1

Performance Rate Description: This measure will include the combined rate of;
Rate 1) Total number of patients aged 18 years or older with a low back injury who achieve an overall score change of > or = the MCID in the MDQ, PROMIS Pain Interference or like mapped measure.

Risk Adjusted Status: Yes

MIPS Reporting Options: Traditional MIPS

Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care

Clinical Recommendation Statement: Patients regularly enter the clinic with compromised lower back function, measurable via the MDQ. Through effective rehabilitation there are marked, measurable improvements. This gap for improvement will always exist in these LBP patients, as this is a true “”””””””pre- vs. post-“””””””” measurement.

Specifically for patients with LBP (N=648) average baseline score was 39.3 (16.5) on the MDQ. Average age was 74.8 (6.4). 63.9% of patients achieved a MCID. The gap is represented by the 36% of Medicare patients that failed to achieve a minimal clinical important difference (MCID), or a proportion of 36% Fail to Progress.”””” (Fritz, Hunter, Tracy, & Brennan, 2011).

Fritz, J. M., Hunter, S. J., Tracy, D. M., & Brennan, G. P. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91(3), 330–345. 10.2522/ptj.20090290

The use of PROMIS Physical Function Computer Adaptive Test (CAT) for measuring low back functional improvement in physical therapy patients is strongly recommended. Supported by robust evidence, including studies by [Lapin et al., 2020][1] and [Thompson et al., 2022][2], the PROMIS Physical Function CAT offers an efficient and precise way to assess low back function. Its adaptive testing tailors questions to patient responses, enhancing accuracy while minimizing patient burden. Validity and reliability, with decreased floor and ceiling effects make it an invaluable tool for evaluating low back function. Integrating the PROMIS CAT into clinical practice empowers therapists to make informed decisions and optimize patient care by tracking progress and tailoring interventions effectively.

[1] Lapin B, Davin S, Stilphen M, Benzel E, Katzan IL. Validation of PROMIS CATs and PROMIS Global Health in an Interdisciplinary Pain Program for Patients With Chronic Low Back Pain. Spine (Phila Pa 1976). 2020 Feb 15;45(4):E227-E235. doi: 10.1097/BRS.0000000000003232. PMID: 31513107.
[2] Thompson NR, Lapin BR, Steinmetz MP, Benzel EC, Katzan IL. Mapping PROMIS physical function and pain interference to the modified low back pain disability questionnaire. Qual Life Res. 2022 Dec;31(12):3467-3482. doi: 10.1007/s11136-022-03174-3. Epub 2022 Jul 6. PMID: 35794422.

Measure Rationale: According to the World Health Organization (2022), MSKD effects 1.71 billion people worldwide, is the leading cause of disability globally, and is the primary reason for rehabilitation treatment. The total economic burden of MSKD is around $980.1B, which represents 5.7% of the gross domestic product and 30% of the national health expenditures (Wright, et al., 2014). Musculoskeletal conditions are the leading cause of disability globally with LBP being the leading cause in 160 countries (WHO, 2022). There is a significant impact on mobility with functional limitations that can result in decreased overall health and welfare, engagement in society, or the ability to work. One study of 2.5 million US patients diagnosed with LBP found that only 1.2% of that population received surgery, however, these patients accounted for 29.3% of 12-month costs or roughly $784 million (Kim, et al., 2019). Frequently these patients received medical imaging within 30 days of new diagnosis and did not work with a physical therapist upon initial diagnosis and ultimately non-adherence to clinical guidelines (Kim et al., 2019). According to Pain Management Best Practices from Health and Human Services (2019), physical therapists (PTs) and occupational therapists (OTs) play a pivotal role in the multidisciplinary team’s management of both acute and chronic pain by contributing to maintaining function in an effort to reduce opioid prescriptions. PTs and OTs are also positioned to improve long-term outcomes by providing high-quality and timely care while reducing downstream costs. Improving quality of care begins with tracking outcomes and use of the Modified Low Back Pain Disability Questionnaire (MDQ – Legacy17) patient reported outcome measure (PROM) has proven to be a reliable cost effective measurement tool. Fritz, et al. (2011) performed an original study on the outcomes of physical therapy in Medicare patients utilizing the Legacy measures including the MDQ. Results of a 3-year study that included over 14,000 episodes in an outpatient setting established that use of Legacy PROs facilitated the identification of factors related to improvement and utilization. Another study that reviewed over 165,000 PROs of Medicare patients found that the use of legacy measures has been validated as a standard approach to identifying accurate functional limitations modifiers and detect improvement while using the MDQ as one of the measurement tools (Brennan, et al., 2017). Lutz, et al. (2020) performed a study that established the (MDQ) provides benchmarks and aids in identifying performance levels of providers over time with a sample size of 315,274 episodes, 182,276 patients and 2,799 therapists. Lamba and Upadhyay (2018) also found that the MDQ was a reliable and effective tool at measuring LBP among a sample of 100 patients. In addition, it has been found that when MDQ was used in combination with the STarT back screening risk stratification tool, the MDQ was useful in predicting outcomes after utilization of therapy (Katzan, et al., 2019). Additionally, the MDQ is a reliable low cost measurement tool that tracks the patient self-reported functional status of those suffering from LBP. Given the economic and pshcyo-social burden of lower extremity pain, the current investment in prevention, treatment, and improved access to care do not align with the prevalence, burden, morbidity and total cost of care on an already overburdened healthcare system.

The use of the PROMIS Physical Function Computer Adaptive Test (CAT) is strongly recommended for physical therapists, orthopedic therapists, and musculoskeletal doctors for assessing back function in clinical practice. Supported by robust psychometric evidence, including studies by Brodke et al. (2016) and Cheung et al. (2019), the PROMIS Physical Function CAT demonstrates excellent reliability, validity, and efficiency. Its adaptive testing algorithm tailors questions to individual responses, enhancing measurement precision and minimizing patient burden. This tool’s clinical applicability is underscored by its ability to capture subtle changes, as highlighted by Horn et al. (2020), making it an indispensable resource for tracking progress and facilitating informed treatment decisions, ultimately improving patient outcomes.

Brennan, G. P., Hunter, S. J., Snow, G., & Minick, K. I. (2017). Responsiveness to change of functional limitation reporting: Cross-sectional study using the intermountain roms scale in outpatient rehabilitation. Physical Therapy, 97(12), 1182–1189. 10.1093/ptj/pzx093
Fritz, J. M., Hunter, S. J., Tracy, D. M., & Brennan, G. P. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91(3), 330–345. 10.2522/ptj.20090290
Katzan, I. L., Thompson, N. R., George, S. Z., Passek, S., Frost, F., & Stilphen, M. (2019). The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain. Spine Journal, 19(4), 645–654. https://doi.org/10.1016/j.spinee.2018.10.002
Kim, L. H., Vail, D., Azad, T. D., Bentley, J. P., Zhang, Y., Ho, A. L., Fatemi, P., Feng, A., Varshneya, K., Desai, M., Veeravagu, A., & Ratliff, J. K. (2019). Expenditures and health care utilization among adults with newly diagnosed low back and lower extremity pain. JAMA Network Open, 2(5), e193676. https://doi.org/10.1001/jamanetworkopen.2019.3676
Lamba, D., & K Upadhyay, R. (2018). Comparison between modified oswestry low back pain disability questionnaire and aberdeen low back pain scale taking low back-specific version of the sf-36 physical functioning scale as a gold stand in patients with low back pain. Asian Journal of Pharmaceutical and Clinical Research, 11(11), 97. 10.22159/ajpcr.2018.v11i11.27909
Lutz, A. D., Brooks, J. M., Chapman, C. G., Shanley, E., Stout, C. E., & Thigpen, C. A. (2020). Risk adjustment of the modified low back pain disability questionnaire and neck disability index to benchmark physical therapist performance: Analysis from an outcomes registry. Physical Therapy, 100(4), 609–620. 10.1093/ptj/pzaa019
World Health Organization (2022). Musculoskeletal health. https://www.who.int/news-room/fact -sheets/detail/musculoskeletal-conditions
Wright, N. C., Looker, A. C., Saag, K. G., Curtis, J. R., Delzell, E. S., Randall, S., & Dawson-Hughes, B. (2014). The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine: Recent US prevalence of osteoporosis and low bone mass. Journal of Bone and Mineral Research, 29(11), 2520–2526. https://doi.org/10.1002/jbmr.2269
Brodke DJ, Saltzman CL, Brodke DS. (2016) PROMIS for Orthopaedic Outcomes Measurement. J Am Acad Orthop Surg. 2016 Nov;24(11):744-749.
Cheung EC, Moore LK, Flores SE, Lansdown DA, Feeley BT, Zhang AL. (2019) Correlation of PROMIS with Orthopaedic Patient-Reported Outcome Measures. JBJS Rev. 2019 Aug;7(8):e9. doi: 10.2106
Horn ME, Reinke EK, Couce LJ, Reeve BB, Ledbetter L, George SZ. Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review. J Orthop Surg Res. 2020 Nov 23;15(1):553. doi: 10.1186