Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy.The goal of health care providers to offer patients the best possible care stems from good intentions and supports a large enterprise of continuing education continuing education: see adult education. continuing education or adult education Any form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904). (CE) in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . The assumption is that CE will increase a heath heath, tract of open land heath, tract of open land characterized by a few scattered trees, abundant moss cover, and numerous low shrubs, principally of the heath family (see heath, in botany). care provider's knowledge, leading to a change in practice behavior and ultimately resulting in improved health care outcomes for patients. (1) Surveys of physicians report an average of at least 40 to 60 hours per year spent attending CE. (2,3) Despite the assumption of improved clinical performance, and the significant time and financial resources devoted to CE, relatively little research has examined the effectiveness of CE in changing behavior or improving clinical outcomes. (4-6) Continuing education has traditionally used passive educational models (eg, lectures, conferences), sometimes combined with interactive learning (eg, workshops with opportunities for hands-on hands-on adj. Involving active participation; applied, as opposed to theoretical: "We're involved in hands-on operations, pulling levers, pushing buttons" Arthur R. Taylor. practice of skills). (7,8) Often, CE is delivered at a single point in time (eg, weekend course); however, other CE opportunities occur longitudinally lon·gi·tu·di·nal adj. 1. a. Of or relating to longitude or length: a longitudinal reckoning by the navigator; made longitudinal measurements of the hull. b. , such as Web-based courses or ongoing educational or quality-improvement programs. Research that has been performed on the effectiveness of CE has generally shown interactive learning with opportunities to practice skills to be more effective than passive learning alone, (6,9,10) and the use of strategies to reinforce new knowledge over time is more effective than a single point-in-time intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant. . (8,11) Physical therapists are also frequent consumers of CE. (12) A recent survey of physical therapists in the United States reported that an average of about 30 hours per year is spent on CE. (13) Similar to physicians, the primary motivation given by physical therapists for attending CE courses is a desire to acquire new knowledge and skills pertinent PERTINENT, evidence. Those facts which tend to prove the allegations of the party offering them, are called pertinent; those which have no such tendency are called impertinent, 8 Toull. n. 22. By pertinent is also meant that which belongs. Willes, 319. to their current practice and related to their area of interest, (14,15) Among physical therapists in Australia Australia (ôstrāl`yə), smallest continent, between the Indian and Pacific oceans. With the island state of Tasmania to the south, the continent makes up the Commonwealth of Australia, a federal parliamentary state (2005 est. pop. and the United Kingdom, the second most common rationale rationale (rash´  nal´),n the fundamental reasons used as the basis for a decision or action. identified for selecting a particular intervention was instruction received from a CE course. (16) Despite research questioning the effectiveness of single point-in-time CE courses, the majority of CE accessed by physical therapists appears to still be delivered in this traditional manner. Concerns about the methods and content of CE have been voiced for many years (17); however, there has been no research to date examining the impact of CE on clinical outcomes among physical therapists. Recent research conducted with patients who had neck pain with or without headaches has shown improved clinical outcomes with the use of manual therapy in combination with exercise. (18-20) Therefore, instruction in manual therapy and corresponding exercise interventions supported by this evidence would be anticipated to improve clinical outcomes. One purpose of this study was to examine the impact of a CE intervention provided to a group of physical therapists on the treatment of patients with neck pain. Effectiveness of the CE intervention was based on the clinical outcomes of patients with neck pain who were treated by therapists before and after they attended a 2-day CE course compared with the clinical outcomes of patients with neck pain who were treated by therapists who did not attend the course. A second purpose was to determine whether physical therapists who attended the CE course and participated in an ongoing clinical improvement project after completion of the course achieved more improvement in clinical outcomes than therapists who attended the CE course but did not participate in the clinical improvement project. Method Data for this study were collected from outpatient outpatient /out·pa·tient/ (-pa-shent) a patient who comes to the hospital, clinic, or dispensary for diagnosis and/or treatment but does not occupy a bed. out·pa·tient n. physical therapy clinics of Intermountain in·ter·moun·tain adj. Located between mountains or mountain systems, especially lying between the Rocky Mountains and the Sierra Nevada or Cascade Range in the western United States. Health Care (IHC IHC Immunohistochemistry IHC Intermountain Health Care IHC Inner Hair Cells IHC International Harvester Company IHC Internet Healthcare Coalition IHC Indian Head Cent IHC Interactive Health Communication IHC International Hurricane Center ), a private, nonprofit A corporation or an association that conducts business for the benefit of the general public without shareholders and without a profit motive. Nonprofits are also called not-for-profit corporations. Nonprofit corporations are created according to state law. , integrated health care integrated health care, n healthcare services combining the best of conventional and complementary health care. delivery system. For this project, 13 clinics located throughout the state of Utah participated. Beginning in January January: see month. 2002, each participating clinic began tracking clinical outcomes for all patients who were receiving physical therapy. Data obtained from each new patient are entered into the Rehab Outcomes Management Systems (ROMS ROMS Russian Multimedia and Internet Society ROMS Regional Ocean Model System ROMS Reactor Operations Monitoring System ROMS Rated Officer Monitoring System ROMS Remote Ocean-Surface Measuring Sensor ) electronic database using an Intranet Java Web application. At each visit, a condition-specific disability outcome score and a 0-10 numeric numeric see numerical. numeric cluster see ten-key pad. pain rating scale anchored with the phrases "no pain" and "worst imaginable i·mag·i·na·ble adj. Conceivable in the imagination: imaginable exploits. i·mag pain" (21) are collected and entered into the ROMS. During the 24-month time period of this study, outcome data were successfully collected on 81% of the patients who were attending the participating clinics. The Neck Disability Index neck disability index, n in chiropractic medicine, parameter used to monitor the progression of a patient throughout the treatment period. Specifically, this questionnaire evaluates changes in a patient's function and measures a self-evaluated disability (NDI NDI National Death Index, see there ) (22) is the region-specific disability scale used for patients with a chief complaint of neck pain in the participating clinics. The NDI consists of 10 items related to neck pain and the patient's tolerance of daily activities, with each item scored from 0 to 5. The total score is summed and expressed as a percentage of disability. The NDI is the most commonly used region-specific scale for patients with neck pain (23) and has been demonstrated to be a reliable and valid outcome measure for patients with neck pain. (24-26) Financial information related to utilization (visits) and physical therapy charges is tracked using a computer software application (AS- as- pref. Variant of ad-. 400) * and integrated with the ROMS database. The numbers of visits, length of stay in physical therapy, and total charges for physical therapy were recorded for each patient. CE Course A 2-day CE course focusing on manual therapy of the spine and corresponding exercise interventions supported by evidence was conducted for physical therapists at the participating clinics during October October: see month. 2003. Two experienced educators and physical therapist clinicians with Fellowship fellowship Graduate education A post-residency training period of 1–2 yrs in a subspecialty–eg, hand surgery, which allows a specialized physician to develop a particular expertise that may have a related subspecialty board; fellowship time is often status in the American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in of Orthopedic orthopedic /or·tho·pe·dic/ (-pe´dik) pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopedics. Manual Therapy taught the course. The course included lecture and interactive hands-on practice sessions, with the instructors in approximately equal proportions. The evidence for manual therapy interventions for patients with neck pain was reviewed. (19,20,27) Written educational materials and course notes were provided to all participants. Therapists at participating clinics were not required to attend the CE course. A total of 57 physical therapists at the participating clinics were invited to attend the CE course, of which 34 therapists (59.6%) chose to attend. Figure 1 shows the characteristics of the physical therapists. Age and years of clinical practice were unavailable for 5 therapists among the nonattendees. Six therapists had obtained Orthopaedic 1. See otrthopedic and orthopedics. Adj. 1. orthopaedic - of or relating to orthopedics; "orthopedic shoes" orthopedic, orthopedical orthopaedic (US), orthopedic adj → Specialty Certification (OCS OCS - Object Compatibility Standard ) status (3 attended and 3 did not). No therapists had Fellowship status in the American Academy of Orthopaedic Manual Therapy. Therapists who chose to attend the course tended to be older (P=.051), with trends toward greater years of clinical practice (P=.12) and more male therapists (P=.10). [FIGURE 1 OMITTED] Clinical Improvement Project for Patients With Neck Pain After completion of the CE course, a separate clinical improvement project was conducted in 4 of the 13 physical therapy clinics. The 4 clinics were selected for the project because they had a high volume of patients with neck pain and the clinic directors expressed a desire to participate. Of the 34 therapists who attended the CE course, 11 (32.4%) also were participants in the clinical improvement project. There were no differences in therapist age, sex, or years of clinical practice between participant and nonparticipant Noun 1. nonparticipant - a person who does not participate individual, mortal, person, somebody, someone, soul - a human being; "there was too much for one person to do" therapists (Fig. 1). The purposes of the clinical improvement project were to standardize stan·dard·ize v. 1. To cause to conform to a standard. 2. To evaluate by comparing with a standard. the assessment, to track the interventions used, and to examine the clinical outcomes of treatment for patients with neck pain. Following the CE course, therapists participating in the project met to review standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. forms for collecting baseline The horizontal line to which the bottoms of lowercase characters (without descenders) are aligned. See typeface. baseline - released version , intervention, and follow-up follow-up, n the process of monitoring the progress of a patient after a period of active treatment. follow-up subsequent. follow-up plan information. The collection of information on interventions used was standardized, but no specific protocols or algorithms The following is a list of the algorithms described in Wikipedia. See also the list of data structures, list of algorithm general topics and list of terms relating to algorithms and data structures. were used. Beginning in December December: see month. 2003, participating therapists met approximately once per month and reviewed the examination and manual therapy techniques taught in the CE course using facilitators and an instructional CD-ROM CD-ROM: see compact disc. CD-ROM in full compact disc read-only memory Type of computer storage medium that is read optically (e.g., by a laser). as learning resources. Five months after the CE course, therapists who participated in the clinical improvement project also participated in an additional small-group (5-6 therapists) follow-up, a 4-hour period of "hands-on" instruction with one of the original CE course instructors. Data Analysis Clinical outcome of patients with neck pain were based on the change in NDI scores, rate of change per visit for the NDI, and achieving a minimum detectable difference in NDI scores. Data of patients who attended fewer than 3 physical therapy sessions and those with initial NDI scores less than 10% were excluded from all analyses. We also excluded patients who were referred after surgery or over age 60 years because manual therapy is less likely to be indicated in these patients, and these groups were excluded from the primary studies supporting manual therapy and exercise interventions for patients with neck pain. Change scores for the NDI were calculated as the difference between initial and final follow-up scores. Change per visit was calculated by dividing the change score by the number of visits for each patient. Minimum detectable change (MDC (1) (Mobile Daughter Card) See riser card. (2) See Meta Data Coalition. ) represents the smallest amount of change in an outcome measure that likely reflects true change rather than measurement error alone. (28) The MDC for the NDI was defined by Westaway et al (29) as 8 points. We therefore categorized cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat any patient with a change score of 8 or greater as achieving the MDC, while patients with a change score of 8 or less were categorized as not achieving the MDC. For analysis of the MDC, we excluded patients with an initial NDI score less than 20% because the MDC was calculated in a sample of patients in which most of the patients had initial scores above this level. (29) The number of physical therapy visits, length of stay, and total physical therapy charges also were recorded for each patient. The effectiveness of the 2-day CE course was examined by comparing the clinical outcomes of patients who were treated by attending or nonattending therapists during the year preceding the CE course (pre-course period) with the outcomes in the year following the CE course (post-course period). Data of patients with an admission date from October 1, 2002, through September September: see month. 30, 2003, were included in the pre-course analysis. Data of patients with admission dates between November November: see month. 1, 2003, and October 31, 2004, were included in the post-course analysis. The data of any patient whose treatment crossed the dates of the CE course (October 9-12, 2003) were not included in the analysis (Fig. 2). [FIGURE 2 OMITTED] Baseline characteristics baseline characteristic Medical practice An initial finding or value in a Pt, before any formal intervention of patients were compared for each time period (pre- pre- word element [L.], before (in time or space). pre- pref. 1. Earlier; before; prior to: prenatal. 2. and post-course) on the basis of age, sex, and initial NDI and pain scores using t tests or chi-square tests chi-square test: see statistics. for continuous or categorical That which is unqualified or unconditional. A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding. Categorical is also used to describe programs limited to or designed for certain classes of people. variables, respectively. A 2-way analysis of covariance Covariance A measure of the degree to which returns on two risky assets move in tandem. A positive covariance means that asset returns move together. A negative covariance means returns vary inversely. (ANCOVA ANCOVA Analysis of Covariance ) was performed with time period (pre- or post-course) and CE attendance (attendee at·tend·ee n. One who is present at or attends a function. See Usage Note at -ee1. attendee Noun a person who is present at a specified event Noun 1. or nonattendee) as the independent variables and change in NDI scores as the dependent variable. Age, sex, and baseline NDI and pain scores were used as covariates. A separate ANCOVA was performed substituting rate of NDI change as the dependent variable. Of particular interest was the interaction effect between time period and CE attendance, examining the hypothesis that clinical outcomes were dependent on both time period and attendance. A chi-square test was used to compare the proportions of patients achieving the MDC for the NDI within each time period. Mann-Whitney U tests Mann-Whitney U test, n.pr See test, Mann-Whitney U. were used to compare physical therapy visits and charges between patient groups for the pre--and post-course periods. We further explored for trends in the clinical outcomes by dividing the pre- and post-course periods into thirds based on the initial examination date. We divided the time periods into thirds in order to examine the data for trends that might be occurring over time independent of the educational interventions. In particular, dividing the pre-course period into thirds instead of considering it as a single time period allowed us to examine for trends occurring as a result of other factors (eg, co-payment co-payment Managed Care That portion of a claim or medical expense that a health plan member must pay out-of-pocket for specific medical services–eg, hospital care, drugs, office visits, etc; the insurer pays the remaining portion changes) prior to any educational intervention. A one-way one-way adj. 1. Moving or permitting movement in one direction only: a one-way street. 2. Providing for travel in one direction only: a one-way ticket. ANOVA anova see analysis of variance. ANOVA Analysis of variance, see there was used to test for a linear trend in the change in NDI scores in pre- and post-course periods for attendees and nonattendees. To examine the effectiveness of the clinical improvement project, we examined the outcomes of only those patients who were treated by attendees of the CE course. We compared clinical outcomes between patients of CE attendees who were also project participants with those of CE attendees who were project nonparticipants during the pre- and post-course periods using ANCOVA and chi-square chi-square (ki´skwar) see under distribution and test. chi-square n. procedures as described previously. Differences in physical therapy visits and charges also were examined using Mann-Whitney U tests. We also examined for trends in clinical outcomes using ANOVA procedures as previously described. Statistical significance was defined as P<.05 for all analyses. Results Overall, data for 2,105 patients with neck pain were included in the ROMS database during the 25-month time period of the study, with data for the 1,365 patients who were eligible for inclusion used in this analysis. The reasons for exclusion are outlined in Figure 3. The mean age of all eligible patients was 42.2 years (SD=14.0), 69.9% were female, 700 patients (51.3%) were treated in the pre-course period, and 665 patients (48.7%) in the post-course period. There were no differences in the characteristics or clinical outcomes between patients treated during the pre- and post-course periods (Tab. 1). [FIGURE 3 OMITTED] Effectiveness of the CE Course The 34 therapists who attended the CE course treated 529 and 482 patients in the pre- and post-course periods, respectively, compared with 171 and 183 patients in the corresponding time periods for the nonattendees. In the pre-course period, patients meeting the inclusion criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. who were treated by attendees had lower baseline NDI scores than patients who were treated by nonattendees had (37.5 versus 40.8, P=.021). Patients who were treated by attendees in the post-course period were younger than those who were treated by nonattendees in the post-course period (41.7 versus 45.2 years, P=.004) and those who were treated by the attendees in the pre-course period (41.7 versus 42.3 years, P=.002) (Tab. 2). There were no differences between attendees and nonattendees in either the pre- or post-course period for baseline pain or NDI scores, number of visits, length of stay, or physical therapy charges (Tab. 2). The ANCOVAs comparing clinical outcomes between CE attendees and nonattendees, adjusted for age, sex, and baseline NDI and pain scores, did not show any significant interactions between time period (pre- or post-course) and attendance for either NDI change scores or rate of change in NDI, and no significant main effects for time period or attendance were observed (Tab. 3). Of the 1,365 patients whose data were included in the analysis, 1,191 patients (87.3%) had an initial NDI score [greater than or equal to] 20%, and their data were included in the analysis of rate of achievement of the MDC for the NDI. The percentage of patients whose data were excluded from the MDC analysis did not differ based on attendance or time period. There were no differences in the percentage of patients who achieved the MDC based on attendance at the CE course or time period (Tab. 2). These results demonstrate that clinical outcomes did not differ in the pre- or post-course time period or based on therapist attendance at the CE course, or the interaction of these 2 factors, indicating that therapists who attended the CE course did not show improvement during the post-course period relative to therapists who did not attend the CE course. The mean change in NDI for the pre- and post-course periods divided into thirds is illustrated in Figure 4. The one-way ANOVA comparing the mean changes scores across the 6 time periods was not significant for either the attendee or nonattendee therapists. No significant linear trends were found across time for either group. [FIGURE 4 OMITTED] Effectiveness of the Clinical Improvement Project Of the 34 therapists who attended the CE course, 11 therapists participated in the clinical improvement project and 23 therapists did not participate. Participant therapists treated 213 patients in the pre-course period and 196 patients in the post-course period. Nonparticipant therapists treated 316 and 286 patients in the pre--and post-course periods, respectively. In the pre-course period, patients who were treated by participant therapists had fewer visits (median=5 versus 6, P=-.009) and lower physical therapy charges (median=$545.59 versus $652.95, P=.001) than patients who were treated by nonparticipant therapists had (Tab. 4). In the post-course period, patients who were treated by participant therapists continued to have lower physical therapy charges (median=$561.84 versus $678.89, P=.002). The length of stay was greater in the post-course period for patients who were treated by participant therapists (median=20 versus 22 days, P=.031). The ANCOVAs comparing clinical outcomes between participants and nonparticipants, adjusted for age, sex, and baseline NDI and pain scores, revealed a significant interaction between time (pre--or post-course) and participation when NDI change scores were the dependent variable (P=.037, mean difference=4.03, 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. =l.30-6.76) (Tab. 5). The interaction effect on NDI change scores is graphed in Figure 5, indicating that therapists who attended the CE course and who participated in the clinical improvement project showed improved clinical outcomes from the pre--to post-course period, whereas therapists who attended the CE course and who did not participate in the clinical improvement project experienced a decrease in clinical outcomes over the same time period. The percentage of patients who achieved the MDC did not differ between therapists based on project participation in either time period (Tab. 4). However, among participant therapists, a significant increase in the percentage of patients who achieved the MDC was observed between the pre- and post-course periods (61.1% versus 71.4%, P=.038). [FIGURE 5 OMITTED] The mean change in NDI scores for the pre- and post-course periods divided into thirds is shown in Figure 6. The one-way ANOVA comparing the mean changes scores across the 6 time periods was not significant for either the participant or nonparticipant therapists. A significant linear trend toward less NDI change was found across time for the nonparticipant therapists (P=.015). A significant linear trend toward greater NDI change was present for participant therapists only when the last time period during the post-course was not considered (P=.018). If the last time period was included, the linear trend was no longer significant (P=.31). [FIGURE 6 OMITTED] Discussion and Conclusions The impact of physical therapist CE on clinical and financial outcomes of patient care has not been reported in the literature. We examined the effects of a 2-day evidence-based CE course by comparing the outcomes of patients with neck pain who were treated by therapists who attended the course with the outcomes of patients who were treated by therapists who were nonattendees. The results did not show any significant improvements in clinical outcomes for patients who were treated by the attendees. Clinical education course attendance did not appear to impact clinical or financial outcomes in any way. Most of the previous research on the impact of CE has focused on the outcomes of changing provider attitudes or behavior, with few studies examining changes in the clinical outcomes of patients. (6) The research that has been performed indicates that changing attitudes or knowledge with CE is more easily achieved than improving clinical outcomes, and the accomplishment of the former does not automatically lead to the latter. (30) We chose to focus on clinical outcomes because the ultimate goal of CE is to improve patient care. Because we did not measure the therapists' attitudes toward the CE content or provider behavior (ie, integrating new skills and evidence into practice), we are not able to determine whether the lack of effect of the CE course was due to the inability of the course to change therapist attitudes, poor adoption of new knowledge into practice, or insufficient skill attainment. What is evident from our results was the ineffectiveness in·ef·fec·tive adj. 1. Not producing an intended effect; ineffectual: an ineffective plea. 2. Inadequate; incompetent: an ineffective teacher. of the CE course alone for altering clinical outcomes. Previous research performed with physicians on changing provider behavior and improving clinical outcomes through integration of evidence into clinical practice concur CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes", R.M. Salter et al, Comp Langs 5(3):163-189 (1981)]. with our results showing the ineffectiveness of a traditional CE approach for accomplishing these goals. (31,32) More recent research suggests that newer approaches involving ongoing interaction with clinicians in smaller groups occurring within the context of the clinicians' practice setting may be more effective for changing clinical performance. (9,33,34) The results of our study generally support the hypothesis that an ongoing, small-group, educational intervention may be more effective than traditional CE delivery methods for improving clinical outcomes. Therapists who participated in the ongoing clinical improvement project demonstrated improved clinical outcomes, based on amount of change in disability during therapy and increased percentage of patients achieving the MDC for change in disability during the post-course time period. Therapists who attended the traditional CE session but who were not participants in the ongoing project did not demonstrate this improvement following the course, instead showing a significant trend toward less change in disability over the time of the study. The participant therapists were able to improve their clinical outcomes for patients with neck pain while maintaining significantly lower median physical therapy charges than nonparticipant therapists, suggesting improved cost-effectiveness cost-effectiveness pertaining to cost-effective. cost-effectiveness analysis a comparison of the relative cost-efficiencies of two or more ways of performing a task or achieving an objective. of care. The ongoing clinical improvement project was able to change clinical outcomes even though the project was focused on standardizing examination procedures and tracking clinical outcomes, instead of on treatment protocols or algorithms. Therapists who participated in this project met monthly following the 2-day CE course, providing opportunities for them to discuss their experiences working with patients with neck pain with other therapists and to discuss barriers to standardization standardization In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting . Clinical outcome data, including disability scores, visits, and costs, were presented at these meetings to track progress and reinforce the practice behavior changes Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. identified as favorable fa·vor·a·ble adj. 1. Advantageous; helpful: favorable winds. 2. Encouraging; propitious: a favorable diagnosis. 3. to promote better outcomes. "Clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher. cli·ni·cian n. facilitators" also were available to discuss cervical cervical /cer·vi·cal/ (ser´vi-k'l) 1. pertaining to the neck. 2. pertaining to the neck or cervix of any organ or structure. cer·vi·cal adj. treatment techniques, evidence-based literature, and the evaluation process. In addition, a follow-up, hands-on review session was conducted approximately 6 months after the original CE course to review hands-on evaluation and treatment skills. We chose to use a pragmatic approach to studying the effects of the CE interventions on clinical outcomes. The advantage of this approach is that it examines the impact of the CE interventions in their actual "real-world" context, (35) in which there is a diversity of both therapist and patient characteristics and where the choice to attend CE and to apply the techniques and decision-making decision-making, n the process of coming to a conclusion or making a judgment. decision-making, evidence-based, n a type of informal decision-making that combines clinical expertise, patient concerns, and evidence gathered from strategies learned in everyday clinical practice is left to the individual therapist. Previous research conducted with physicians has shown the efficacy of alternative approaches to CE, (6) but the effectiveness of implementing small-group, on-going Adj. 1. on-going - currently happening; "an ongoing economic crisis" ongoing current - occurring in or belonging to the present time; "current events"; "the current topic"; "current negotiations"; "current psychoanalytic theories"; "the ship's current position" CE interventions with physical therapists has not been previously investigated. The pragmatic approach taken in this research also creates limitations in interpretation of the results. Alternative explanations exist for the differences observed among the therapists in this study. Therapists were not randomly assigned as·sign tr.v. as·signed, as·sign·ing, as·signs 1. To set apart for a particular purpose; designate: assigned a day for the inspection. 2. to attend or not attend the traditional CE session, but self-selected to attend or not attend. It is possible that therapists who were already skilled in manual therapy and practicing as manual therapists may have chosen not to attend the course. We approached the participants in the ongoing clinical improvement project about participation based on volume of patients and geographic considerations. A selection bias may have existed in this process. The atmosphere in the facilities that were chosen and the influence of colleagues within those facilities could influence the effect of training; however, these factors are difficult to model in the analyses performed. The project participants treated a greater volume of patients with neck pain than most of the nonparticipants treated, which may have provided more opportunities for refinement of skills. Prospective, randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. studies are needed in physical therapy to examine different educational strategies for improving clinical outcomes. The magnitude of the differences in mean NDI changes based on project participation and time period was statistically significant, but smaller than the MDC for the NDI scores (mean difference=4 points, MDC=8 points). We anticipated a smaller treatment effect in our study because of the heterogeneity het·er·o·ge·ne·i·ty n. The quality or state of being heterogeneous. heterogeneity the state of being heterogeneous. of the patient sample and the lack of standardization in the treatment. We also included an examination of the effect of the CE intervention at the individual patient level because of concerns that statistically significant changes in aggregate outcomes (ie, mean changes in disability) may not represent clinically important changes at the individual patient level (ie, achieving the MDC). (36) Although the average amount of improvement in disability among all patients who were treated by the participants in the pre--and post-course periods did not reach the threshold of the MDC, a significantly greater percentage of patients who were treated by the participants met the MDC threshold in the post-course period, indicating that more individual patients were receiving a benefit in the post-course period and suggesting that the intervention may have had a clinically important effect on outcomes. Measurement is an important component for improving health care quality. (37) We help our patients and our profession by measuring the outcomes of our interventions, whether related to the treatment of patients or continuing education interventions for the professional development of physical therapists. Professional development through CE demands a significant investment of resources for the expressed purpose of improving the quality of patient care. In order to rationalize ra·tion·al·ize v. 1. To make rational. 2. To devise self-satisfying but false or inconsistent reasons for one's behavior, especially as an unconscious defense mechanism through which irrational acts or feelings are made to appear sustaining the investment in continuing education, we need to understand the most effective CE formats and measure the outcomes of the process. This article was received December 6, 2005, and was accepted April 28, 2006. References (1) Cantillon P, Jones R. Does continuing medical education continuing medical education See CME. in general practice make a difference? BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 1999;318:1276-1279. (2) Frank E, Baldwin Baldwin, cities, United States Baldwin. 1 Uninc. city (1990 pop. 22,719), Nassau co., SE N.Y., on the south shore of Long Island, on Baldwin Bay; settled 1640s. A fishing center and summer resort, it has varied manufactures. G, Langlieb AM. Continuing medical education habits of US women physicians. J Am Med Womens Assoc. 2000;55:27-28. (3) Nylenna M, Aasland OG. Primary care physicians and their information-seeking behaviour. Scand J Prim Health Care. 2000;18:9-13. (4) Davis D, Thomson M, Oxman A, Haynes B. Changing physician performance: a systematic review of the effect of continuing education strategies. JAMA JAMA abbr. Journal of the American Medical Association . 1995;274:700-705. (5) Grimshaw JM, Russell IT. Effect of clinical guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. on medical practice: a systematic review of rigorous evaluations. Lancet lancet /lan·cet/ (lan´set) a small, pointed, two-edged surgical knife. lan·cet n. . 1993;342: 1317-1322. (6) Thomson O'Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2001:CD003030. Issue 1. (7) Davis D, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CE: a review of 50 randomized controlled trials A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. . JAMA. 1992;268:1111-1117. (8) Mazmanian PE, Davis DA. Continuing medical education and the physician as a learner. JAMA. 2002;288:1057-1061. (9) Davis D, O'Brien M, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874. (10) White M, Michaud G, Pachev G, et al. Randomized trial of problem-based versus didactic di·dac·tic adj. Of or relating to medical teaching by lectures or textbooks as distinguished from clinical demonstration with patients. seminars for disseminating dis·sem·i·nate v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates v.tr. 1. To scatter widely, as in sowing seed. 2. evidence-based guidelines on asthma asthma (ăz`mə, ăs`–), chronic inflammatory respiratory disease characterized by periodic attacks of wheezing, shortness of breath, and a tight feeling in the chest. A cough producing sticky mucus is symptomatic. management to primary care physicians. J Contin Educ Health Prof 2004;24:237-243. (11) Davis D, Taylor-Vaisey A. Translating guidelines into practice: a systemic systemic /sys·tem·ic/ (sis-tem´ik) pertaining to or affecting the body as a whole. sys·tem·ic adj. 1. Of or relating to a system. 2. review of theoretical concepts, practical experience and research evidence in the adoption of clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. . CMAJ CMAJ Canadian Medical Association Journal . 1997;157:408-416. (12) Rappolt S, Tassone M. How rehabilitation rehabilitation: see physical therapy. therapists gather, evaluate, and implement new knowledge J Contin Educ Health Prof. 2002;22: 170-180. (13) Landers MR, McWhorter JW, Krum LL, Glovinsky D. Mandatory continuing education in physical therapy: survey of physical therapists in states with and states without a mandate. Phys Ther. 2005;85: 861-871. (14) Karp NV. Physical therapy continuing education, part 1: perceived harriers and preferences. J Contin Educ Health Prof. 1992;12:111-120. (15) Tassone MR, Speechley M. Geographical challenges for physical therapy continuing education: preferences and influences. Phys Ther. 1997;77:285-295. (16) Turner PA, Whitfield TWA TWA Time-weighted average, see there . Physiotherapists' reasons for selection of treatment techniques: a cross-national survey. Physiotherapy physiotherapy: see physical therapy. Theory and Practice. 1999;15:235-246. (17) DeMont M. Response to "Continuing education rating system needed" [letter to the editor]. Phys Ther. 1993;73:712. (18) Gross AR, Hoving JL, Haines TA, et al (Cervical Overview Group). A Cochrane review of manipulation and mobilization mobilization Organization of a nation's armed forces for active military service in time of war or other national emergency. It includes recruiting and training, building military bases and training camps, and procuring and distributing weapons, ammunition, uniforms, for mechanical neck disorders. Spine. 2004;29:1541-1548. (19) Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner general practitioner n. Abbr. GP A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. for patients with neck pain: a randomized, controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. . Ann ANN, Scotch law. Half a year's stipend over and above what is owing for the incumbency due to a minister's relict, or child, or next of kin, after his decease. Wishaw. Also, an abbreviation of annus, year; also of annates. In the old law French writers, ann or rather an, signifies a year. Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 2002;136: 713-722. (20) Jull G, Trott P, Potter A potter is someone who makes pottery. Potter may also refer to: People
adj. Serving, tending, or having the power to manipulate. n. Any of various objects designed to be moved or arranged by hand as a means of developing motor skills or understanding abstractions, especially in therapy for cervicogenic headache headache Pain in the upper portion of the head. Episodic tension headaches are the most common, usually causing mild to moderate pain on both sides. They result from sustained contraction of face and neck muscles, often due to fatigue, stress, or frustration. . Spine. 2002;27:1835-1843. (21) Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue (electronics) analogue - (US: "analog") A description of a continuously variable signal or a circuit or device designed to handle such signals. The opposite is "discrete" or "digital". and simple numerical numerical expressed in numbers, i.e. Arabic numerals of 0 to 9 inclusive. numerical nomenclature a numerical code is used to indicate the words, or other alphabetical signals, intended. rating scales. Pain. 1994;56:217-226. (22) Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14:409-415. (23) Pietrobon R, Coeytaux RR, Carey TS, et al. Standard scales for measurement of functional outcome for cervical pain or dysfunction dysfunction /dys·func·tion/ (dis-funk´shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc´tional erectile dysfunction impotence (2). : a systematic review Spine. 2002;27:515-522. (24) Hairns F, Waalen J, Mior S. Psychometric psy·cho·met·rics n. (used with a sing. verb) The branch of psychology that deals with the design, administration, and interpretation of quantitative tests for the measurement of psychological variables such as intelligence, aptitude, and properties of the neck disability index. J Manipulative Physiol Ther. 1998;21:75-80. (25) Riddle riddle, puzzling question, specifically one that consists of a fanciful description or definition of something to be guessed. A famous riddle was asked by the Sphinx: "What goes on four legs in the morning, on two at noon, on three at night?" Oedipus guessed the DL, Stratford PW. Use of generic versus region-specific functional status measures on patients with cervical spine disorders Cervical spine disorders are a problem for many adults. The cervical spine contains many different anatomic structures, including muscles, bones, ligaments, and joints. Each of these structures has nerve endings that can detect painful problems when they occur. . Phys Ther. 1998;78:951-963. (26) Wheeler AH, Goolkasian P, Baird AC, Darden BV. Development of the Neck Pain and Disability Scale: item analysis, face, and criterion-related validity. Spine. 1999;24:1290-1294. (27) Gross AR, Kay KAY Kick Ass Year KAY Kansas Association of Youth TM, Kennedy C, et al. Clinical practice guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. on the use of manipulation or mobilization in the treatment of adults with mechanical neck disorders. Man Ther. 2002;7:193-205. (28) Stratford PW, Binkley FM, Riddle DL. Health status measures: strategies and analytic an·a·lyt·ic or an·a·lyt·i·cal adj. 1. Of or relating to analysis or analytics. 2. Expert in or using analysis, especially one who thinks in a logical manner. 3. Psychoanalytic. methods for assessing change scores. Phys Ther. 1996; 76:1109-1123. (29) Westaway MD, Stratford PW, Binkley JM. The patient-specific functional scale: validation See validate. validation - The stage in the software life-cycle at the end of the development process where software is evaluated to ensure that it complies with the requirements. of its use in persons with neck dysfunction. J Orthop Sports Phys Ther. 1998;27:331-338. (30) Umble KE, Cervero RM. Impact studies in continuing education for health professionals: a critique of the research syntheses. Eval Health Prof. 1996;19:148-174. (31) Berenholtz S, Pronovost PJ. Barriers to translating evidence into practice. Curr Opin Crit Care. 2003;9:321-325. (32) Grimshaw JM, Shirran L, Thomas (language) Thomas - A language compatible with the language Dylan(TM). Thomas is NOT Dylan(TM). The first public release of a translator to Scheme by Matt Birkholz, Jim Miller, and Ron Weiss, written at Digital Equipment Corporation's Cambridge Research Laboratory runs R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39 (suppl) :2-45. (33) Robertson MK, Umble KE, Cervero RM. Impact studies in continuing education for health professions: update. J Contin Educ Health Prof. 2003;23:146-156. (34) Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets (jargon) magic bullet - (Or "silver bullet" from vampire legends) A term widely used in software engineering for a supposed quick, simple cure for some problem. E.g. "There's no silver bullet for this problem". : a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153:1423-1431. (35) Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy to effectiveness transition. Am J Public Health. 2003;93:1261-1267. (36) Schmitt JS, Di Fabio RS. Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. Clin J Epidemiol. 2004;57: 1008-1018. (37) Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Med Care. 2003;41 (suppl):30-38. The Bottom Line The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Summaries are written by members of The Bottom Line Committee. [Brennan GP, Fritz fritz n. Informal A condition in which something does not work properly: Our television is on the fritz. [Perhaps from German Fritz JM, Hunter SJ. Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy. Phys Ther. 2006;86:1251-1262.] What problems did the researchers set out to study, and why? Continuing education (CE- ce- for words beginning thus, see also those beginning coe-. ) courses are very popular among many physical therapists, but it is unknown whether participation in CE leads to improved outcomes in patients who receive physical therapy from therapists who take CE courses. The authors examined the effects of 2 different CE delivery models on patient outcomes in clinical settings. What types of patients participated in the study? Thirty-four of 57 physical therapists employed in 13 clinics in Utah attended a 2-day CE course. Eleven of these 34 attendees further participated in an ongoing clinical improvement project for patients with neck pain. Outcome data were obtained for 1,365 patients; average age was 42 years, and more than two thirds of the patients were women. Chief complaint was neck pain. What new information does this study offer? To date, studies examining the impact of CE on patient care have focused primarily on physician practice. The studies evaluating the impact of traditional lecture presentations in physician professional practice do not indicate that didactic presentations improve clinical performance. In contrast, some researchers (1) have shown that the use of small-group discussion and practice sessions to enhance clinical skills may be effective in improving physician practice. The current study adds to our knowledge of the impact that the mode of delivery of CE may have on the performance of physical therapists in the clinic. How did the researchers go about the study? Two experienced educators and physical therapist clinicians with fellowship status in the American Academy of Orthopedic Manual Therapy taught a 2-day course at the participating clinics, focusing on manual therapy of the spine and therapeutic exercise interventions for physical therapists. The course included lecture and interactive hands-on practice sessions. Course notes were provided to all participants. After completion of the course, a separate clinical improvement project was conducted in 4 of the participating 13 physical therapy clinics, which included monthly meetings to review the examination and manual therapy techniques taught in the course. The clinical improvement project utilized facilitators and an instructional CD-ROM as learning resources. An additional small-group follow-up, with a 4-hour period of hands-on instruction with one of the original course instructors, was attended by the physical therapists participating in the clinical improvement project. Data on outcomes for eligible patients treated by the physical therapists who did or did not attend the CE course were collected before (pre-course) and after (post-course) the period when the CE course was offered. Neck Disability Index (NDI) scores from the initial and final therapy sessions, 0-10 numeric pain rating scales, utilization information, and physical therapy charges were tracked and recorded for each patient. The effectiveness of the 2-day CE course was examined by comparing the clinical outcomes of patients who were treated by attending or nonattending therapists during the year preceding the course with the outcomes in the year following the course. To examine the effectiveness of the additional clinical improvement project, researchers compared clinical outcomes during the pre--and post-course periods between patients who were treated by the course attendees who participated in the "extra" education project and patients treated by therapists who attended only the 2-day course. Differences in physical therapy visits and charges also were examined. How might the results of this study apply to patients who are treated by physical therapists from this point forward? No differences were found in clinical outcomes between attendees and nonattendees in either the pre- or post-course period for baseline pain or NDI scores, number of visits, length of stay, or physical therapy charges. Attendance at the CE course did not affect clinical treatment outcome in any of the ways that were examined by the investigators. However, comparing treatment outcomes between the therapists who attended only the CE course with those who both attended the course and participated in the clinical improvement project suggested that the "extra" project improved clinical outcomes from the pre--to post-course period, whereas therapists who attended the CE course and who did not participate in the clinical improvement project experienced a decrease in clinical outcomes over the same time period. This study shows that the CE course did not result in improved clinical outcomes when comparing patient outcomes between therapists who did and did not attend a 2-day course. Closer examination of the outcomes for the clinicians who attended the course suggests that physical therapists should consider the manner in which CE is delivered prior to attending a course. The totality TOTALITY. The whole sum or quantity. 2. In making a tender, it is requisite that the totality of the sum due should be offered, together with the interest and costs. Vide Tender. of evidence to date provides preliminary support for the notion that interactive workshops with practice sessions may be more effective in improving professional practice than CE courses delivered in a lecture format only. Furthermore, the results of this study indicate that follow-up sessions and practice aimed at facilitating the synthesis of course material into clinical practice may promote improved outcomes for the patients of some therapists. What are the limitations of the study, and what further research is needed? As the authors acknowledged, physical therapists who attended the CE course from participating clinics were self-selected to attend or not attend, and it is possible that skill levels in manual therapy or other uncontrolled factors may have had an impact on therapists' decision to attend the course. A selection bias also may have existed for the ongoing clinical improvement project, as researchers chose clinic participation based on volume of patients and geographic considerations. Future research-- using prospective, randomized studies where possible-should focus on the effectiveness of practicing clinical skills and the use of follow-up sessions to promote improved clinical outcomes in physical therapy CE courses. Reference (1) Thomson O'Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2001:CD003030. Issue 1. [DOI (Digital Object Identifier) A method of applying a persistent name to documents, publications and other resources on the Internet rather than using a URL, which can change over time. : 10.2522/pti.20050382.bl] * IBM (International Business Machines Corporation, Armonk, NY, www.ibm.com) The world's largest computer company. IBM's product lines include the S/390 mainframes (zSeries), AS/400 midrange business systems (iSeries), RS/6000 workstations and servers (pSeries), Intel-based servers (xSeries) Corp, 1133 Westchester Ave AVE Avenue AVE Average AVE Alta Velocidad Espanola (train between Madrid and Seville) AVE Alta Velocidad Española (Spanish: High Speed Train) AVE Audio Video Entertainment AVE Advertising Value Equivalent , White Plains, NY 10604. Gerard P Brenna, Julie M Fritz, Stephen J Hunter GP Brennan, PT, PhD, is Director for Clinical Quality and Outcomes, Rehabilitation Agency, Intermountain Health Care, Salt Lake City, Utah For ships of the United States Navy of the same name, see . Salt Lake City is the capital and the most populous city of the U.S. state of Utah. The name of the city is often shortened to Salt Lake, or its initials, S.L.C. . JM Fritz, PT, PhD, ATC ATC Air Traffic Control ATC Average Total Cost ATC Certified Athletic Trainer ATC At the Center (Hartford, Maine retreat center) ATC Applied Technology Council ATC All Things Considered , is Associate Professor, Division of Physical Therapy, University of Utah The University of Utah (also The U or the U of U or the UU), located in Salt Lake City, is the flagship public research university in the state of Utah, and one of 10 institutions that make up the Utah System of Higher Education. , and Clinical Outcomes Research Scientist, Intermountain Health Care, 520 Wakara Way, Salt Lake City, UT 84108 (USA). Address all correspondence to Dr Fritz at: julie.fritz@hsc.utah.edu. SJ Hunter, PT, OCS, is Director, Rehabilitation Agency, Intermountain Health Care. Dr Fritz provided concept/idea/research design and data collection and analysis. Dr Brennan and Dr Fritz provided writing. Dr Brennan provided project management, subjects, and institutional liaisons. Dr Hunter provided facilities/equipment. This research was approved for exempt review by the Institutional Review Board of Intermountain Health Care. This research, in part, was presented as an abstract at the Combined Sections Meeting of the American Physical Therapy Association The American Physical Therapy Association (APTA) is a national professional organization representing more than 66,000 members. Its goal is to foster advancements in physical therapy practice, research, and education. ; February 23-27, 2005; New Orleans New Orleans (ôr`lēənz –lənz, ôrlēnz`), city (2006 pop. 187,525), coextensive with Orleans parish, SE La., between the Mississippi River and Lake Pontchartrain, 107 mi (172 km) by water from the river mouth; founded , La. [DOI: 10.2522/pti.20050382
Table 1.
Comparison of Baseline Characteristics and Clinical Outcomes
of Patients Who Were Treated in the Pre- and Post-Course Periods (a)
Pre-course
(n=700)
Age (y), [bar.X] [+ or -] SD 41.8 [+ or -] 13.8
Sex (% female) 69.7%
Baseline NDI score, [bar.X] [+ or -] SD 38.3 [+ or -] 16.1
Baseline pain rating, [bar.X] [+ or -] SD 5.5 [+ or -] 2.3
Visits, [bar.X] [+ or -] SD 6.6 [+ or -] 4.7
(median=5)
Length of stay (d), [bar.X] [+ or -] SD 29.6 [+ or -] 34.9
(median=21)
Total physical therapy charges, $766.93 [+ or -] $565.41
[bar.X] [+ or -] SD (median=$617.49)
Change in NDI, [bar.X] [+ or -] SD 13.3 [+ or -] 15.9
Rate of change in NDI, [bar.X] [+ or -] SD 2.9 [+ or -] 4.9
Achieved MDC for NDI change 66.6%
scores (% yes) (n=620)
Post-course
(n=665)
Age (y), [bar.X] [+ or -] SD 42.6 [+ or -] 14.2
Sex (% female) 70.1%
Baseline NDI score, [bar.X] [+ or -] SD 37.9 [+ or -] 17.2
Baseline pain rating, [bar.X] [+ or -] SD 5.5 [+ or -] 2.3
Visits, [bar.X] [+ or -] SD 6.6 [+ or -] 4.7
(median=5)
Length of stay (d), [bar.X] [+ or -] SD 31.4 [+ or -] 30.4
(median=21)
Total physical therapy charges, $795.80 [+ or -] $634.89
[bar.X] [+ or -] SD (median=$619.96)
Change in NDI, [bar.X] [+ or -] SD 12.7 [+ or -] 16.3
Rate of change in NDI, [bar.X] [+ or -] SD 2.5 [+ or -] 4.0
Achieved MDC for NDI change 68.0%
scores (% yes) (n=571)
No significant differences were found between groups.
NDI=Neck Disability Index, MDC=minimum detectable change.
Table 2.
Comparison of Characteristics of Patients Who Were Treated
by Therapists Attending or Not Attending the Continuing
Education Course in the Pre- and Post-course Periods (a)
Patients Treated by Attendees
Pre-course Post-course
(n=529) (n=482)
Age (y), [bar.X] 42.3 [+ or -] 13.6 41.7 [+ or -] 14.0 (b)
[+ or -] SD
Sex (% female) 70.5% 69.3%
Baseline NDI score, 37.5 [+ or -] 16.06 37.3 [+ or -] 17.5
[bar.X]
[+ or -] SD
Baseline pain 5.5 [+ or -] 2.3 5.5 [+ or -] 2.4
rating, [bar.X]
[+ or -] SD
Visits, [bar.X] 6.4 [+ or -] 4.3 6.5 [+ or -] 4.4
[+ or -] SD (median=5) (median=5)
Length of stay (d), 28.7 [+ or -] 34.3 30.2 [+ or -] 28.9
[bar.X] (median=21) (median=21)
[+ or -] SD
Total physical $738.98 $784.43 [+ or -]
therapy charges, $587.81
[bar.X] (median=$605.28) (median=$637.44)
[+ or -] SD
Achieved MDC for NDI 64.7% 67.9%
change scores (n=465) (n=408)
(% yes)
Patients Treated by Nonattendees
Pre-course Post-course
(n=171) (n=183)
Age (y), [bar.X] 40.3 [+ or -] 14.3 (c) 45.2 [+ or -]
[+ or -] SD 14.4 (b,c)
Sex (% female) 67.3% 72.1%
Baseline NDI score, 40.7 [+ or -] 16.4 (b) 39.3 [+ or -] 16.4
[bar.X]
[+ or -] SD
Baseline pain 5.6 [+ or -] 2.3 5.4 [+ or -] 2.3
rating, [bar.X]
[+ or -] SD
Visits, [bar.X] 7.2 [+ or -] 5.7 6.9 [+ or -] 5.3
[+ or -] SD (median=6) (median=5)
Length of stay (d), 32.2 [+ or -] 36.6 34.5 [+ or -] 33.9
[bar.X] (median=22) (median=22)
[+ or -] SD
Total physical $853.41 [+ or -] $828.26 [+ or -]
therapy charges, $735.39 $754.42
[bar.X] (median=$663.54) (median=$610.58)
[+ or -] SD
Achieved MDC for NDI 72.3% 68.1%
change scores (n=155) (n=163)
(% yes)
(a) NDI=Neck Disability Index, MDC=minimum detectable change.
(b) Significant difference between patients treated by attendees
and nonattendees.
(c) Significant difference between patients in the pre--and
post-course periods.
Table 3.
Results of the 2-Way Analyses of Covariance Comparing Clinical
Outcomes (Change in Neck Disability Index [NDI] Scores and Rate
of Change in NDI Scores) Between Continuing Education Course
Attendees and Nonattendees in the Pre--and Post-course Periods (a)
Change in NDI Scores
Attendees Nonattendees
Pre-course period, 13.1 [+ or -] 16.1 13.8 [+ or -] 15.2
[bar.X] [+ or -] SD
Post-course period, 12.8 [+ or -] 16.7 12.5 [+ or -] 15.0
[bar.X] [+ or -] SD
Rate of Change in NDI Scores
Attendees Nonattendees
Pre-course period, 2.9 [+ or -] 5.1 2.8 [+ or -] 4.2
[bar.X] [+ or -] SD
Post-course period, 2.4 [+ or -] 4.0 2.5 [+ or -] 4.1
[bar.X] [+ or -] SD
Significant
Source SS df MS F F
Time period (pre- 42.0 1 42.0 0.19 0.66
or post-course)
Course attendance 118.7 1 118.7 0.54 0.47
Time period x 4.2 1 4.2 0.019 0.89
course
attendance
Error 301109.1 1358 221.7
Significant
Source SS df MS F F
Time period (pre- 24.3 1 24.3 1.2 0.27
or post-course)
Course attendance 3.2 1 3.2 0.17 0.68
Time period x 9.1 1 9.1 0.47 0.50
course
attendance
Error 26440.7 1357 19.5
(a) No significant interaction or main effects were found. Rate
of change was calculated by dividing the change score by the
number of physical therapy sessions attended for each patient.
Table 4.
Comparison of Characteristics of Patients Treated by Therapists
Who Attended the Continuing Education Course and Who Participated
or Did Not Participate in the Clinical Improvement Project in the
Pre--and Post-course Periods (a)
Patients Treated by
Participants
Pre-course
(n=213)
Age (y), [bar.X] [+ or -] SD 42.4 [+ or -] 12.9
Sex (% female) 68.5%
Baseline NDI score, [bar.X] [+ or -] SD 36.9 [+ or -] 14.8
Baseline pain rating, [bar.X] [+ or -] SD 5.6 [+ or -] 2.2
Visits, [bar.X] [+ or -] SD 6.0 [+ or -] 4.16
(median=5)
Length of stay (d), [bar.X] [+ or -] SD 27.7 [+ or -] 26.1 (c)
(median=20)
Total physical therapy charges, $673.33 [+ or -] $478.09 (b)
[bar.X] [+ or -] SD (median= $545.59)
Achieved MDC for NDI 61.1% (c)
change scores (% yes) (n=190)
Patients Treated by
Participants
Post-course
(n=196)
Age (y), [bar.X] [+ or -] SD 40.8 [+ or -] 14.1
Sex (% female) 73.5%
Baseline NDI score, [bar.X] [+ or -] SD 37.8 [+ or -] 17.6
Baseline pain rating, [bar.X] [+ or -] SD 5.5 [+ or -] 2.4
Visits, [bar.X] [+ or -] SD 6.2 [+ or -] 4.3
(median=5)
Length of stay (d), [bar.X] [+ or -] SD 31.9 [+ or -] 27.3 (c)
(median=22)
Total physical therapy charges, $715.18 [+ or -] $512.26 (b)
[bar.X] [+ or -] SD (median= $561.84)
Achieved MDC for NDI 71.4% (c)
change scores (% yes) (n=168)
Patients Treated by
Nonparticipants
Pre-course
(n=316)
Age (y), [bar.X] [+ or -] SD 42.3 [+ or -] 14.1
Sex (% female) 71.8%
Baseline NDI score, [bar.X] [+ or -] SD 37.8 [+ or -] 16.7
Baseline pain rating, [bar.X] [+ or -] SD 5.4 [+ or -] 2.4
Visits, [bar.X] [+ or -] SD 6.8 [+ or -] 4.4 (b)
(median=6)
Length of stay (d), [bar.X] [+ or -] SD 29.4 [+ or -] 39.0
(median=22)
Total physical therapy charges, $785.39 [+ or -] $503.86 (b)
[bar.X] [+ or -] SD (median= $652.95)
Achieved MDC for NDI 67.3%
change scores (% yes) (n=275)
Patients Treated by
Nonparticipants
Post-course
(n=286)
Age (y), [bar.X] [+ or -] SD 42.3 [+ or -] 14.0
Sex (% female) 66.4%
Baseline NDI score, [bar.X] [+ or -] SD 37.0 [+ or -] 17.5
Baseline pain rating, [bar.X] [+ or -] SD 5.6 [+ or -] 2.3
Visits, [bar.X] [+ or -] SD 6.6 [+ or -] 4.5
(median=5)
Length of stay (d), [bar.X] [+ or -] SD 29.0 [+ or -] 29.9
(median=21)
Total physical therapy charges, $837.46 [+ or -] $635.58 (b)
[bar.X] [+ or -] SD (median= $678.89)
Achieved MDC for NDI 65.41%
change scores (% yes) (n=240)
(a) NDI=Neck Disability Index, MDC=minimum detectable change.
(b) Significant difference between patients treated by participants
and nonparticipants.
(c) Significant difference between patients in the pre- and
post-course periods.
Table 5.
Results of the 2-Way Analyses of Covariance (ANCOVAs) Comparing
Clinical Outcomes (Change in Neck Disability Index [NDI] Scores and
Rate of Change in NDI Scores) Between Continuing Education Course
Attendees Who Participated or Did Not Participate in the Clinical
Improvement Project in the Pre- and Post-course Periods (a)
Change in NDI Scores
Participants Nonparticipants
Pre-course period,
[bar.X] [+ or -] SD 12.4 [+ or -] 18.6 13.5 [+ or -] 13.9
Post-course period,
[bar.X] [+ or -] SD 14.9 [+ or -] 16.4 11.3 [+ or -] 16.8
Rate of Change in NDI Scores
Participants Nonparticipants
Pre-course period,
[bar.X] [+ or -] SD 3.0 [+ or -] 6.2 2.9 [+ or -] 4.3
Post-course period,
[bar.X] [+ or -] SD 2.7 [+ or -] 3.8 2.2 [+ or -] 4.1
Significant
Source df SS MS F F
Time period (pre- or
post-course) 1 2.8 2.8 0.01 0.91
Project participation 1 384.0 384.0 1.7 0.19
Time period x project 1 971.2 971.2 4.3 0.04
participation
Error 1004 226054.4 225.2
Significant
Source df SS MS F F
Time period (pre- or
post-course) 1 53.8 53.8 2.6 0.11
Project participation 1 21.4 21.4 1.0 0.31
Time period x project 1 4.7 4.7 0.23 0.63
participation
Error 1003 20474.1 20.4
(a) A significant interaction effect was present for the ANCOVA using
the NDI change scores as the dependent variable.
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