Roger M. Nelson

Clinical prediction rules: What are they and what do they tell us?

QUESTION Clinical prediction rules are research-based tools that quantify the contributions of relevant patient characteristics to provide numeric indices that assist clinicians in making predictions. Clinical prediction rules have been used to describe the likelihood of the presence or absence of a condition, assist in determining patient prognosis, and help the classification of patients for treatment. The recent rapid rise in the use of clinical prediction rules raises questions about the conditions under which they may be used most appropriately. What is the potential role of clinical prediction rules in physiotherapy practice and what are the strategies by which clinicians can determine their appropriate use for a given clinical setting? CONCLUSION Clinical prediction rules use quantitative methods to build upon the body of literature and expert opinion and can provide quick and inexpensive estimates of probability. Clinical prediction rules can be of great value to assist clinical decision making but should not be used indiscriminately. They are not a replacement for clinical judgment and should complement rather than supplant clinical opinion and intuition. The development of valid clinical prediction rules should be a goal of physiotherapy research. Specific areas in need of attention include deriving and validating clinical prediction rules to screen patients for potentially serious conditions for which current tests lack adequate diagnostic accuracy or have unacceptable cost and risk, and to assist in classification of patients for treatments that are likely to result in substantially different outcomes in heterogeneous groups of patients.

Evaluating Research Studies That Address Prognosis for Patients Receiving Physical Therapy Care: A Clinical Update

A prognosis is a broad statement that predicts a patients likely status, or degree of change, at some time in the future. Clinicians are likely to improve the accuracy of their judgments of prognosis by incorporating relevant research findings. In recent years, there has been substantial growth in the number of primary studies and systematic reviews addressing prognosis for people likely to receive physical therapy care. The purpose of this clinical update is to provide a framework for identifying, appraising, and utilizing these research findings to help make prognostic judgments.

Spanish-Language Version of the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS): Preliminary Validation

Background and Purpose An instrument that provides valid measurements of satisfaction with physical therapy care for Spanish-speaking patients will enhance communication and ensure their representation in quality assurance analyses and research on health care disparities. The purpose of this investigation was to provide preliminary information on the factor structure, group- and individual-level reliability, and criterion-referenced validity of measurements obtained from a Spanish-language version of the MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care (MRPS). Subjects A total of 203 Spanish-speaking patients in the New York City area participated in this study. Methods Consenting subjects completed a 20-item MRPS after discharge from outpatient physical therapy care. Several translators performed “forward” and “backward” translation of the MRPS, followed by consensus agreement on item structure. Factor structure was investigated using item-correlation and exploratory factor analysis. Group-level reliability for single test administration was assessed using the Cronbach alpha, and individual-level reliability was assessed by calculating the standard error of the measure (SEM). Concurrent validity was tested by comparing the item scores and mean scores of factors to global measures of satisfaction. Results The means of individual item scores (1–5) ranged from 3.22 for “I did not wait too long” to 4.80 for “My therapist treated me respectfully.” There were no sex-based differences in item scores. Exploratory factor analysis suggested a 2-factor solution: a 7-item “external” factor and a 3-item “internal” factor. The correlations (r) of the mean scores from these factors with the 2 global measures ranged from .59 to .82. The SEM was 0.16 for the internal factor and 0.25 for the external factor. Discussion and Conclusion The underlying factor structure of the Spanish-language version of the MRPS was identical to the English-language version. Our findings provide preliminary support for the reliability and validity of measurements obtained from the Spanish-language version of the MRPS. Further study is needed to assess the stability of these findings in other samples. As with English-speaking patients, Spanish-speaking patients satisfaction with physical therapy care is most strongly linked to the professional behavior of the clinician.

Preserving the Quality of the Patient- Therapist Relationship: An Important Consideration for Value-Centered Physical Therapy Care

Current best evidence suggest that, when adjusting for risk, a substantial number of patients receiving outpatient physical therapy report good outcomes and have lower cost of care or frequency of adverse events when compared to pharmacologic or invasive procedures. In other words, physical therapy care, supported by the best available research evidence, is often a bargain when compared to other treatment approaches. However, a question that must be asked is, ‘How much do patients value their physical therapy care?’ J Orthop Sports Phys Ther 2008;38(2):34–35. doi:10.2519/jospt.2008.0113

Patient satisfaction with musculoskeletal physiotherapy care in Australia: An international comparison

Abstract Objectives: (1) To attain a quantitative estimate of patient satisfaction with physiotherapy care for musculoskeletal conditions in Australia; (2) to compare the observed level of patient satisfaction with care in Australia with those from other countries; and (3) to compare factors contributing to patient satisfaction between Australia and the United States (US). Methods: We conducted a prospective study of 274 patients presenting for physiotherapy treatment of a musculoskeletal disorder in Australian clinics. Patient satisfaction was measured using the 20-item MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) and satisfaction scores were compared with those from Northern Europe, North America, the United Kingdom, and Ireland. To investigate factors contributing to patient satisfaction between Australia and the US, we compared 20-item MRPS data from Australian and Spanish-speaking US cohorts. Results: Mean Australian MRPS satisfaction score was 4·55 (95% confidence interval: 4·51–4·59) on a scale of 1 to 5, where 1 indicates high dissatisfaction and 5 indicates high satisfaction. This high level of patient satisfaction is consistent with international data. Australian respondents specifically valued interpersonal aspects of care, including advice and information about their condition and an explanation about self-management. The correlation between treatment outcomes and global patient satisfaction was low (r = −0·22). A comparison of data collected from Australia and the US showed that MRPS items regarding interpersonal aspects of care, such as the therapists’ communication skills, correlated strongly with global satisfaction in both countries. However, there were other questionnaire items for which the correlation with global satisfaction was significantly different between Australia and the US. Conclusions: Patient satisfaction with musculoskeletal physiotherapy care in Australia is high and comparable with Northern Europe, North America, the United Kingdom and Ireland. Comparison of data between Australia and the US indicates that while some determinants of patient satisfaction are common, country-specific differences also exist.

Intercultural comparison of patient satisfaction with physiotherapy care in Australia and Korea: an exploratory factor analysis

Abstract Objectives: The aim of this study was to conduct a cross-cultural comparison of the factors that influence patient satisfaction with musculoskeletal physiotherapy care in Australia and Korea. Methods: Prospective studies were conducted in Australia and Korea. Patient satisfaction data were collected using the MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) from a total of 1666 patients who were attending clinics for physiotherapy treatment of a musculoskeletal condition. Exploratory factor analysis was conducted to identify factors determining patient satisfaction in each cohort. Results: A four-factor solution for the MRPS was found for the Australian and Korean data sets, explaining 61 and 55% of the variance respectively. Communication and respect, convenience and quality time and person-focused care were factors common to both countries. One factor unique to Korea was courtesy and propriety. For both cultures, global patient satisfaction was significantly but weakly correlated with the outcome of treatment. Conclusions: The interpersonal aspect of care, namely effective communication and respect from the therapist, appears to be the predominant and universal factor that influences patient satisfaction with physiotherapy care, although other culturally specific factors were identified. Physiotherapists can maximize patient satisfaction with care by addressing those features that uniquely contribute to patient satisfaction in the cultural context in which they are working.

The relationship between patient satisfaction with physical therapy care and global rating of change reported by patients receiving worker's compensation

This study examined relationships between patient satisfaction with physical therapy care and global rating of change; 1,944 respondents completed the Medrisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MR-12) and a nine-point Global Rating of Change Scale (GROC) following a course of physical therapy for a work-related musculoskeletal problem. Ninety percent of all respondents reported being satisfied or very satisfied with their overall care, whereas 70.1% of all respondents indicated they improved following treatment. Respondents who reported improvement had significantly higher scores for all measures of satisfaction (p<0.01) than did those who reported failure to improve; however, both of these groups had mean scores of greater than 4.0 on the MR-12, indicating that respondents were likely to be satisfied or very satisfied with care regardless of perceived change following treatment. Scores>4.0 from the MR-12 had high sensitivity to detect those respondents classified as “improved” (0.87–0.95), but low specificity to differentiate between those who were classified as “improved” and those who were classified as “did not improve” (0.22–0.30). Our findings support the hypothesis that patient satisfaction with care is primarily independent of perceived clinical change.

The next evolution.

Roger M. Nelson, PT, PhD, FAPTA, has served the profession as a clinician, educator, researcher, and mentor for close to 50 years. Dr Nelson received his bachelor of science degree in physical therapy from New York University in 1965. He received his master of science degree from the Sargent College of Allied Health Professions, Boston University, in 1971 and his doctor of philosophy degree from the University of Iowa in 1981. His record of service includes 25 years as a commissioned officer in the US Public Health Service. He has created both national and international collaborations for education, research, and patient care and has been instrumental in gaining the recognition of physical therapists as core members of the health care team. Past Vice President of Expert Clinical Benchmarks at MedRisk Inc, he is professor emeritus at Lebanon Valley College and a former professor at Thomas Jefferson University and the College of Staten Island. Dr Nelson has authored and co-authored more than 50 publications in the peer-reviewed literature and has made more than 180 presentations to local, national, and international scientific meetings. He has published 2 textbooks. He served on the APTA Board of Directors and in the APTA House of Delegates and chaired the task force that developed APTAs Guide to Physical Therapist Practice . Dr Nelson has received numerous US Public Health Service awards and has been honored by APTA as a Catherine Worthingham Fellow. Mr President, McMillan lecturers of prior years, Board of Directors, fellow physical therapists, family, and friends, I want to thank you for this opportunity to share with you today my vision for the next evolution in the physical therapy profession (Figure). Figure. Dr Nelson presenting the 44th Mary McMillan Lecture. I would like to start off with a question for you. What is the …