Hart D L, Dobrzykowski E A
Focus On Therapeutic Outcomes, Knoxville, Tenn, USA.
J Orthop Sports Phys Ther. 2000 Apr;30(4):183-93. doi: 10.2519/jospt.2000.30.4.183.
Effect of clinical specialization was studied in a retrospective analysis of a commercial outcomes database.
To assess effectiveness of care as measured by changes in health status and efficiency as measured by visits, duration of treatment episode, and net revenue between patients treated by clinicians with and without orthopaedic clinical specialist certification (OCS).
Clinical specialization is becoming common in physical therapy, but there are no studies to support improved efficiency or effectiveness with advanced practitioner competencies.
A total of 258 adults treated in practices participating in the Focus on Therapeutic Outcomes process during 1996 comprised the data set. Seven physical therapists with OCS treated 129 patients (clinical specialist group). These patients were matched to 129 patients not treated by physical therapists with OCS (comparison group) randomly chosen from the aggregate data set. All patients completed a standardized health status questionnaire at initial evaluation and discharge. Standardized response means (SRMs) were calculated to measure change during treatment.
Therapists with OCS were more efficient than therapists without OCS, using fewer visits (9.1 +/- 6.7 vs 11.2 +/- 7.4) for less estimated cost ($949 +/- $736 vs $1238 +/- $1227) during the same treatment duration (35.9 +/- 48.3 vs 35.4 +/- 25.6 days) and performed fewer treatment procedures. Overall, there was no difference in effectiveness as measured by change in health status, that is, unit of functional improvement per episode (0.89 +/- 1.0 SRM for clinical specialists compared with 0.88 +/- 1.0 SRM for comparison group). The OCS group had better value (unit of functional improvement per estimated dollar) and utilization (unit of functional improvement per visit) for the constructs of physical functioning (value: 1.31 +/- 2.7 vs 0.78 +/- 1.8; utilization: 1.25 +/- 2.2 vs 0.76 +/- 1.6) and role physical (value: 1.26 +/- 2.9 vs 0.44 +/- 3.5; utilization: 1.11 +/- 1.9 vs 0.51 +/- 2.3) (SRMs for OCS group vs comparison group, respectively).
Our data support the conclusion that physical therapists with OCS are more efficient compared with clinicians without OCS. Study limitations in design, small sample size, and low number of clinicians are discussed.
在对一个商业结果数据库进行回顾性分析时，研究了临床专科化的影响。
评估医疗效果，以健康状况变化衡量；评估医疗效率，以就诊次数、治疗疗程时长以及有和没有骨科临床专科认证（OCS）的临床医生所治疗患者之间的净收入衡量。
临床专科化在物理治疗中变得越来越普遍，但尚无研究支持高级从业者能力可提高效率或效果。
1996年期间参与“关注治疗结果”项目的医疗机构中接受治疗的258名成年人构成了数据集。7名拥有OCS的物理治疗师治疗了129名患者（临床专科组）。这些患者与从汇总数据集中随机选取的129名未接受有OCS的物理治疗师治疗的患者（对照组）进行匹配。所有患者在初始评估和出院时均完成了一份标准化健康状况问卷。计算标准化反应均值（SRM）以测量治疗期间的变化。
拥有OCS的治疗师比没有OCS的治疗师效率更高，在相同治疗时长（35.9±48.3天对35.4±25.6天）内就诊次数更少（9.1±6.7次对11.2±7.4次），估计成本更低（949±736美元对1238±1227美元），且执行的治疗程序更少。总体而言，以健康状况变化衡量的效果没有差异，即每个疗程功能改善单位（临床专科组为0.89±1.0 SRM，对照组为0.88±1.0 SRM）。在身体功能（价值：1.31±2.7对0.78±1.8；利用率：1.25±2.2对0.76±1.6）和角色功能（价值：1.26±2.9对0.44±3.5；利用率：1.11±1.9对0.51±2.3）方面，OCS组在构建方面具有更好的价值（每估计美元的功能改善单位）和利用率（每次就诊的功能改善单位）（分别为OCS组与对照组的SRM）。
我们的数据支持以下结论，即拥有OCS的物理治疗师比没有OCS的临床医生效率更高。讨论了研究在设计、样本量小和临床医生数量少方面的局限性。
