Using the AMPAC score and age to identify potential overutilization of PT consults on a hospital medicine service

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Maylyn Martinez, MD, Matthew Cerasale, MD MPH, Marla Robinson MSc, Meghan Sweis, MSN, Andrew Schram, MD MBA, Micah Prochaska, MD MPH, Elizabeth Murphy, MD, David Meltzer, MD PhD, Vineet Arora, MD MAPP

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Background: Physical therapy (PT) is a valuable tool to help prevent the functional decline hospitalized patients experience but is a constrained resource in most hospital settings. The Activity Measure-Post Acute Care (AMPAC) score is a validated tool that has been used to predict discharge destination within 48 hours of admission and to assess overutilization of PT consults on a neurosurgery service. We aimed to assess overutilization of PT consults on a hospital medicine service using validated AMPAC score cutoffs.

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Methods: We conducted a retrospective chart review of all patients admitted to the uncovered hospital medicine services at a large academic hospital for one year. For patients who had a PT consult at any time during their admission we obtained age, admission AMPAC score, and discharge disposition. PT consults were considered “overutilization” in patients with AMPAC score>/=19 based on previous studies validating this cutoff for predicting discharge to home. Descriptive statistics were used to categorize patients by age and to summarize discharge destination. Multivariable logistic regression was used to examine independent associations between age group, AMPAC group, and an interaction term (age group x AMPAC group) with odds of being discharged home.

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Results:  Of the 6,634 patients admitted during the study period, 58% (n=3582) had a PT consult during admission. The mean age was 66.3 +/-15.4 and the mean AMPAC score was 18.3 +/- 5.3. Seventy percent of patients were discharged home (N=2497). Using the AMPAC of >/= 19, 55% of PT consults were “overutilization”. Patients <65 with AMPAC>19 represented 29% of all PT consults. Those with AMPAC>19 had increased odds of discharge to home (OR 3.58 [95% CI=2.17–5.91]; P<0.001) as did those age<45 years (OR 1.81 [95% CI=1.09-3.00]; P=0.02). A significant interaction existed between all ages and AMPAC>/=19 (For age<45 OR 2.85 for discharge home [95% CI=1.37–4.30] P=0.002). Combining age with AMPAC>/=19 had additional predictive value for discharge to home (Pr=89% [95% CI 81%-97%] using age <45 vs. (Pr=83% [95% CI 77%-90%]) using age<45 alone.

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Conclusions: Nearly a third of PT consults on an uncovered hospital medicine service represent potential overutilization. Avoiding these could save 527 hours by conservative estimate. Combining age with AMPAC scores is a strong predictor of discharge to home and these patients may not require a PT consult. An interdisciplinary team is now working on a health IT intervention to guide clinicians on when a PT consult may or may not be needed.