Physical therapy cannot move forward as a profession until those who practice it resolve the issue of unwarranted variation in practice.

Tara Jo Manal, PT, DPT, FAPTA, in her delivery of the 22nd John H. P. Maley Lecture, was unequivocal in sending this message to the profession.

"The greatest challenge to the value of physical therapy is unwarranted variation—situations in which wide variation of care is not explained by the type or severity of the condition or by patient preferences," she said to a capacity audience on June 23 as part of APTA's NEXT Conference and Exposition.

Physical therapy is not the only health care discipline with this problem; unwarranted variation is a challenge within all of health care in meeting the triple aim of improving societal health, enhancing the individual patient experience, and reducing costs.

But even if physical therapy has not yet been in the "center of the crosshairs," Manal said, our profession increasingly has been identified as an area of interest as payment moves toward value-based systems in order to reduce waste in spending. The lack of standardization in physical therapist practice "puts all physical therapists at risk for reductions in covered rehabilitation services," she said.

The profession's response must be to "invest inward to solidify our procedures, use what we already know to maximize our return on our clinical efforts, and solve this problem," Manal said. As a start, she suggested that the profession "stop looking to expand our scope and promote our ability to practice at the top of our license until we get our house in order, to ensure that all patients are cared for at the highest level in every physical therapy setting with every provider."

Clinical practice today is "chaotic," Manal said. Some factors can't be modified, such as limitations set by payers and regulation. And it's hard to avoid "the chaos of the human factor," such as sick coworkers, appointment glitches, and equipment breakdowns. But what can be modified "is the disorganization and even confusion that occurs when we fail to standardize our physical therapy care," she said. When PTs take a "blank page" approach to every patient and treatment, clinical success is based on the premise that they "can remember all the information … for any given condition at any given moment" in applying treatment. "That is quite simply an unrealistic expectation."

Creating and using evidence-based patterns of care will avoid the blank-page dilemma, Manal said, and how PTs and PTAs access needed knowledge to do so is key. Reading only primary literature isn't feasible—Manal cited a 2009 study concluding that for internists to stay current in their field they would need to read 34 articles daily, a "daunting" effort. Instead, she argued for reading synthesis documents such as clinical practice guidelines, which review, weigh, and grade available evidence.

Among the reasons that clinical care patterns aren't more widely adopted, Manal said, are a lack of understanding of their added value to daily care and the belief of many clinicians that they already follow best practices.

To the first reason, Manal countered that "standardized rules … add value by reducing clinical chaos and improving outcomes. [They] assess risk and suggest matched-treatment interventions to maximize the success of your physical therapy care." However, to make the most of standardized tests and measures, Manal said PTs must perform them at regular time intervals and as described in the literature, "not using our favorite modification." Further, tests with poor reliability and no validity need to be abandoned.

This is not to say that evidenced-based care patterns are "cookie-cutter," Manal explained. "Some patients progress quickly and need no special efforts, while others require creativity and change—but guidelines ensure that milestones are met before progressions occur."

To PTs who believe "I already do that," Manal argued that therapists who incorporate guidelines and use standardized patterns of care "unburden themselves from the fallacy of being all-knowing and, instead, benefit from the best we as a profession have to offer."

Manal suggested that patient self-reporting and performance-based outcomes "can help tell you whether you are at or above the current best standard of care, or would benefit from adherence to standardized care patterns to decrease clinical chaos."

She pointed to the APTA Physical Therapy Outcomes Registry as a tool to enable clinicians to compare themselves with colleagues. She noted, though, that, first, comparative data must exist, meaning "therapists must participate in collecting minimum data sets at specific time intervals" to make accurate comparisons.