Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect

Document Type

Peer-Reviewed Article

Publication Date



Physical Therapy


Background Valid comparison of patient outcomes of physical therapy care requires risk adjustment for patient characteristics using statistical models. Because patients are clustered within clinics, results of risk adjustment models are likely to be biased by random, unobserved between-clinic differences. Such bias could lead to inaccurate prediction and interpretation of outcomes.

Purpose The purpose of this study was to determine if including between-clinic variation as a random effect would improve the performance of a risk adjustment model for patient outcomes following physical therapy for low back dysfunction.

Design This was a secondary analysis of data from a longitudinal cohort of 147,623 patients with lumbar dysfunction receiving physical therapy in 1,470 clinics in 48 states of the United States.

Methods Three linear mixed models predicting patients' functional status (FS) at discharge, controlling for FS at intake, age, sex, number of comorbidities, surgical history, and health care payer, were developed. Models were: (1) a fixed-effect model, (2) a random-intercept model that allowed clinics to have different intercepts, and (3) a random-slope model that allowed different intercepts and slopes for each clinic. Goodness of fit, residual error, and coefficient estimates were compared across the models.

Results The random-effect model fit the data better and explained an additional 11% to 12% of the between-patient differences compared with the fixed-effect model. Effects of payer, acuity, and number of comorbidities were confounded by random clinic effects.

Limitations Models may not have included some variables associated with FS at discharge. The clinics studied may not be representative of all US physical therapy clinics.

Conclusions Risk adjustment models for functional outcome of patients with lumbar dysfunction that control for between-clinic variation performed better than a model that does not.




Physical Therapy