Patient-reported Outcomes of Care in Physical Therapy Practice
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Patient-reported Outcomes of Care in Physical Therapy Practice
Kansas APTA Fall Conference November 8, 2013
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Objectives
The participant will understand•The importance of patient-reported
outcomes (PRO’s) in physical therapy practice
•Evidence-based recommendations for selected PRO instruments
•How to use PRO’s in clinical practice
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Course Overview
•Background and Introduction•History of outcomes assessment and
PRO’s•Patient reported outcomes
▫Common Misperceptions▫Traditional and Contemporary Measures▫Psychometric Properties – The Basics▫Administration, Scoring, Practice Session▫How to Use in Clinical Care▫Managing with Outcomes
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INTRODUCTIONS AND BACKGROUND TO COURSE
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Donald Berwick, MD – former nominee for CMS Chief
“….offering payments for outcomes and value by some definition will help. We need to stop paying for volume. That is the key. We have to stop paying for [volume] and start paying for
the results we want which is health and safety and good outcomes for our patients.
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Volume vs. Value-Based Healthcare
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Outcomes• Falls• Medication errors• Hospital re-admissions• Infection rate• Pain• Satisfaction• Physical Impairments (ROM, strength, etc.)• Functional limitations • Disability (inability to perform roles – work, home,
social)• ….
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Patient Case
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Focus of this course is Patient Reported Outcomes
(PRO’s)
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PRO Measures
• Questionnaires with responses collected directly from the patient
• Directly assesses the patient’s perception• Aka “patient self-report measures”• Used in clinical practice and research• Used to document change in status for
outcomes or predictive purposes
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PRO’s commonly assess:
• Quality of life/health-related quality of life– Physical, psychological and social
• Functioning (disability)– E.g., personal care, ADL’s, walking
• Symptoms or other aspects of well being– E.g., depression, pain
• General health perceptions
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Why use PRO’s?
Because we have to. Because we want to.
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PRO’s have emerged as the gold standard of patient assessment
• Strong and well established psychometric properties of numerous measures
• Mandated by some payers (Aetna, Oxford)
• CMS Functional Limitation Reporting• Pay for performance models (Health Partners, MN)
• Endorsement by policymakers (US Dept Health & Human Services, National Quality Measures Clearinghouse, Institute of Medicine, NIH and many more)
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PRO’s to help determine Medicare G-Codes and Severity Modifiers
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Value-Based Purchasing Model
• Health Partners is a Minnesota-based not-for-profit HMO
• Worked with Therapy Partners (independent PT practices) to develop successful value-based purchasing model using an established PRO database (Focus on Therapeutic Outcomes, FOTO).
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Value Based Purchasing Model
• FOTO outcomes = patient reported functional change + # visits
• Reimbursement based on level of value compared to national database– Greater change + fewer visits – Equal change and equal visits– Lesser change and more visits
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Results of VBP Model for Therapy Partners
• PT’s achieved “higher than expected” or “expected” value for majority of cases– Improved reimbursement
• 33% less utilization compared to benchmark• A win-win-win scenario for patients, payers and providers.
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Proposed by APTA:Physical Therapy Classification and Payment System (PTCPS)
Guiding Principles
“The model will facilitate and promote the use and reporting of quality measures, electronic health records, and participation in national registries to provide essential data to improve the model over time.”
http://www.apta.org/PTCPS/GuidingPrinciples/Accessed October 7, 2013
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Why would we want to use PRO’s?• Use data to enhance outcomes of care during
everyday clinical practice• Compliment shift toward evidence based
practice• Documented quality of care• Quantify effectiveness and efficiency for– Individual therapist– Therapy practice– Interventions (research)
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HISTORY OF OUTCOMES ASSESSMENTTo understand where we are and why we are here, it’s important to understand where we’ve been.
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Health Care Trends
• Era of Expansion• Era of Cost Containment• Era of Assessment and Accountability
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Era of Expansion
• Between WWII and 1960’s• Medicare and Medicaid
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Era of Cost Containment
• 1970’s and 1980’s• DRG’s and HMO’s
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Era of Assessment and Accountability
“The emphasis is no longer on unbridled growth nor on blind cost containment, but on a balance between assessment of gains achieved for certain costs and an accountability for those costs incurred.”
-Jette AM. Outcomes Research: Shifting the Dominant Research Paradigm in Physical Therapy.
Phys Ther 1995;75(11):965-70.
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Health Care “Effectiveness”Goal: Strike a proper balance between
outcomes of care and costNeed: To provide patients, payers and
practitioners with better insights into the effects of health care on a patient’s life using
observations or measurements made in routine clinical care settings.
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Achieving Health Care Effectiveness
Evaluation of treatment practice based on outcomes and cost
Assembly and monitoring of large-scale databases
Development of mechanisms to disperse this information to health care
practitioners
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Era of Assessment and Accountability
Seeks a balance between achieving high quality health care while being
accountable to cost.
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Early Concepts in Outcomes Assessment
Health-Related Quality of Life+
Economic Assessment
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Health“a state of complete physical, mental, and social well-being not merely the
absence of disease and infirmity”WHO 1948
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Early concepts in outcomes assessment:Health-Related Quality of Life
• Aspects of a patient’s physical, psychological and social functioning that can be directly affected by the health care system.
• Assesses the patient’s perception of the impact of an illness and its treatment.
• Questionnaires are generic or condition-specific
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Why Patient Perception?
• The usefulness of traditional measures diminishes as chronic illnesses become more prevalent.
• Limitations in the usefulness of objective measures.
• Need to understand the impact of treatment on a patient’s life from the patient’s perspective.
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Examples of common health-related quality of life measures (generic)
• The Medical Outcomes Study Short-Form 36 Item Health Survey (SF-36)
• SF-12 • The Sickness Impact Profile (SIP)• Euro QOL• The Nottingham Health Profile
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Historical Perspective: The SF-36
• Became the gold standard for assessing general health-related quality of life
• Frequently used in research 1990’s• Foundation for further development of
outcomes assessment (e.g., condition specific measures)
• Excerpt from SF-36…
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The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
5. Lifting or carrying groceries
6. Climbing several flights of stairs
7. Climbing one flight of stairs
8. Bending, kneeling, or stooping
9. Walking more than a mile
10. Walking several blocks
11. Walking one block
12. Bathing or dressing yourself
http://www.rand.org/health/surveys_tools/mos/mos_core_36item_survey.html
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Historical perspective:Economic Assessment
• Premise: resources are finite• Goal: to maximize the net benefit obtained
from the resources produced by society.• Example of economic assessment research:
lumbar diskectomy vs. no surgery >>> what’s the bang for the buck?
• Intention to guide decision-making, not to replace insight and judgment of healthcare providers.
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History of Outcomes AssessmentSummary
Outcomes Assessment =
Health-related Quality of Life+
Economic Assessment
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1990’s to 2013
Health-related quality of life
Pay for performance
Comparative effectiveness researchValue-based purchasing
Economic assessment
Value = benefit/cost
Alternative payment system
Functional limitation reporting
Pay for reporting
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PATIENT-REPORTED OUTCOMES OF CARE
Common MisperceptionsTraditional and Contemporary MeasuresPsychometric Properties – The BasicsAdministration, Scoring, Practice SessionHow to Use in Clinical CareManaging with Outcomes
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COMMON MISPERCEPTIONS OF PRO’S
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Common misperception of PRO’s
It’s subjective and therefore not reliable.
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Reality• Good to excellent validity and reliability
established for numerous PRO measures of function/disability
Sullivan MS et al. Phys Ther 2000;Simmonds MJ et al. Spine 1998;Teixeira et al. Phys Ther 2011
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Common misperception of PRO’s
Impairment and physical performance measures are more accurate.
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Reality• Poor correlations between impairment
measures and function, BUT moderate correlations between physical performance tests and self-report of disability
• Inadequate reliability/validity for impairment measures
• Impairment-based interventions may not sufficiently affect actual or perceived performance in life.
Sullivan MS et al. Phys Ther 2000; Simmonds MJ et al. Spine 1998; Teixeira et al. Phys Ther 2011; Lee CE et al. Arch Phys Med Rehabil 2001; Stratford PW et al. J Clin Epidemil 2006
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Common misperception of PRO’s
• Only self-report measures are influenced by psychosocial factors (fear, illness behaviors, etc.)
>>> Not true. PPM’s have been shown to be influenced by psychosocial factors.
Hart 1998; Thomas, Spine 2007; Hart J Rehab Outcome Meas 1998; Gatchel Spine 2008
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Patient perception in compliment to other measures
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One more reason why assessing patient perception is vital…
PERCEPTION DRIVES BEHAVIOR.BEHAVIOR DRIVES COST.
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TRADITIONAL AND CONTEMPORARY PRO MEASURES
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Patient Case
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PRO Measures
Traditional Measures• “Paper pencil” • Manual scoring• Result is a raw score• Manual data collection,
analysis, reporting
Contemporary Measures• Electronic• Computer adaptive testing• Item response theory• May be risk-adjusted• Benchmarked comparisons
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Examples
Traditional Measures• Oswestry• Neck Disability Index• Lower Extremity Functional
Scale (LEFS)• DASH or Quick DASH• SPADI• KOOS• WOMAC
Contemporary Measures• Activity Measure for Post
Acute Care (AM-PAC)• Care Connections • Lifeware (UDSMR)• Focus on Therapeutic
Outcomes (FOTO)
• Non-Rehab specific– PROMIS– Neuro QOL
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Focus on Low Back PainTraditional Measure: ODQ• Oswestry Low Back Pain
Disability Questionnaire• Modified version omits sex
question• 10 questions with 0-5 rating
scale responses• Scoring: sum and multiply
by 2 >> 0-100, higher score = higher disability
• Nonlinear scale
Contemporary Measure: LCAT
• Lumbar Computer Adaptive Test
• Proprietary (FOTO)• Computer adaptive testing• Item response theory• Risk-adjusted for 9 variables• 25 questions in item bank• Computer-scored; 0-100 with
higher score = better function
• Linear scale Fritz&Irrang 2001 Phys Ther; Hart et al. 2012 JOSPT; Hicks&Manal 2009 Pain Med; Hart et al. 2010
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Concepts in Contemporary PRO Measurement
• Computer Adaptive Testing (CAT)• Item Response Theory (IRT)• Risk Adjustment
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Computer Adaptive Testing (CAT)
• A computer-based test that adapts to the ability level of the respondent.
• First question is usually medial level difficulty. • Subsequent questions are tailored based on previous
responses.• The CAT program selects from an established pool of items
(questions). • Statistical calculations follow each response. The session
terminates when a stopping rule (certain level of precision/acceptable error) has been reached.
• Commonly used in education and the military.
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CAT Pros and Cons
Advantages• Precise• Time efficient• Immediate results• Electronic integration
capability
Disadvantages• Development is complex
and requires large sample sizes
• For PT providers: different questions will likely be asked at each follow up test
• Cost to users
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Item Response Theory
• The math behind the CAT. • Allows for design, analysis and scoring of the
CAT measure.
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What is Risk-Adjustment?
• Used in the reporting of healthcare outcomes• Is a mathematical tool that adjusts for
differences in risk among patients• Allows for fairer comparison of outcomes
between hospitals, practices, individual practitioners. (Apples to apples comparison)
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How does risk-adjustment work?
• PT-related examples: – younger, more acute, fewer other health
conditions, fewer surgeries tend to get better outcomes
– Older age, more chronic, more health conditions, more surgeries tend to get worse outcomes
• Scores are “adjusted” by adding or subtracting the influence of each of the risk-adjustment variables.
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How does Computer Adaptive Testing work in the LCAT?
• 1st question: median level difficulty– “Today, because of your back problem, do you or would
you have any difficulty at all performing….?”– 6 response choices ranging “no difficulty” to “Unable to
perform the activity”• Subsequent questions match to ability of the patient• E.g., ability to get out of bed (low) vs. run a mile (high)
• Questions continue until acceptable level of error is reached (SEM <4/100 or SD < .36 on the 0-100 scale) aka “stopping rule”
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Other Measures
• Neurological• Balance • Falls Risk• Pain• Fatigue• Asthma• Fear Avoidance• Somatization
• Depression• Pediatric• Cancer• Pelvic Floor• TMJ• Pulmonary• Cardiac• ….
A measure for everything under the sun!
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WHICH MEASURES TO CHOOSE???
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I want to stick with paper-pencil measures. Where’s the Easy Button???
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Clinical Practice Guidelines
• Neck– NDI and Patient Specific
Functional Scale
• Low Back Pain– Oswestry Disability Index– Roland-Morris Disability
Questionnaire
• Hip– WOMAC– LEFS– Harris Hip Score
• Foot/Ankle– FAAM (plantar fasciitis)
(These are paper-pencil measures.)
Examples of CPG’s from JOSPT:
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Commonly Used Traditional Measures for Orthopedic PT
Lower Extremity Functional Scale (LEFS)
Neck Disability Index (NDI)
DASH (Disabilities of Arm, Shoulder & Hand) or
Quick DASH
Oswestry Disability Index (ODI) or Modified ODI
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APTA Resources
• Functional Limitation Reporting Measures:– http://
www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx
• APTA website– http://www.apta.org/Payment/Medicare/CodingB
illing/FunctionalLimitation/
– Functional Limitation Reporting Toolkit
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Want to consider contemporary measures?
• AM-PAC http://crecare.com/am-pac/ampac.html
• Care Connections http://www.careconnections.com/outcomes/
• Lifeware (UDSMR) http://www.lifeware.org/• FOTO www.patient-inquiry.com
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PSYCHOMETRIC PROPERTIES OF PRO’S – THE BASICS
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Statistics
"There are three kinds of lies: lies, damned lies, and statistics."
-Mark Twain"Chapters from My Autobiography", 1906
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Statistics
“In God we trust; all others bring data.”
– W. Edwards Deming
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Statistics for PRO Measures
• Validity– Does it measure what it purports to measure?– Floor/ceiling effects?
• Reliability– Are the results the same when repeated under the
same conditions? (e.g., test-retest, internal consistency)
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Statistics for PRO Measures
• Responsiveness: ability to detect change– Minimal Detectable Change (MDC): change that is
noticeable by the statistics– Minimum Clinically Important Difference (MCID):
change that is noticeable to the patient • Standard Error of Measure (SEM): how much
measurement error can we expect?
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Minimum Clinically Important Difference (MCID)
The smallest difference in a score in a domain of interest that patients perceive as beneficial and that would mandate, in the absence of side-effects and a change in the patient’s management.
Jaeschke R et al.Controll Clin Trials 1989
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Psychometric Properties ofODQ and LCAT
ODQ• Test retest reliability .90• Good construct validity• SEM 5.4• MCID 6 • Ceiling effect, no floor effect• Time: <5 min
LCAT• Internal consistency
reliability .92• Good construct validity• SEM 3.1• MCII (MCID) 5• No floor or ceiling effects• Time: <2 min
Hart et al. 2012 JOSPT; Fritz&Irrang 2001 Phys Ther;Hicks&Manal 2009 Pain Med; Deutscher 2009 Phys Ther; Hart et al. 2010
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Other MCID’s
• http://www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx
• LEFS (general population) = 9 (Binkley, Phys Ther 1999)
• NDI = 5 points or 10% (Riddle&Stratford 1998 Phys Ther)
• QuickDASH– 8% (4 points) (Mintken et al. BMC Musculoskeletal Disorders 2009)
– 19% - (Polson et al. 2010 Man Ther)
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ADMINISTRATION AND PRACTICE SESSION
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Practice Session
• Practice and demo’s of selected PRO measures
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Administering Questionnaire(s)
1. Follow validated instructions2. Do NOT interpret questions for the
patient• Re-read• Re-emphasize• Objectively re-state
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Suggested Supplement to Validated Instructions:
“This questionnaire is the start of your evaluation.”
or “Your therapist will use this information in your
evaluation.”
Help patients see the value. Promote accuracy of responses.
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How to avoid interpreting questions for patients
Patient: “I don’t understand this question.”
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How to avoid interpretingExample: The FABQ-PA
CompletelyDisagree
Unsure Completely Agree
0 1 2 3 4 5 6
4. I should not do physical activities which (might) make my pain worse.
5. I cannot do physical activities which (might) make my pain worse.
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How to avoid interpreting
1. Re-read the questionnaire’s validated instructions or questions– Example: FABQ-PA instructions
Here are some of the things which other patients have told us about their pain. For each statement please circle any number from 0 to 6 to say how much physical activities such as bending, lifting, walking or driving affect or would affect your back pain.
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How to avoid interpreting
2. Re-emphasize the questionnaire’s validated instructions or question– Example: FABQ-PA instructions• “I should not do physical activities which (might) make
my pain worse.”
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How to avoid interpreting
3. Objectively re-state the questionnaire’s validated instructions or question– Example: FABQ-PA instructions
“Mr. Smith, how strongly do you agree or disagree with this statement:‘I should not do physical activities which (might) make my pain worse.’”
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Scoring
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USING PRO’S IN CLINICAL CARE
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How do PT’s measure outcomes?
Impairments +
PRO’s +
Physical performance measures
Roush SE, Sharby N. Phys Ther 2011Functional Limitation Reporting Toolkit, APTA 2013
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PRO’s + PPM’s = a great team• Measure different aspects
of function• Facilitate a clearer picture
of true function than when used in isolation
• Severity modifiers for G-codes
Wittink H et al. Spine 2003
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The bottom line…
• Use PRO measures as the gold standard, but supplement with PPM to facilitate optimal evaluation and intervention decision making.
Functional Limitation Reporting Toolkit, APTA 2013;Bean JF et al. Phys Ther 2011;Wittink H et al. Spine 2003; Stratford PW et al. J Clin Epidemil 2006
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Impairments
• ROM• Muscle length/flexibility• Joint accessory mobility• Strength • Motor control• Movement patterns• Balance• Sensation• Pain
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Physical Performance Measures (PPM’s)
• An observed functional task or group of functional tasks
• Chosen PPM varies based on patient ability and goals
• Ideal: standardized and validated measures• Measurement criterion: scoring, ROM, # reps,
time, time to fatigue, pain level, fatigue/exertion level, grading of motor control
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Examples of PPM’sStandardized Measures• Berg Balance Scale• Timed Up and Go• 6 Minute Walk Test• 9-Hole Peg Test• 1-Mile Walk/Run• PILE (lifting test)• Functional Movement
Screen (FMS)• Y Balance Test • Single Leg Stance
Other• Single leg squats• Double leg squats• Crunch Hold • Superman Hold• 1-leg hop distance• Planks
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Choosing PPM: Consider Clinical Practice Guidelines
E.g., Hip CPG – JOSPT 2009:
“Examination – Activity Limitation and Participation Restriction Measures: Clinicians should utilize easily reproducible physical performance measures, such as the 6-minute walk, self-paced walk, stair measure, and timed up-and-go tests to assess activity limitation and participation restrictions associated with their patient’s hip pain and to assess the changes in the patient’s level of function over the episode of care. (Recommendation based on strong evidence.)”
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USING PRO’S IN CLINICAL CARE
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1st Visit
• PRO score• Responses to individual questions• Information from other PRO’s/screening tools– E.g., fear, depression, PSFS
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1st Visit
Patient Interview• Establish value of the PRO and focus history-
taking on function right away: – “Thank you for doing the questionnaire. This is
helpful to me. I see that you are having difficulty with….”
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1st Visit
• Establish a common language by using the functional questions…– to communicate– to set goals with the patient– help establish expectations and value of
treatment » May help reduce NS/CS rate.
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Initial Evaluation• Consider your primary PRO score (patient’s
perception of their functioning/quality of life) in conjunction with– Other patient self-report measures• Pain, PSFS, etc.
– Yellow flags (e.g., psychosocial such as FABQ)– PPM’s– Impairment measures
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Initial Evaluation
• Influence therapist decision making toward– Prognosis– Functional limitation reporting– Goal setting– Intervention strategies
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Intake Summary, P. 1
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Using PRO’s to help determine G-codes and modifiers
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Intake Report, P. 2
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At Each Visit• Continue to use functional questions as a
common language to:– Establish direction – “We are working on your
strength to improve your ability to reach overhead.”
– Tie progress into patient’s perception of improved function – “Now that your strength has improved, are you having less difficulty with stairs?”
– Let the patient see their reports as part of discussion.
Value and Communication = Better Outcomes
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Using PRO’s in Intervention Strategies
• Verbal communication– “Remember the short term goal we set that you
would be able to reach a shelf at shoulder height? Where do you feel you are at on that?”
• Therapeutic activities– Lift and lower light weight (“dishes”) from shelf at
shoulder height while facilitating proper scapulo-humeral rhythm or mobilization with movement.
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When to re-assess PRO measures?
• Minimum Requirement: Need at least one re-take for discharge.
• However, if you wait until the patient’s last visit to have the patient re-take the PRO questionnaire, you miss a vital opportunity to maximize outcomes. – “My patient answered these questions wrong; I know
they improved more than this.”– Did the patient answer wrong, or does the therapist
have mistaken perception?
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Interim PRO’s: When to Do?
• Recommended: –At re-evaluation time or every 1-3
weeks. –When patient returns to referral
source. –When you think the patient may not
come back.
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Interim and Discharge PRO Assessments: Scripting
• “Would you mind taking this questionnaire again to help me get an updated functional status assessment for your chart…your progress report…your discharge summary…?” – What you value, so shall your patient.
• “If it asks you something you haven’t tried, estimate how you think it would be if you tried.”
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Interim PRO ScoresRe-assessing PRO measure(s) frequently
helps with–Clinical decision-making that is timely,
functionally-based, patient-focused.–Communication with the patient• Does the therapist perceive improved function but
the patient does not? • Address differences in perception while you still
have the opportunity.
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Example of a contemporary PRO measure in action:
FOTO Patient Reports for Clinical use
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Status Report, P 1
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Status Report, P 2
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Documentation
• Where do you document your PRO score(s)?– Subjective– Objective– Assessment/Functional Limitations
• Goal setting• Coding
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Goal Setting
Examples of Goals using PRO’s– Oswestry Disability Index (ODQ) will improve to
60%– Functional Status score will improve to 75/100– Patient will report minimal to no difficult walking
one mile.
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Goal Setting
Compliment PRO goals with PPM goals– Berg Balance Score* will improve to 41/56 (low fall
risk).– Affected 1-leg hop distance will improve to equal with
unaffected leg with good motor control. – Sidelying plank hold will improve to 30 seconds
bilaterally with good motor control.
*Validated/normed measures ideal but not always applicable to your patient; one more reason to use both PRO and PPM measures and goals.
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Goal Setting
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Documentation: Use of Interim PRO Scores
• Include PRO score changes in documentation. • Use PRO score change (and other measures)
to help objectively validate need for continued treatment.
• Lack of improvement in PRO score(s)may help justify need for early Discharge.
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Using MCID in Determining Progress
• Usefulness– Detecting early but important change…or lack of
change– Documentation– Goals– Communication with patient
• Limitations
Hajiro & Nishimura, Eur Respir J 2002;Hart et al. Phys Ther 2012
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Discharge Report
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GETTING BETTER OUTCOMES
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How can I improve my outcomes?
• Value• Serial assessments • Therapeutic alliance • Psychosocial management skills• Current best practice impairment-
based knowledge and skills
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Value“What you value,
so will those you touch.”*
• Patients generally do not mind providing PRO information as long as they understand that it is used and valued in their care.
• Application of functional questions. • Scripting• NS/CX rates
*Al Amato, PT, MBA,President, FOTO
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Serial Assessments
Deutscher D et al. Arch Phys Med Rehabil 2009
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Status Report, P 1
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Impairment-based knowledge and skills
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Therapeutic Alliance
1. Agreement on goals2. Agreement on interventions3. Affective bond
Ferreira et al. Phys Ther 2012; Hall et al. Phys Ther 2010;Roberts et al. Phys Ther 2012; Roberts&Bucksey Phys Ther 2007; Bordin, Psychotherapy 1979;
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Psychosocial Management
• Overlap with therapeutic alliance concepts• Use PRO and PPM data in conjunction with
yellow flag measures to guide clinical decision making
• Related to fear avoidance beliefs and behaviors, depression, somatization, self-efficacy, etc.
“Psychologically oriented physical therapy” – PTJ May 2011 edition; Numerous works by Fordyce, Vlaeyen >> operant conditioning, graded exposure, graded exercise, education, etc. Werneke et al. JOSPT 2011; Hart et al. Phys Ther 2009; George et al. JOSPT 2008; Hill&Fritz Phys Ther 2011
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Psychosocial Management of Fear• How do we address elevated Fear Avoidance
issues in treatment?– Cognitive Behavioral approach• Gradual (hierarchical) and controlled exposure to feared
activities, guided by therapist. (aka Operant Graded Exercise - Fordyce et al.)
• Education (next slide)• Exercises to reinforce education and exposure to feared
activities/movements. • Problem solving. (Vlaeyen et al)
Focus on the feared activities in the clinic and in the home program
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Psychosocial Management of Fear
• Cognitive Behavioral Approach– Education • common condition • does not require overprotection• return to activity, avoid prolong rest• address patient’s concerns & worries• teach difference “hurt” vs. “harm”
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MANAGING WITH OUTCOMESChoosing an outcomes systemImplementation of an outcomes systemQuality Assurance/ImprovementProfessional Development
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Choosing an Outcomes System
• What are your goals?– Uses of PRO data– Patient condition types
• Is funding an option?
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Questions to ask when comparing electronic PRO database services
• What data is collected– Eg, function, pain, satisfaction, # visits,…– Take demonstration– See sample reports– Categories – Ortho, Neuro, etc.
• Psychometric properties of the key measure(s)• Do they risk adjust? If so, how many and what
variables• How many providers in the benchmark• How many patients in the database
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Questions to ask when comparing electronic PRO database services
• Does it translate into % limitation and offer a severity modifier?
• How long has the company been in business• Email administration• Languages• Other available questionnaires beyond key measures• Approved by entities relevant to your practice (PQRS,
CMS, NQF)• # articles published in peer reviewed scientific journals• Costs
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Contemporary PRO in Action
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Completion Rates and Your Outcomes Data
• What percentage of your patients does your outcomes data represent?
• Before you analyze your outcome, be sure your sample size is large enough to represent your true patient population.– Individual clinician– Individual clinic– Entire practice
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Calculating Completion Rates
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Implementation
• Establish urgency, educate• Garner key supporters• Identify an outcomes champion• Establish accountability
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Implementation
• Educate, educate, educate• Enable and empower• Provide timely feedback• Ramp up time• Recognition
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Quality Assurance/Improvement
• Quality Assurance/Improvement– Completion rates– Patient treatment outcomes– Utilization (# visits per episode)– Patient satisfaction (if applicable)– Expert therapists– Allocation of resources to improve quality– QI indicators for administrative reporting
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Professional Development
• Professional Development– Internal motivation
• Continuing Ed • Employee Satisfaction• Accountability – Completion rates
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SummaryQ & A
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Other ReferencesChilds JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.Delitto A, George SZ, Van Dillen L, et al. Low Back Pain: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys Ther. 2012:42(4):A1-A57.Cibulka MT, White DA, Woehrle J, et al. Hip pain and mobility deficitys – hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys. 2009;39(4):A1-A25.McPoil TG, Martin RL, Cornwall MW, Wukich DK, MD, Irrgang JJ, Godges JJ. Heel Pain – Plantar Fasciitis: A Clinical Practice Guideline linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther.. 2008;38: A1-A18.Guccione AA, Mielenz TJ, DeVellis RF, et al. Development and Testing of a Self-report Instrument to Measure Actions: Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL). Phys Ther. 2005;85(6):515-530.http://www.apta.org/OPTIMAL/ResearchReportAbstract/, accessed October 7, 2013De Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM. Minimal changes in health status questionnaires: distinction between minimum detectable change and minimally important change. Health Qual Life Outcomes. 2006: 4:54Published online 2006 August 22. doi: 10.1186/1477-7525-4-54Cite the scoring manual from the SF-36 to support the administering tests partKoes et al. BMJ 2006, George et al. Spine 2003, Sieben et al. Eur J Pain 2004 – predictive power of psychosocial screening/fear avoidance; support for serial screening of fear avoidance as predictive of outcomesJaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Controll Clin Trials 1989; 10: 407–415.Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940-2953.Firch E, Brooks D, Stratford P, Mayo N. Physical Rehabilitation Outcome Measures.Second ed. Hamilton, ON: BC Decker Inc; 2002:186-187.Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;81:776-788.Vianin, M. (2008). Psychometric properties and clinical usefulness of the oswestry disability index. Journal of chiropractic medicine, 7: 161-163.Davies, C.C. & Nitz, A.J. (2009). Psychometric properties of the roland-morris disability questionnaire compared to the oswestry disability index: A systematic review. Physical Therapy, 14 (6): 399-408.Hicks GE, Manal TJ. Psychometric properties of commonly used low back disability questionnaires: are they useful for older adults with low back pain? Pain Med. 2009;10:85-94.
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References, contHart DL, Stratford PW, Werneke MW, Deutscher D, Wang YC. Lumbar computer adaptive test and modified Oswestry low back pain disability questionnaire: relative validity and important change. J Ortho Sports Phys Ther. 2012:42(6):541-551.Vernon HT, Mior SA. The Neck Disability Index: a study of reliability and validity. J Manip Physiol Ther 1991;14:409-415. Pietrobon B, Coeytaux RB, Carey TS, Richardson WJ, DeVellis RF. Standard scales for measurement of functional outcome for cervical pain or dysfunction - A systematic review. Spine 2002; 27(5):515-522.Hains F, Waalen J, Mior S. Psychometric properties of the neck disability index. Journal of Manipulative and Physiological Therapeutics 1998; 21(2):75-80.Vernon H. Assessment of self-rated disability, impairment, and sincerity of effort in whiplash-associated disorder. Journal of Musculoskeletal Pain 2000; 8(1-2):155-167.Riddle DL, Stratford PW. Use of generic versus region-specific functional status measures on patients with cervical spine disorders. Physical Therapy 1998; 78(9):951-963.Vernon H. The Neck Disability Index: State-of-the-art, 1991-2008. J Manip Physiol Ther 2008;31:491-502.
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Additional Sources of InformationMark Werneke, MS, PT, Dip. MDT, CentraState Medical Center, Freehold, NJ. Personal correspondence.Al Amato, MBA, PT, President of Focus on Therapeutic Outcomes, Inc. Personal correspondenceDennis Hart, PhD, PT, Director of Consulting and Research Services, Focus on Therapeutic Outcomes, Inc. Personnel correspondence. Trish Hayes, FOTO Regional Coordinator. (provided slides of printed patient reports.)Deanna Hayes (presenter) – clinical experience
Resourceshttp://www.qualitymeasures.ahrq.gov/tutorial/HealthOutcomeMeasure.aspxhttp://www.apta.org/OutcomeMeasures/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/OutcomeMeasures.html