AROC Clinical Benchmarking Workshop Review

1. AROC Clinical Benchmarking Workshop Review Craig Evans and Tony Fitzsimons 19th March 2010

2. What is AROC? “Australasian Rehabilitation Outcomes Centre” – University of Wollongong • Provide a national benchmarking system to improve clinical outcomes • Collect outcome information - rehab centres across Australia (155) and NZ (12); ~ 1200 amputee rehab episodes • Annual Reports (The AROC Annual Report: the state of rehabilitation in Australia in 2008 – http://chsd.uow.edu.au/Publications/2009_pubs/son_2008.pdf)

3. So what happened at the workshop? • Greg Bowring – Practice guidelines for amputee management • VA/DoD Clinical Practice guideline for Rehabilitation of Lower Limb Amputation (http://www.healthquality.va.gov/amputation/amp_sum_508.pdf)

4. VA – Amputation Rehabilitation Health-Related Outcomes and confounders

5. Current Guideline Outcome Measures

6. Models of Care Highly variable between centres making benchmarking a difficult task!

7. Model Variation Factors • Availability of staff /teams • Inpatient rehabilitation admission criteria • Geographic location (metro/regional/remote) • Ability to slot clients into community services • Lack of local specialty expertise • Ability to access funding for home mods • “Parking” patients • Timing of prosthetic clinics and visits • Timing and type of prosthetic intervention. • Ability/funding to access technology to assist in healing, pain management, & prosthetic phases • Prosthetic funding models • Patient Type changing

8. AROC Data • Inclusions – full data sets • Exclusions – Ambulatory, outpatients, mortality

9. AROC Impairment Codes Amputation of limb • 5.1 – Single Upper Extremity Above Elbow • 5.2 - Single Upper Extremity Below Elbow • 5.3 - Single Lower Extremity Above Knee • 5.4 - Single Lower Extremity Below Knee • 5.5 - Double Lower Extremity Above Knee • 5.6 - Double Lower Extremity Above/Below Knee • 5.7 - Double Lower Extremity Below Knee • 5.8 – Partial Foot Amputation • 5.9 – Other Amputation

10. AN-SNAP Version 2 Classes • Amputation of Limb • 2-224 Motor 72-91 • 2-225 Motor 14-71* *Cohort groups too broad. Smaller Cohort groups = smaller samples Functional vs “adequate sample” groups

11. SYNATIX Data Collection FormExamples of Data Presentation

12. Hurdles to achieving outcome benchmarks • Consequences of prolonged immobility • Presence of medical co-morbidities • Cognitive function • Adjustment issues • Learning capacity • Inappropriate accommodation • Intransigent attitudes

13. Agreed Stages of Amputee Management

14. New AN-SNAP Codes? Ceiling effect in higher FIM scores

15. New Data Collection • Date of Surgery • Date ready for casting • Date of first prosthetic fitting – reason for delay • Clinically ready for discharge • Discharge Delay Reason • Home mods • Equipment • Community support • ACAT / Residential Care availability

16. New Outcome Measures • Ambulatory Data – FIM not sensitive enough • 6 min walk test • TUG • ?? 10mWT, Amppro, 4SST, K-classification, LCI, mobility aide and assistance • Other • Clinical Frailty index • MMSE ? – as a screening tool

17. What does it mean for us? • Data collection • What else should we be collecting that could make a difference or improve our practice?