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Patient-reported Outcomes of Care in Physical Therapy Practice. Kansas APTA Fall Conference November 8, 2013. Objectives. The participant will understand The importance of patient-reported outcomes (PRO’s) in physical therapy practice

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patient reported outcomes of care in physical therapy practice

Patient-reported Outcomes of Care in Physical Therapy Practice

Kansas APTA Fall Conference

November 8, 2013


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
course overview
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

“….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.

Donald Berwick, MD – formernominee for CMS Chief

  • 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)
  • ….
pro measures
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
pro s commonly assess
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
why use pro s
Why use PRO’s?

Because we have to.

Because we want to.

pro s have emerged as the gold standard of patient assessment
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)
value based purchasing model
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).
value based purchasing model1
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
results of vbp model for therapy partners
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.

proposed by apta physical therapy classification and payment system ptcps guiding principles
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.”

Accessed October 7, 2013

why would we want to use pro s
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)
health care trends
Health Care Trends
  • Era of Expansion
  • Era of Cost Containment
  • Era of Assessment and Accountability
era of expansion
Era of Expansion
  • Between WWII and 1960’s
  • Medicare and Medicaid
era of cost containment
Era of Cost Containment
  • 1970’s and 1980’s
  • DRG’s and HMO’s
era of assessment and accountability
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. PhysTher 1995;75(11):965-70.

health care effectiveness

Health Care “Effectiveness”

Goal: Strike a proper balance between outcomes of care and cost

Need: 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.

achieving health care effectiveness

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

era of assessment and accountability1

Era of Assessment and Accountability

Seeks a balance between achieving high quality health care while being accountable to cost.

early concepts in outcomes assessment
Early Concepts in Outcomes Assessment

Health-Related Quality of Life


Economic Assessment



“a state of complete physical, mental, and social well-being not merely the absence of disease and infirmity”

WHO 1948

early concepts in outcomes assessment health related quality of life
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
why patient perception
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.
examples of common health related quality of life measures generic
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
historical perspective the sf 36
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…

historical perspective economic assessment
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.
history of outcomes assessment summary
History of Outcomes AssessmentSummary

Outcomes Assessment =

Health-related Quality of Life


Economic Assessment

1990 s to 2013
1990’s to 2013

Health-related quality of life

Economic assessment

Pay for reporting

Pay for performance

Value-based purchasing

Comparative effectiveness research

Value = benefit/cost

Functional limitation reporting

Alternative payment system

patient reported outcomes of care


Common Misperceptions

Traditional and Contemporary Measures

Psychometric Properties – The Basics

Administration, Scoring, Practice Session

How to Use in Clinical Care

Managing with Outcomes

common misperception of pro s
Common misperception of PRO’s

It’s subjectiveand therefore not reliable.

  • Good to excellent validity and reliability established for numerous PRO measures of function/disability

Sullivan MS et al. PhysTher 2000;

Simmonds MJ et al. Spine 1998;

Teixeira et al. PhysTher 2011

common misperception of pro s1
Common misperception of PRO’s

Impairment and physical performance measures are more accurate.

  • 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. PhysTher 2000; Simmonds MJ et al. Spine 1998; Teixeira et al. PhysTher 2011; Lee CE et al. Arch Phys Med Rehabil2001; Stratford PW et al. J ClinEpidemil2006

common misperception of pro s2
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
one more reason why assessing patient perception is vital
One more reason why assessing patient perception is vital…



pro measures1
PRO Measures

Traditional Measures

Contemporary Measures


Computer adaptive testing

Item response theory

May be risk-adjusted

Benchmarked comparisons

  • “Paper pencil”
  • Manual scoring
  • Result is a raw score
  • Manual data collection, analysis, reporting

Traditional Measures

Contemporary Measures

Activity Measure for Post Acute Care (AM-PAC)

Care Connections


Focus on Therapeutic Outcomes (FOTO)

Non-Rehab specific


Neuro QOL

  • Oswestry
  • Neck Disability Index
  • Lower Extremity Functional Scale (LEFS)
  • DASH or Quick DASH
  • KOOS
focus on low back pain
Focus on Low Back Pain

Traditional Measure: ODQ

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

  • 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

Fritz&Irrang 2001 PhysTher; Hart et al. 2012 JOSPT;

Hicks&Manal 2009 Pain Med; Hart et al. 2010

concepts in contemporary pro measurement
Concepts in Contemporary PRO Measurement
  • Computer Adaptive Testing (CAT)
  • Item Response Theory (IRT)
  • Risk Adjustment
computer adaptive testing cat
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.
cat pros and cons
CAT Pros and Cons



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

  • Precise
  • Time efficient
  • Immediate results
  • Electronic integration capability
item response theory
Item Response Theory
  • The math behind the CAT.
  • Allows for design, analysis and scoring of the CAT measure.
what is risk adjustment
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)
how does risk adjustment work
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.
how does computer adaptive testing work in the lcat
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”
other measures
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!

clinical practice guidelines
Clinical Practice Guidelines

Examples of CPG’s from JOSPT:

  • 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.)

commonly used traditional measures for orthopedic pt
Commonly Used Traditional Measures for Orthopedic PT

Lower Extremity Functional Scale (LEFS)

Neck Disability Index


DASH (Disabilities of Arm, Shoulder & Hand) or Quick DASH

Oswestry Disability Index (ODI) or Modified ODI

apta resources
APTA Resources
  • Functional Limitation Reporting Measures:
  • APTA website
    • Functional Limitation Reporting Toolkit
want to consider contemporary measures
Want to consider contemporary measures?
  • AM-PAC
  • Care Connections
  • Lifeware (UDSMR)
  • FOTO

"There are three kinds of lies: lies, damned lies, and statistics."

-Mark Twain

"Chapters from My Autobiography", 1906


“In God we trust;

all others bring data.”

  • W. Edwards Deming
statistics for pro measures
Statistics for PROMeasures
  • 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)
statistics for pro measures1
Statistics for PROMeasures
  • 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?
minimum clinically important difference mcid
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.

JaeschkeR et al.ControllClin Trials 1989

psychometric properties of odq and lcat
Psychometric Properties ofODQ and LCAT



Internal consistency reliability .92

Good construct validity

SEM 3.1


No floor or ceiling effects

Time: <2 min

  • Test retest reliability .90
  • Good construct validity
  • SEM 5.4
  • MCID 6
  • Ceiling effect, no floor effect
  • Time: <5 min

Hart et al. 2012 JOSPT; Fritz&Irrang 2001 PhysTher;Hicks&Manal2009 Pain Med; Deutscher 2009 PhysTher; Hart et al. 2010

other mcid s
Other MCID’s
  • LEFS (general population) = 9 (Binkley, PhysTher 1999)
  • NDI = 5 points or 10% (Riddle&Stratford1998 PhysTher)
  • QuickDASH
    • 8% (4 points) (Mintken et al. BMC Musculoskeletal Disorders 2009)
    • 19% - (Polson et al. 2010 Man Ther)
practice session
Practice Session
  • Practice and demo’s of selected PRO measures
administering questionnaire s
Administering Questionnaire(s)
  • Follow validated instructions
  • Do NOT interpret questions for the patient
    • Re-read
    • Re-emphasize
    • Objectively re-state
suggested supplement to validated instructions
Suggested Supplement to Validated Instructions:

“This questionnaire is the start of your evaluation.”


“Your therapist will use this information in your evaluation.”

Help patients see the value.

Promote accuracy of responses.

how to avoid interpreting questions for patients
How to avoid interpreting questions for patients


“I don’t

understand this


how to avoid interpreting example the fabq pa
How to avoid interpretingExample: The FABQ-PA

I should not do physical activities which (might) make my pain worse.

I cannot do physical activities which (might) make my pain worse.

how to avoid interpreting
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.

how to avoid interpreting1
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.”
how to avoid interpreting2
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.’”

how do pt s measure outcomes
How do PT’s measure outcomes?





Physical performance measures

Roush SE, Sharby N. PhysTher 2011

Functional Limitation Reporting Toolkit, APTA 2013

pro s ppm s a great team
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

the bottom line
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. PhysTher 2011;

Wittink H et al. Spine 2003;

Stratford PW et al. J ClinEpidemil 2006

  • ROM
  • Muscle length/flexibility
  • Joint accessory mobility
  • Strength
  • Motor control
  • Movement patterns
  • Balance
  • Sensation
  • Pain
physical performance measures ppm s
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
examples of ppm s
Examples of PPM’s

Standardized Measures


Single leg squats

Double leg squats

Crunch Hold

Superman Hold

1-leg hop distance


  • 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
choosing ppm consider clinical practice guidelines
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.)”

1 st visit
1st Visit
  • PRO score
  • Responses to individual questions
  • Information from other PRO’s/screening tools
    • E.g., fear, depression, PSFS
1st visit
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….”
1 st visit1
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.
initial evaluation
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
initial evaluation1
Initial Evaluation
  • Influence therapist decision making toward
    • Prognosis
    • Functional limitation reporting
    • Goal setting
    • Intervention strategies
at each visit
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

using pro s in intervention strategies
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.
when to re assess pro measures
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?
interim pro s when to do
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.
interim and discharge pro assessments scripting
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.”
interim pro scores
Interim PRO Scores

Re-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.
  • Where do you document your PRO score(s)?
    • Subjective
    • Objective
    • Assessment/Functional Limitations
  • Goal setting
  • Coding
goal setting
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.
goal setting1
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.

documentation use of interim pro scores
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.
using mcid in determining progress
Using MCID in Determining Progress
  • Usefulness
    • Detecting early but important change…or lack of change
    • Documentation
    • Goals
    • Communication with patient
  • Limitations

Hajiro & Nishimura, EurRespir J 2002;

Hart et al. PhysTher 2012

how can i improve my outcomes
How can I improve my outcomes?
  • Value
  • Serial assessments
  • Therapeutic alliance
  • Psychosocial management skills
  • Current best practice impairment-based knowledge and skills

“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

serial assessments
Serial Assessments

DeutscherD et al. Arch Phys Med Rehabil2009

therapeutic alliance
Therapeutic Alliance
  • Agreement on goals
  • Agreement on interventions
  • Affective bond

Ferreira et al. PhysTher 2012; Hall et al. PhysTher 2010;

Roberts et al. PhysTher 2012; Roberts&BuckseyPhysTher 2007;

Bordin, Psychotherapy 1979;

psychosocial management
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.

Wernekeet al. JOSPT 2011; Hart et al. PhysTher 2009;

George et al. JOSPT 2008; Hill&FritzPhysTher 2011

psychosocial management of fear
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

psychosocial management of fear1
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”
managing with outcomes
Choosing an outcomes system

Implementation of an outcomes system

Quality Assurance/Improvement

Professional Development

choosing an outcomes system
Choosing an Outcomes System
  • What are your goals?
    • Uses of PRO data
    • Patient condition types
  • Is funding an option?
questions to ask when comparing electronic pro database services
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
questions to ask when comparing electronic pro database services1
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
completion rates and your outcomes data
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
  • Establish urgency, educate
  • Garner key supporters
  • Identify an outcomes champion
  • Establish accountability
  • Educate, educate, educate
  • Enable and empower
  • Provide timely feedback
  • Ramp up time
  • Recognition
quality assurance improvement
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
professional development
Professional Development
  • Professional Development
    • Internal motivation
  • Continuing Ed
  • Employee Satisfaction
  • Accountability
    • Completion rates
thank you
Thank you!

Deanna Hayes, PT, DPT, MS


Other References

Childs 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 PhysTher. 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 PhysTher. 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, IrrgangJJ, Godges JJ. Heel Pain – Plantar Fasciitis: A Clinical Practice Guideline linked to the International Classification of Function, Disability, and Health from the OrthopaedicSection of the American Physical Therapy Association. J Orthop Sports PhysTher.. 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). PhysTher. 2005;85(6):515-530., accessed October 7, 2013

De 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:  10.1186/1477-7525-4-54

Cite the scoring manual from the SF-36 to support the administering tests part

Koes 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 outcomes

JaeschkeR, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. ControllClin Trials 1989; 10: 407–415.

Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940-2953.

FirchE, 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. PhysTher. 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.


References, cont

Hart 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 PhysTher. 2012:42(6):541-551.

Vernon HT, Mior SA. The Neck Disability Index: a study of reliability and validity. J ManipPhysiolTher 1991;14:409-415.

PietrobonB, 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.

HainsF, 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 ManipPhysiolTher 2008;31:491-502.


Additional Sources of Information

Mark Werneke, MS, PT, Dip. MDT, CentraState Medical Center, Freehold, NJ. Personal correspondence.

Al Amato, MBA, PT, President of Focus on Therapeutic Outcomes, Inc. Personal correspondence

Dennis 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