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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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Kansas APTA Fall Conference
November 8, 2013
The participant will understand
“….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
Because we have to.
Because we want to.
for patients, payers
“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
“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.
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.
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
Seeks a balance between achieving high quality health care while being accountable to cost.
Health-Related Quality of Life
“a state of complete physical, mental, and social well-being not merely the absence of disease and infirmity”
Outcomes Assessment =
Health-related Quality of Life
Health-related quality of life
Pay for reporting
Pay for performance
Comparative effectiveness research
Value = benefit/cost
Functional limitation reporting
Alternative payment system
Traditional and Contemporary Measures
Psychometric Properties – The Basics
Administration, Scoring, Practice Session
How to Use in Clinical Care
Managing with Outcomes
It’s subjectiveand therefore not reliable.
Sullivan MS et al. PhysTher 2000;
Simmonds MJ et al. Spine 1998;
Teixeira et al. PhysTher 2011
Impairment and physical performance measures are more accurate.
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
>>> Not true. PPM’s have been shown to be influenced by psychosocial factors.
PERCEPTION DRIVES BEHAVIOR.
BEHAVIOR DRIVES COST.
Computer adaptive testing
Item response theory
May be risk-adjusted
Activity Measure for Post Acute Care (AM-PAC)
Focus on Therapeutic Outcomes (FOTO)
Traditional Measure: ODQ
Contemporary Measure: LCAT
Lumbar Computer Adaptive Test
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
Fritz&Irrang 2001 PhysTher; Hart et al. 2012 JOSPT;
Hicks&Manal 2009 Pain Med; Hart et al. 2010
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
A measure for everything
under the sun!
Examples of CPG’s from JOSPT:
(These are paper-pencil measures.)
Lower Extremity Functional Scale (LEFS)
Neck Disability Index
DASH (Disabilities of Arm, Shoulder & Hand) or Quick DASH
Oswestry Disability Index (ODI) or Modified ODI
"There are three kinds of lies: lies, damned lies, and statistics."
"Chapters from My Autobiography", 1906
“In God we trust;
all others bring data.”
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
Internal consistency reliability .92
Good construct validity
MCII (MCID) 5
No floor or ceiling effects
Time: <2 min
Hart et al. 2012 JOSPT; Fritz&Irrang 2001 PhysTher;Hicks&Manal2009 Pain Med; Deutscher 2009 PhysTher; Hart et al. 2010
“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.
I should not do physical activities which (might) make my pain worse.
I cannot do physical activities which (might) make my pain worse.
1. Re-read the questionnaire’s validated instructions or questions
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.
2. Re-emphasize the questionnaire’s validated instructions or question
3. Objectively re-state the questionnaire’s validated instructions or question
“Mr. Smith, how strongly do you agree or disagree with this statement:
‘I should not do physical activities which (might) make my pain worse.’”
Physical performance measures
Roush SE, Sharby N. PhysTher 2011
Functional Limitation Reporting Toolkit, APTA 2013
Wittink H et al. Spine 2003
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
Single leg squats
Double leg squats
1-leg hop distance
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.)”
Value and Communication = Better Outcomes
Re-assessing PRO measure(s) frequently helps with
Examples of Goals using PRO’s
Compliment PRO goals with PPM goals
*Validated/normed measures ideal but not always applicable to your patient; one more reason to use both PRO and PPM measures and goals.
Hajiro & Nishimura, EurRespir J 2002;
Hart et al. PhysTher 2012
“What you value,
so will those you touch.”*
*Al Amato, PT, MBA,
DeutscherD et al. Arch Phys Med Rehabil2009
Ferreira et al. PhysTher 2012; Hall et al. PhysTher 2010;
Roberts et al. PhysTher 2012; Roberts&BuckseyPhysTher 2007;
Bordin, Psychotherapy 1979;
“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
Focus on the feared activities in the clinic
and in the home program
Deanna Hayes, PT, DPT, MS
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.
http://www.apta.org/OPTIMAL/ResearchReportAbstract/, 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.
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.
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