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 • Evidence-based recommendations for selected PRO instruments • How to use PRO’s in clinical practice
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
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) • ….
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: • 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? Because we have to. Because we want to.
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 • 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 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 • 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 “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
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)
To understand where we are and why we are here, it’s important to understand where we’ve been. History of Outcomes Assessment
Health Care Trends • Era of Expansion • Era of Cost Containment • Era of Assessment and Accountability
Era of Expansion • Between WWII and 1960’s • Medicare and Medicaid
Era of Cost Containment • 1970’s and 1980’s • DRG’s and HMO’s
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” 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 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 Accountability Seeks a balance between achieving high quality health care while being accountable to cost.
Early Concepts in Outcomes Assessment Health-Related Quality of Life + Economic Assessment
Health “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 • 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? • 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) • 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 • 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 • 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 AssessmentSummary Outcomes Assessment = Health-related Quality of Life + Economic Assessment
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 It’s subjectiveand therefore not reliable.
Reality • 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’s Impairment and physical performance measures are more accurate.
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. 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’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… PERCEPTION DRIVES BEHAVIOR. BEHAVIOR DRIVES COST.
PRO Measures Traditional Measures Contemporary Measures Electronic 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
Examples Traditional Measures 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 • Oswestry • Neck Disability Index • Lower Extremity Functional Scale (LEFS) • DASH or Quick DASH • SPADI • KOOS • WOMAC