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

INTRODUCTIONS AND BACKGROUND TO COURSE

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.

Volume vs. Value-Based Healthcare

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)• ….

Patient Case

Focus of this course is Patient Reported Outcomes

(PRO’s)

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)

PRO’s to help determine Medicare G-Codes and Severity Modifiers

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)

HISTORY OF OUTCOMES ASSESSMENTTo understand where we are and why we are here, it’s important to understand where we’ve been.

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.

Phys Ther 1995;75(11):965-70.

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.

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…

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

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

Pay for performance

Comparative effectiveness researchValue-based purchasing

Economic assessment

Value = benefit/cost

Alternative payment system

Functional limitation reporting

Pay for reporting

PATIENT-REPORTED OUTCOMES OF CARE

Common MisperceptionsTraditional and Contemporary MeasuresPsychometric Properties – The BasicsAdministration, Scoring, Practice SessionHow to Use in Clinical CareManaging with Outcomes

COMMON MISPERCEPTIONS OF PRO’S

Common misperception of PRO’s

It’s subjective and therefore not reliable.

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

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. 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

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

Patient perception in compliment to other measures

One more reason why assessing patient perception is vital…

PERCEPTION DRIVES BEHAVIOR.BEHAVIOR DRIVES COST.

TRADITIONAL AND CONTEMPORARY PRO MEASURES

Patient Case

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

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

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

Concepts in Contemporary PRO Measurement

• Computer Adaptive Testing (CAT)• Item Response Theory (IRT)• Risk Adjustment

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

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

Item Response Theory

• The math behind the CAT. • Allows for design, analysis and scoring of the

CAT measure.

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?

• 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?

• 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

• 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!

WHICH MEASURES TO CHOOSE???

I want to stick with paper-pencil measures. Where’s the Easy Button???

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:

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

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

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

PSYCHOMETRIC PROPERTIES OF PRO’S – THE BASICS

Statistics

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

-Mark Twain"Chapters from My Autobiography", 1906

Statistics

“In God we trust; all others bring data.”

– W. Edwards Deming

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)

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?

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

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

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)

ADMINISTRATION AND PRACTICE SESSION

Practice Session

• Practice and demo’s of selected PRO measures

Administering Questionnaire(s)

1. Follow validated instructions2. Do NOT interpret questions for the

patient• Re-read• Re-emphasize• Objectively re-state

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.

How to avoid interpreting questions for patients

Patient: “I don’t understand this question.”

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.

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 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 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.’”

Scoring

USING PRO’S IN CLINICAL CARE

How do PT’s measure outcomes?

Impairments +

PRO’s +

Physical performance measures

Roush SE, Sharby N. Phys Ther 2011Functional Limitation Reporting Toolkit, APTA 2013

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…

• 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

Impairments

• ROM• Muscle length/flexibility• Joint accessory mobility• Strength • Motor control• Movement patterns• Balance• Sensation• Pain

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’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

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.)”

USING PRO’S IN CLINICAL CARE

1st Visit

• PRO score• Responses to individual questions• Information from other PRO’s/screening tools– E.g., fear, depression, PSFS

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….”

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• 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 Evaluation

• Influence therapist decision making toward– Prognosis– Functional limitation reporting– Goal setting– Intervention strategies

Intake Summary, P. 1

Using PRO’s to help determine G-codes and modifiers

Intake Report, P. 2

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

• 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?

• 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?

• 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

• “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 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.

Example of a contemporary PRO measure in action:

FOTO Patient Reports for Clinical use

Status Report, P 1

Status Report, P 2

Documentation

• Where do you document your PRO score(s)?– Subjective– Objective– Assessment/Functional Limitations

• Goal setting• Coding

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 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.

Goal Setting

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

• 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

Discharge Report

GETTING BETTER OUTCOMES

How can I improve my outcomes?

• Value• Serial assessments • Therapeutic alliance • Psychosocial management skills• Current best practice impairment-

based knowledge and skills

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

Serial Assessments

Deutscher D et al. Arch Phys Med Rehabil 2009

Status Report, P 1

Impairment-based knowledge and skills

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;

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

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 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 OUTCOMESChoosing an outcomes systemImplementation of an outcomes systemQuality Assurance/ImprovementProfessional Development

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

• 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 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

Contemporary PRO in Action

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

Calculating Completion Rates

Implementation

• Establish urgency, educate• Garner key supporters• Identify an outcomes champion• Establish accountability

Implementation

• Educate, educate, educate• Enable and empower• Provide timely feedback• Ramp up time• Recognition

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– Internal motivation

• Continuing Ed • Employee Satisfaction• Accountability – Completion rates

SummaryQ & A

Thank you!

Deanna Hayes, PT, DPT, MSDeanna.hayes@att.net

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.

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.

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