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RESEARCH REPORT

Record Audit: A Study of the Quality and Effectiveness of the Treatment of Knee Conditions Caroline Dobson

Key Words Attendances, outcomes, physiotherapy input units, quality, effectiveness.

Summary This report utilised record audit methods to examine the quality and effectiveness of treatment of knee conditions in the physiotherapy outpatient department at Stockport Infirmary from September to December 1991. Information was gathered from patients’ clinical records and analysed by condition. The m e t b and methods which were used in the study are described. Anelysis of the data showed that patients were Seen within a reasonable time, with acute patients generally being seen first. The study showed that 92.5% of patients demonstrated a positive result from physiotherapy intervention. The study highligMed the problem of non-attendance as a major waste of physiotherapy resources and also that the lack of a specific diagnosis by the referring doctor caused increased treatment times.

Introduction As accountability and quality assurance issues become more important for patient treatment, it is essential to have meaningful information on the resources required to treat typical conditions. It has been asserted that a clinical audit approach, based on clear definitions with emphasis on outcomes and quality of care, will provide a powerful multi- professional incentive to set the direction for purchasers and providers alike. This survey was intended as a pilot study to investigate whether record audit is indeed a valid method of gaining such information. It involved the collection and analysis of data from the records of patients who had been treated and discharged from the physiotherapy out-patient department at Stockport Infirmary in the period September to December 1991. A specific group of patients was chosen for the study; it was decided to include all patients who had been referred for treatment for knee conditions because there were enough of them and they had definite diagnoses on referral, so were easier to categorise. It should be noted that these diagnoses were those of the referring doctor and do not reflect any subsequent re-assessment by a physio- therapist.

A number of metrics were designed to reflect the original aims of the study: .Quality was determined by the length of time a patient had to wait for physiotherapy treatment; defined as from the date the referral was received

by the department to the date of initial contact with the patient. .Efficiency and effectiveness were determined by (1) the number of patient attendances at the physiotherapy department, (2) outcome of treat- ment using a scheme of pre-existing categories, and (3) amount of physiotherapy input units (PIUS) to the patient.

Definitions Physiotherapy Inputs (PIUS) The PIU is a metric used to meaeure the total input to a patient by a physiotherapist. Treatment time is measured in terms of therapist input time by face-to-face contact with patients, plus indirect work such as maintaining a check on t h m who are practising alone, or receiving treatment on a machine. Because of the supervisory element, the time patients may be in the department receiving treatment can be significantly longer than the direct contact with physiotherapiets. Indirect care also includes clinical record keeping as it is part of the clinical treatment process. To determine PIUs accurately, the beginning and end of a patient’s treatment regime must be defined.

Patients who are referred for treatment but do not attend (DNA) for their first appointment can waste many clinical hours and should have PIUS allotted to them.

Differentiation is made between grades of staff to allow for skill mix and variable staff CO&, and it has been designed that through this Merent- iation, the overall case costing is irrespective ofthe grade of stafftreating the patient. The categorim- tion of PIUs is shown in table 1.

Table 1: Number of physbthempy input unb allocated tor treatment time showing dlfferentld wdghtlng tor 8t8fl ot differing seniority

Grade of staff Time (minutes) PIU rating

Senior 5 1 Junior 5 1

Senior Junior Helper

10 10-15

10

2 2 1

Senior 15 3

Senior 20 4 Junior 20 3 Helper 20 2

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During patient treatment, the physiotherapist keeps a record of the time spent with the patient, and enters it along with clinical information on the patient’s record card.

On discharge of the patient, the PIUs are summed and an overall PIU rating for that case can be determined.

Outcome Measures Outcomes of treatment are a means of describing what has occurred to patients as a result of their contact with physiotherapists and should reflect the effectiveness of treatment. On initial contact, physiotherapist and patient identify and agree symptoms to be addressed during the period of treatment. On discharge, outcomes are decided on retmspective assessment of the alleviation of thoae symptoms. The scoring methods can be labelled numerically or alphabetically as the result has no intrinsic numerical value; it is purely descriptive (Wegetaffe, 1993). The outcome categories are:

Related to the patient’s condition D1. Problem grossly deteriorated D2. No change in patient’s condition D3. Maintenance achieved D4. Problem resolvinghmproving D6. Problem resolved

Descriptor of patient discharge status D6. Transferred to another department D7. Failed to attend (has never attended) D8. Patient self discharges (ceases to attend without informing the department) D9. Inappropriate referral D10. Assessment only D l l , Assessment and advice D12. Own discharge (ceases to attend but informs the department) D13. Doctor discharges patient before physio- therapy is complete DO. Patient died

The metrice given for outcomes may also be cross- referenced, eg D4.6 represents a situation where the patient was improving with treatment but was transferred to another department for continuing treatment. Outcomes show not only the effective- nees of treatment, but also self discharges and failure to attend. Obviously, in this methodology, outcomes are difficult to assess where goals are not decided upon at the onset of treatment (Kaye, 1991).

Method As physiotherapy intervention is patient based and problem oriented, any measure developed to describe outcome requires data collected at a minimum of two points; namely the beginning and end of an episode of care (Wagstaf€e, 1993). Relevant data were therefore collected from treatment records following discharge of patients from the department.

The data collected include:

.Total PIUs on discharge

.Outcome of patient’s treatment

.Number of patient attendances in the department .Date of referral to physiotherapy .Diagnosis (as supplied by the referring doctor)

As the study continued, it became apparent that there were enough people with knee conditions to analyse them in groups by specific diagnosis. These were categorised as follows - figures are numbers of subjects.

.Knee pain (including anterior knee pain) - 33 OOsteo-arthritis - 34 .Ligamentous iqjuries - 39 *Muscular injuries - 11 .Fractures around the knee - 8 OMeniscal injuries - 12 .Post anthmscopy/menisc&my - 10 .Patellar conditions including osteochondritis, chondromalacia, dislocation - 40

Patients included in the study ranged from 8 to 80 years old. The data were collected from September to December 1991 inclusive. The time of year could have a bearing on the type of condition referred, for example it included the start of the season for many sports, 80 there was a greater likelihood of so& tissue injuries.

Results Waiting Times Figure 1 shows the waiting times in working days for all patients included in the study. Some patients were seen on the first day of referral (waiting time zero in figure 1). The majority of patients were seen within 21 working days, the mean waiting time, irrespective of condition, being 16.6 working days. So it can be seen that the vast majority of acute conditions were seen within seven working days, that is less than the mean waiting time, whereas chronic conditions - such as arthritis, knee pain and patellar problems - waited for longer periods.

21 B

92-98

85-91

bo I , 0 10 20 30 40 50 60 70

Number of patients

Fig 1: Walting tlmes In worklng days

PIUS Figure 2 shows the number of PIUs for each condition compared to the mean PIU irrespective of condition. The mean value was 19.8 PIU, which represents 1 hour and 39 minutes of senior physio- therapist time with a patient. The conditions requiring more input are those above the mean. Comparing individual conditions it is noted that knee pain, patellar problems, arthritis and fractures have a PIU rating which is above the mean, whereas other conditions fall below this level.

Knee pain is a vague description by the referring doctor, so it is likely that this unspecific diagnosis causes difficulty in identifying the structure at fault, so making treatment more difficult and therefore longer. Fractures usually require a period of immobilisation, and therefore have secondary problems such as stiffness and weakness, 80 longer treatment will be required to restore full function. By contrast, recent injuries are normally referred quickly, helping to avoid

9G.l 25.6 L W

24.9

24 - 2 22- & 20-

a 6 a

z 18-

16-

14-

12- 13.2

P T PT L A M MN F Category

L W I 24.9

24 - 2 22- & 20-

a 6 a

z 18-

16-

14-

12- 13.2

P T PT L A M MN F Category

Fig 2 Avemge number of PIUS for each condlUon (excluding DNA$). compared to overall average

Key: P = knee pain, T = post-arthroscopylmeniscectomy, PT = patellar conditions, L = ligamentous conditions. A = osteo-arthrltis, M = muscular conditions. MN = meniscal injuries, F = fractures about the knee

secondary problems, and thus reducing the overall treatment time - this emphasises the need for early referral to physiotherapy.

Attendances Figure 3 shows the number of patient attendances during their episode of care. The mode for patient attendances is between one and four, with the majority of patients attending between one and eight treatment sessions.

804

IC 2536 37-40

Number of attendances Fig 3: Patlent attendames Mng thdr prlsd at cum

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The significant number of patients with zero attendances fail to turn up for their first treatment session with no notifieation to the department.

Outcomes of Treatment Figure 4 shows the main outcome measures (as described previously), as percentages of the number of patients rounded to the nepest integer value. Due to an insufficient sample size of 0.51, the D2 category is not included in the chart.

The D7 category, ie patients who fail to attend for their first appointment (DNAs), recorded a value of 14% which translates into a large amount of clinical time lost. Individual conditions with a high DNA rate include knee pain and patellar conditions.

There were 8% of patients who failed to attend for subsequent treatments, the D8 category. Reasons may include physiotherapists continuing treatment too long without any further positive result, or patients being dissatisfied. Outcome indicators show the effectiveness of treatment. All patients in the groups D3, D4, D5 and D11 show a positive result with treatment, ie one in which they have benefited from the intervention. For all patients presenting with knee conditions there is a 92.5% positive result of treatment.

Table 2 shows the negative and positive results for individual conditions. In some groups there were not enough patienta to determine effectiveness. Oeteo-arthritis and knee pain do not respond as well to treatment aa other conditions.

Tabla 2: Outcome of treatment Identified as a positive or negative result expressed M a percentage of the number of patients In that category, DNA and 08 wndRkm not InCruded. The number of patients and DNA8 in each condition category during the period of the study are dw shown

ConditioruSlNcU~ NO 04 hsitive Negative DNA at feun patients result(%) resun(%) (NO)

Osteo-arthriis 29 Knee pain 23 87.0 13.0 7 Ligament 31 96.8 3.2 3 Patella 30 96.7 3.3 8

1 2

Arthroscopy 13

0 Muscular 8

0 Meniscal 7 Fractures 7

‘Insufficient sample size to record

86.2 13.8 4

Discussion Waiting Times Acute conditions do not wait as long as chronic conditions for treatment. This is important as it shows acute injuries are treated first and there is prioritisation of waiting lists according to clinical requirements. Short waiting times will be perceived as desirable by both patients and their referring doctors and 80 demonstrate a high quality of treatment.

PIUS All conditions fall very close to the mean PIU value, except for knee pain and fractures. As discussed, due to the problems of immobilisation, fractures have secondary difficulties that require more therapist input. Knee pain is an unspecific diagnosis 80 an in-depth assessment is required by the therapist to determine a more accurate clinical diagnosis. Knee pain can arise from many diverse causes such as altered foot biomechanics, referred pain, etc, so that a number of different treatment strategies may have to be tried before a successful treatment regime can be identified. Better initial diagnosis would improve PIU ratings, therefore lowering the physiotherapy cost to treat this condition.

Acute injuries, when referred early, usually require much less treatment and therefore less therapist input, 90 making them more cost-effective to treat.

Attendances It was shown that the majority of conditions have a similar number of attendance values except fractures which require on average three more attendances per patient.

Outcomes As half to three-quarters of an hour is kept aside for the treatment of new patients, a DNA rate of 14% represents a significant amount of clinical

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time lost in nonattendance. Acute conditions had a low DNA rate. Patients were given appointments in various ways, including directly to the patient, by telephone or post. The DNA rating was similar for all groups and did not vary according to how the appointments were given. There is a particularly high rate of DNA in knee pain and patella groups, especially anterior knee pain, probably due to the unspecified diagnoses, which could be improved by more precise information from the refemng doctor. Better patient education on the benefits of physiotherapy at the time of referral might reduce the overall DNA rate as patients should then be more motivated to attend for treatment.

A high percentage of patients discharged themselves before completion of the course of the treatment. Again, therapist time was lost as appointments had been made for them. This could be resolved by: .Setting realistic goals with patients at the outset of treatment 80 they can monitor their own progress. .Constant assessment of patients so that if treatment is no longer effective, it is changed or stopped. Effectiveness was shown by the use of outcome indicators. Physiotherapy for knee conditions was shown to be 92.5% effective over all conditions.

Conclusions 1. One measure of quality was the length of time a patient was on the waiting list. The majority of patients waited no longer than three working weeks for treatment, with a large number seen within seven working days. The majority of acute conditions were seen within one working week, and needed a shorter course of treatment than if they were left until secondary problems had started.

2. Most conditions had a similar PIU rating except for knee pain. Treatment of this condition could be improved by: .Better referral from doctors. .Patients who are referred with this diagnosis being treated by physiotherapists more skilled in the assessment and evaluation of musculoskeletal conditions, who can therefore find an optimum treatment regime more quickly. .A further in-depth study being performed by a senior physiotherapist to determine the likely conditions grouped under knee pain - this is under way.

3. Effectiveness and efficiency was shown by the use of outcome indicators to determine a positive result. As seen, 92.5% of patients were treated effectively.

This study has shown that the quality and effectiveness of treatment cun be measured and relate well to particular diagnoses and outcomes.

Future Studies The difficulties highlighted by this study arising from the unspecified diagnosis of knee pain might benefit from a study of the subsequent diagnoses by physiotherapista to try to identify whether there is a small number of specific conditions which generally give rise to the type of symptoms found in these patients.

This study concentrated on audit of patient records as the data source. The analysis is therefore independent of treatment techniques and individ- ual physiotherapists’ skills. An obvious further study would be to conduct a treatment (clinical) audit. It should be noted that such an approach would however require much stricter controls over the physiotherapists involved and would be bound to cause disruption within the department.

One of the most striking results of this work is the identification of the large waste of resource caused by patient non-attendance, both initially and during their course of treatment. A number of possible reasons for this have been diecuesed, but a follow-up study could show the effectiveness of possible measures to reduce this wastage. The same methods of data collection and analysis could be employed.

Acknowledgments Thanks to Sue Wagstaffe, Margaret Goode and Barry Dobson for all their help with this article. This work was undertaken as part of a local authority project (Health Pickup), while the author wa8 working as a senior I1 physiotherapist in Stockport Heslth Auttrority. The alms of the

collection. The report was successluly passed in July 1992. projectwen3to imeasetheawamessand undenffandingofdata

Author Caroline Dabson MCSP is a private practitioner.

Addm80 for Correspondence Mra C Dobson, 14 Brooklawn Drive, Didsbury. Mancheater M 2 0 3GZ.

R e h m m s Department of Health (1993). ‘Clinical audit A policy statement’.

Dobson, C (1992). ‘The quantitative study of the duration and outcomes of the treatment of knee conditions’, Health pickup study. Kaye, S (1991). ‘The value of audit in clinical practice’, Physlo- therapy, 77, 10, 705-707. Wagstaffe, S (1993). ‘Thedevelopment of outcome indicatorsfor use in physiotherapy practice’. Williams, J (ISal). CWcukting Staffing levels in Physbttmrapy

PhysiOtheTepy, 7@,8,!542 - 544.

services, Pampas Publiitions, Rothemam.