Introduction to Selfreporting Tools: Patient Outcomes Assessment

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Introduction to Self-reporting ToolsPatient
Outcomes Assessment
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• Be delightfully surprised when any treatment at
  all is effective
• Always assume a treatment is ineffective unless
  there is evidence to the contrary
• Cochrane, 1971

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Questions

• Can we distinguish between positive and negative
  effects of treatment?
• What is the magnitude of these effects?
• Is there a net measure of effects that can be
  interpreted?
• Is the treatment doing what we want it to?
• improve function?

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Outcomes

• Outcomes Assessment
• Collection and recording of information relative
  to health processes
• Outcomes Management
• Using information in a way that enhances patient
  care
• (Hansen DT, Mior S, Mootz RD in Yeomans SG The
  Clinical Application of Outcomes Assessment,
  Stamford Connecticut, Appleton Lange, 2000)

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The Era of Outcomes Assessment

• Outcomes in clinical practice provide the
  mechanism by which the health care provider, the
  patient, the public, and the payer are able to
  assess the end results of care and its effect
  upon the health of the patient and society
• (Anderson Weinstein, 1994)

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Health Policy

• With the dawning of the era of accountability,
  there are new social mandates directed toward
  health care providers and health-related
  facilities. Measurements of quality,
  satisfaction, efficacy and effectiveness now
  serve as essential elements for health care
  decisions and matters of health policy
• (Hansen et al, 2000)

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Patient Outcomes Assessment
Patient-reported outcomes
Clinician-reported outcomes
Caregiver-reported outcomes
HRQL Functional status Well-being, Satisfaction
with health, satisfaction with treatment
/symptoms, treatment adherence
E.G., Clinical impressions Signs Functional
status Number of events (e.g. giving way)
Caregiver burden Dependency Global impression
Biological and physiological outcomes
E.G.,B/P, FEV1 Tumor size, Survival
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The Patients Perspective is ...

• A unique indicator of the impact of
  disease/dysfunction
• Essential for evaluating treatment efficacy
• Useful for interpreting clinical outcomes
• A key element in treatment decision-making

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Outcomes Assessment

• Assessment of effectiveness of treatment
• best achieved by repeated application of
  standardized measurement in evaluations
• Outcomes term to describe and quantify the
  consequences of health care interventions
• Can be differentiated in terms of observer
  perspectivePT vs patient

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Outcomes Assessment

• Does linear relationship exists between
  impairments and broader patient-level outcomes?
• More impairments are decreased, the more the
  disability will be reduced?
• Ex pt with hip fracture PT intervention to
  increase strength of weak muscles will result an
  improvement in patient function

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Outcomes Assessment

• Relationship between impairments and disability
  is complex and affected by many factors
• Individuals pyschologic response to injury
• Attitudes of significant others in pts social
  network
• Patients physical environment

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Terminology

• Health Status death, disease, disability,
  discomfort, dissatisfaction (5 Ds)
• Functional Status performance of social roles
  and activities
• Well-Being wellness, feelings
• Quality of life safe environment, adequate
  housing, guaranteed income, respect, love,
  freedom, spirituality, meaning and purpose
• Health-related quality of life those aspects of
  quality of life attributed to health
• Patient-reported outcomes all of above plus
  adherence to treatment and patient satisfaction
  with health care

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Health-Related Quality of Life

• Represents the patients evaluation of the
  impact of a health condition and its treatment on
  relevant aspects of life
• The evaluative component can be measured by
• severity
• bothersomeness
• importance
• satisfaction

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Health-Related Quality of Life

• Represents the patients evaluation of the
  impact of a health condition and its treatment on
  relevant aspects of life
• The relevant aspects of life are measured as
  domains, including, but NOT only
• physical
• psychological
• social

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WHO Definition of Quality of Life

• Individuals perceptions of their position in
  life in the context of the culture and value
  systems in which they live, and in relation to
  their goals, expectations, standards, and
  concerns
• It is a broad ranging concept affected in a
  complex way by the persons physical health,
  psychological state, level of independence,
  social relationships, personal beliefs, and their
  relationship to salient features of the
  environment.

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Determinants of Health and Quality of Life
Environment (Outside Individual)
Social Cultural
Economic Political
Physical Geographic
Health Social Care
General Quality of Life
Health-Related Quality of Life
Functional Status
Health Perceptions
Symptoms
Opportunity
Individual
Lifestyle Health Behavior
Biology Life Course
Personality Motivation
Values Preferences
Illness Behavior
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Outcomes Criteria

• Utility Is it useful?
• Reliability Is it dependable?
• Validity Does it do what it is supposed to?
• Sensitivity Can it identify patients with a
  condition?
• Specificity Can it identify those that do not
  have the condition?
• Responsiveness Can it measure differences
  over time?

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Outcome Measures Appropriate for Clinical Use

• Questionnaires
• General health status
• Pain
• Functional status
• Patient satisfaction
• Physiological outcomes
• Utilization measures
• Cost measures

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Outcomes Measures Appropriately Used

• When outcome measures are appropriately used and
  integrated
• into an evidence-based, patient-centered model
  of practice, there is accountability and quality
  assurance
• (Hansen DT, Mior S, Mootz RD in Yeomans SG The
  Clinical Application of Outcomes Assessment,
  Stamford Connecticut, Appleton Lange, 2000)

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Subjective Questionnaires

• Subjective outcomes assessment information is
  gathered by the patient in self-administered
  questionnaires and scored by
• health care provider,
• staff members
• computer

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Subjective Questionnaires

• In spite of the definition associated with the
  term subjective, these pen-and-paper tools
  have been described as very valid and reliable
  in many cases more so than many of the
  objective tests that health care providers have
  relied upon for years
• (Chapman-Smith, 1992 Hansen, 1994 Mootz, 1994)

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Classifying Patient Reported Measures of Function

• Generic measures of health status
• Applicable across a number of disease processes
  and across demographic and cultural subgroups
• Specific measures of health status
• Designed to focus on aspects of health that are
  specific to the primary condition of interest
• ie body part, condition

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Advantages of Generic and Specific Measures

• Generic
• comprehensiveness
• comparison across interventions and conditions
• established psychometric properties
• Specific
• tailored to disease, body region, condition,
  population
• may be more acceptable to respondents
• may be more responsive

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Disadvantages of Generic and Specific Measures

• Generic
• may not be responsive enough
• may not have focus of interest
• some are lengthy
• Specific
• comparisons across conditions and interventions
  may not be possible
• may miss unanticipated effects

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General Health Questionnaires (GHQ)

• One can benefit from the use of a GHQ because it
  is not condition-specific and, therefore, can be
  applied to virtually any complaint
• Yeomans SG The Clinical Applications of
  Outcomes Assessment, 2000

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Application Intervals of General Health
Questionnaires

• Initial eval for baseline establishment of
  outcomes and to identify problems for prompt
  management
• At a plateau in care or discharge for outcomes
  assessment of treatment benefits ( or lack
  thereof)
• Six months after discharge in order to evaluate
  long-term benefits of treatment
• (research)

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SF 36 General Health Questionnaire

• Designed for self administration, telephone
  administration or administration during personal
  interview
• Measures 8 health concepts
• Physical functioning
• Role limitations because of physical health
  problems
• Bodily pain
• Social functioning
• General mental health
• Role limitations because of emotional problems
• Vitality
• General health perceptions

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SF 36 General Health Questionnaire

• This can serve as a very practical reference tool
  to use for patient report of findings, to
  insurers to justify medical necessity for
  additional care, and to the health care provider
  to facilitate the decision making process of case
  management (referral, discharge)

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SF-36

• Some of the scales such as physical functioning
  and bodily pain are sensitive to change over time
  and parallel the patients symptoms well

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Generic Pain Questionnaire

• Visual Analogue Scales
• Reliable and valid (Jensen and Karoly, 1993)
• Advantages over other measurement methods (Scott
  and Huskisson 1976, Price et al 1994)

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Generic Pain Questionnaires

• Quadruple Visual Analogue Scale
• Four specific factors
• Current pain level
• Average or typical pain level
• Pain level at its best
• Pain level at its worst

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Generic Pain Questionairres

• Quadruple Visual Analogue Scale
• Frequency
• Every 2 weeks since a patients failure to
  progress over a 2-week period may indicate a need
  for a change in management approaches
• (Haldeman et al, 1993)

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Specific Measures of Health Status

• Region specific
• LB, Knee, Hip, Foot/Ankle, Arm/Shoulder/Hand
• Condition specific
• CTS, TMJ, HA
• Disease specific
• Arthritis

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Condition-specific

• Over 40 low back functional questionnaires exist
  with five identified by researchers as gold
  standards (Kopec and Esdaile, 1995)
• Oswestry Low Back Pain Disability Questionnaire
  (Fairbank et al, 1980)
• Sickness Impact Profile
• Roland-Morris Disability Questionnaire
• Million Visual Analogue Scale
• Waddell Disability Index

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Oswestry - Score Interpretation

• To score rated 0-5 add up/out of 50
• 0-20 Minimal Disability
• 20-40 Moderate Disability
• 40-60 Severe Disability
• 60-80 Crippled
• 80-100 Bed Bound or Exaggerating
• 
  Fairbanks et al, 1980

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Modified Oswestry

• Retitled section 8, now identified as Social
  Life
• This section was originally entitled sex life
  and was left blank quite often by respondents
• In the revised version, all ten sections are
  completed more often than in the original version
  
• Hudson-Cook N, Tomes-Nicholson K, Breen AC. A
  Revised Oswestry Back Disability Questionnaire.
  Manchester Univ Press, 1989

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Oswestry Questionnaire

• A score of 11 may be used as an appropriate
  cut-off score for health care providers to
  consider for discharge and/or return to work in
  an uncomplicated Low Back Pain case (Erhard et al
  1994)

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• Minimum Clinically Important Difference MCID
  amount of change that best distinguishes between
  patients who have improved and those remaining
  stable
• OSW 6 pts

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Neck Disability Inventory (NDI)

• Was designed by modifying the Oswestry Low Back
  Pain Disability Questionnaire
• Score like Oswestry disability calculated
• Vernon Mior, 1991

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KOS (Knee Outcome Survey)

• Results suggest that the (KOS) is a reliable,
  valid and responsive instrument for the
  assessment of functional limitations that result
  from a wide variety of pathological disorders and
  impairments of the knee
• Synder-Mackler et al, JBJS 1998
• Rated 5-0 with 0 being unable ADL score/70
  sport score/55
• Global Rating Scale (GRS) included

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Outcome-Based Practice

• Correlating this information to the patients
  specific clinical data and then making a clinical
  decision based on the results represents a
  difficult but important step in making the
  paradigm shift into becoming an outcome-based
  practice
• Yeomans SG The Clinical Application of Outcomes
  Assessment, Stamford Connecticut, Appleton
  Lange, 2000

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4 Steps to Become Outcomes Based

• Utilize subjective/objective tools
• Score the tools at the initial visit to establish
  baseline measures ( helps with goal setting!)
• Repeat the instrument after 2-4 week intervals
  and at discharge to track the effects of
  treatment
• Base clinical decisions on the outcome results

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Medical Necessity

• The fully developed clinical record (chart)
  defines the medical necessity of the case in
  the eyes of the insurer

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Medical Necessity Documentation

• Provider must document
• Etiology of complaint
• (onset, severity, frequency , duration)
• Patients health history
• Current subjective complaints
• Current objective clinical findings
• Diagnosis
• Treatment plan
• Measurements of patient improvement (outcome
  assessment)