Outcome Measures in Rehab: Current and Future
Jessica Meiley, senior orthopedic technician, Laura Engelman, OTR/L, occupational therapist, and Jillian Ng, PT, physical therapist
The use of outcome measures by occupational therapists, physical therapists and speech and language pathologists is at the very foundation of all three professions, which measure human functionality using tests and measures.
Types of Outcome Measures Used
These metrics fall into two categories: impairment measures and functionality measures. Impairment measures objectively capture data on clinically significant factors, such as strength (manual muscle testing), range of motion (goniometry), gait, cognition, sensation, reflexes and more. These measures may be thought of as the “vital signs” of human movement and functionality. Functional measures objectively quantify functionality (anything related to the human “movement” system), including whether a patient can ambulate and perform activities of daily living.
There is a strong relationship between impairment and functional measures, which is the basis for the therapist’s involvement. For example, we know that a person needs at least 120 degrees of knee flexion in order to go up and down stairs, and that there is a direct correlation between decreased strength (manual muscle strength measures) in the legs and an increased risk of falls.
Some measures of functionality include tests administered by the therapist, while others are reported in patient surveys (called patient reported outcome measures or PROM). Research efforts to design valid and reliable therapist-administered tests, measures and PROM have increased dramatically, as a result of a shift toward patient-focused care and value-driven payment methodology. Medicare part B requires us to submit codes that identify patients’ baseline functional status, functional goal and final functional status at discharge with claims in order to receive payment for care.
Many believe that in the near future, payment will be based on whether or not there has been a measurable change in patients’ baseline functionality over time.
How Outcome Measures Are Used
These data are captured during the initial evaluation of the patient, where we use impairment tests and measures of functionality. These data help identify underlying causes of impaired functionality and become the basis for our treatment plans as well as establishing the baseline functional status of the patient.
A physical therapist who sees a patient with a history of increased falls might administer one of a number of valid and reliable tests to quantify risk. The “timed up and go” test is a reliable predictor of risk for falls that can be administered by the therapist. If the score is high, the therapist would take several different impairment measures to determine which are contributing most to increased risk. The parameters with the greatest deficit become the basis for establishing the patient’s treatment plan and are the baseline data we use to measure the patient’s progress.
We periodically reassess the patient against baseline measures to determine whether treatment has been effective. This facilitates our ability to adjust care based on changes and ensures that clinical documentation objectively reflects changes in patients’ functionality. While outcome measures are used to manage individual patients, increasingly, we can use these data in aggregate to support clinical improvement initiatives and clinical research.
One of our well-known clinical improvement initiatives, care of patients undergoing total knee replacement, established a standardized data set of outcomes and used them to compare the effect of changes in patient management, such as eliminating the use of continuous passive motion machines (CPM) post-operatively and increasing the frequency of physical therapy treatment.
Current Challenges and Future Vision
Our challenges lie in establishing a standardized set of outcome measures (for a specific diagnosis), gathering the data in a consistent and standardized way, and capturing it in a system that enables clinicians to effectively use it. Our colleagues across Partners have worked hard to identify hundreds of clinical impairment and functional outcome measures that have been “built” into the system. Another challenge is learning how to analyze data across time for an individual patient, or aggregating it for clinical improvement activities and research. In many ways, this is also our greatest opportunity because it will help us more accurately measure the effectiveness and value of our care.
We are now pursuing strategies that will facilitate our ability to capture PROM, either with iPads in our ambulatory clinics or by sending surveys to patients through Patient Gateway. In a value-driven health care system, capturing these data is the new imperative.