Good Practice: Outcome Measurement
By: Leanne Loranger, PT
Everywhere I turn these days I keep coming up against the topic of outcome measures. I’ve been to meetings where measures and their importance have been discussed, at conferences where every second comment was about clinical outcomes and how those outcomes can be used to support the argument for ongoing expenditures for physiotherapy, and had emails and social media comments coming my way about the importance of using outcomes in practice.
But what can I possibly say about outcome measures that hasn’t been said before? The truth is that nothing has really changed when it comes to the importance of gathering outcome measures data since I started working in 1995. As the saying goes, the best time to start was 20 years ago, the second best time is today. But are we using outcome measures in practice? Really? And are we able to consistently demonstrate that what we are doing is making a difference to the health of Albertans? Not just a difference between how they feel walking into physiotherapy and walking out an hour later but a real, lasting difference?
Sadly, I don’t think we are doing a good job of demonstrating our impact, but now more than ever we need to do so in a clear, measurable, irrefutable manner.
In February I had the opportunity to attend the American Physical Therapy Association’s Combined Sections Meeting and the thing that struck me about the presentations was that every speaker whether an academic or clinician talked about their outcomes in a big way. They didn’t just talk about patient satisfaction, and they weren’t using a single measure to demonstrate their effect. Consistently, these speakers were able to show data about the programs they were associated with and the multiple tools that they were using to demonstrate their effectiveness and the difference they were making to their patient’s lives.
Then, shortly after returning home, I had the opportunity to meet and speak with Katherine Berg (yes, as in the Berg Balance Scale!) It was quite the thrill to meet someone from our profession who was involved early on in the development of outcome measures relevant to physiotherapists and patients. She was here to speak about another tool that she has been involved in developing and refining, the interRAI. This is a tool that is commonly used in Alberta Health Services when determining appropriate living arrangements for people who cannot return to their prior living environment. I was surprised to learn that many of subscales of the interRAI correlate closely to more traditional physiotherapy-related outcome measures such as the Functional Independence Measure (FIM) when it comes to detecting clinically relevant changes1 and measuring the effectiveness of treatment.2
Her key message to physiotherapists is to use big data; universal data sets that are common across disciplines to show our impact. Talking about the change on a Berg Balance Scale is great, if you work in isolation, but as soon as you work as part of a multidisciplinary team the outcomes that you collect need to be relevant and transparent to other members of the team. By using common language and common measurement tools we can demonstrate patient improvement and link that change to the treatment provided or other improvements in care delivery.
Even if you do work in isolation, showing an impact is important for patients and for payers. Those impacts must be relevant to the patient. It seems to me that it doesn’t matter much if the patient changes three points on an outcome measure score unless they perceive an important change in their condition or ability to function. Most well-developed outcome measures have an associated Minimal Clinically Important Difference (MCID) that will give you an indicator of how much change is required to make “a difference in the life of the patient.”3 Clinicians need to be aware of both the outcomes they measure and the MCID of the scores they are using.
Another important question is that of how much improvement should you expect to see? Interesting answers to that question are now available through Focus on Therapeutic Outcomes (FOTO) which provides age, gender and risk adjusted information about patients so that you can judge not only the change your patients achieve, but also what their anticipated outcomes are.2 The data set also provides information, in an aggregate manner, of how your clinic’s outcomes compare with those of other clinics.4 Would you like to know if your outcomes are better than others? If your clinic’s outcomes were worse, wouldn’t you look into why and alter your practices?
OK, so I have talked about the common themes around outcome measures and why we need to be using them, but what’s different today? Fair question! As many community physiotherapy providers will know, the current Community Rehabilitation Plan contracts have recently been extended for the coming 2-3 years pending a review of the provincial community rehabilitation policy by Alberta Health. It is too early to tell what the outcome of this review will be. However, Physiotherapy Alberta fundamentally believes that all Albertans should have equal access to affordable physiotherapy services, regardless of where they live and applaud the move to review key policy and develop appropriate models of care.
Research suggests that early access to physiotherapy services leads to improved patient satisfaction, better functional outcomes5,6,7 and, in some cases, may decrease the need for more costly and invasive interventions. Other research shows that when physiotherapists are used to triage musculoskeletal injuries there are lower costs to the system, fewer inappropriate tests ordered and similar or better patient outcomes.8,9,10 The problem is that these findings are research-based. We don’t know if those findings hold true in a real-world clinical environment. This means that we don’t know what services and models of care are the best investments for our limited health-care dollars. Don’t you want to know? Having a robust, physiotherapy-specific clinical data set that demonstrates the impact physiotherapy has on improving patient function and quality of life or value is an incredibly powerful tool when considering physiotherapy service delivery, availability and funding.
Of course the best thing would be if we had 20 years of data as proof of our impact. Second best is to start today. By consistently collecting and comparing aggregate patient data to identify better ways of caring for patients we can make stronger arguments that funding physiotherapy actually makes a difference to people in the long term, so let’s not wait another 20 years to start!
- Glenny C, Stolee P, Husted J, Thompson M, Berg K. Comparison of the responsiveness of the FIM and the interRAI post acute care assessment instrument in rehabilitation of older adults. Arch Phys Med Rehabil. 2010; 91:1038-1043.
- Glenny C, Stolee P, Thompson M, Husted J, Berg, K. Underestimating physical function gains: comparing FIM motor subscale and interRAI post acute care activities of daily living scale. Arch Phys Med Rehabil. 2012; 93:1000-1008
- Law M, MacDermid J. Introduction to evidence-based practice. Evidence-based rehabilitation: A guide to practice. Thorofare: SLACK Incorporated. 2008.
- Canadian Physiotherapy Association Focus on therapeutic outcomes (FOTO): CPA’s national outcome measures database, powered by FOTO. Available at: http://www.physiotherapy.ca/Practice-Resources/Outcome-Measures/FOTO Accessed on May 14, 2015.
- Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De Souza LH. Early intervention for the management of acute low back pain. Spine. 2004; 29 (21): 2350-2356.
- Zigenfus GC, Yin J, Giang GM, Fogarty WT. Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. Journal of Occupational and Environmental Medicine. 2000; 42(1):35.
- MS Australia. Strength and cardiorespiratory exercise for people with multiple sclerosis (MS). MS Practice for Health Professionals. n.d. Available at: http://www.msaustralia.org.au/sites/default/files/strength.pdf Accessed on May 20, 2015.
- Sutton M, Govier A, Prince S, Morphett M. Primary-contact physiotherapists manage a minor trauma caseload in the emergency department without misdiagnoses or adverse events: an observational study. Journal of Physiotherapy. 2015; 61: 77-80.
- Canadian Physiotherapy Association. The value of physiotherapy: Musculoskeletal conditions. Available at: http://www.physiotherapy.ca/getmedia/ccbbd054-8ff4-4d45-af75-96a9133caf49/CPA_TheValueOfPhysio2012_Musculoskeletal-v1.pdf.aspx Accessed on May 20, 2015.
- Canadian Physiotherapy Association. The value of physiotherapy: Stroke. Available at: http://www.physiotherapy.ca/getmedia/63b49e56-5fc4-42fd-a86f-93faa772e957/CPA_TheValueOfPhysio2012_Stroke-v1.pdf.aspxv Accessed on May 20, 2015.