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IS YOUR TREATMENT EFFECTIVE?

Mark Werneke

 

How do you know if what you are doing is working?  You don’t want to waste your time, or your patients’ time and money. Physiotherapy is supposed to add value to the health system, not be a drain on it. After decades of collecting outcomes during routine clinical practice, I would like to share with you my clinical thoughts on ways to achieve efficient and effective patient outcomes.

 

Share this post – feel free to pick a tweet:

  • How do you know if what you are doing is working? #QualityPT http://ow.ly/V7g0o
  • “Being effective means measuring what you’ve done so that you can use that info and learn from it.” http://ow.ly/V7giJ #QualityPT
  • “It is fascinating to see how the patient’s self-report outcome data tells a story.” #QualityPThttp://ow.ly/V7ggL
  • “After risk adjustment analyses…Sara’s outcome performance was better than Rob’s.” #QualityPT http://ow.ly/V7gfm

Here’s why being effective is important

Decades of discussion have gone into what makes a physiotherapist “effective.” Some believe further education, while others (like myself) have found research suggesting that years of clinical experience, continuing education courses, and specialty certification(s) may not be as important as traditionally thought.

To me, being effective means adding value to patient care. That means being able to measure what you’ve done so that you can use that information and learn from it.

My focal area of clinical interest lies in managing patients with cervical and lumbar impairments from a biopsychosocially-informed perspective. In that realm, I share an unrelenting passion for collecting data and multi-domain outcomes. I do this by using psychometrically sound measures during every day clinical practice to guide patient management.

How you can learn from what you’ve measured

Evidence suggests for clinicians and instructors to learn from their clinical experience and years of training, they must be provided with optimal patient feedback about what they are doing right or wrong at the patient bedside.

Optimal “patient” feedback is:

  • Patient self-report objective assessments
  • Performed serially throughout patient’s episode of care
  • Risk adjusted to improve the meaningfulness of your interpretation of that feedback
  • A helpful compass for establishing patient rehabilitation prognosis
  • A guide for clinical decisions regarding optimal treatment strategies

It is fascinating to see how the patient’s self-report outcome data tells a story.  I love being able to know whether I should confirm or change a patient’s intervention based on serial and optimal “patient” feedback assessments.

Unexpected results

Mr. B was a 55 year-old computer analyst with complaints of intermittent low back and left leg pains to the mid-calf. Mr. B loved to exercise in his home gym; physical activity appeared to make him feel better. But his pain pattern persisted, especially with prolonged standing and walking.

If you are thinking unilateral stenosis, then you are correct. To me, Mr. B’s problem appeared to be a straightforward biomechanical case. However, my baseline psychosocial screening results were unexpected.

While the patient appeared to be managing his pain fairly well, his StarT (Subgroups forTargeted Treatment Back Screening Tool) classification was high. Furthermore, his intake self-efficacy measurement scores for coping and managing pain were very low.

Based on these baseline screening results, I added cognitive behavioral training (CBT) to my treatment plan. Education, specific functional training, and problem solving are a few key components of CBT.

At discharge, Mr. B had fewer visits and higher functional status than originally predicted.  His psychosocial screening results were now good.  If I had not thoroughly screened Mr. B’s biopsychosocial status at intake, my outcome results may not have been as efficient or as effective.

What you need to know about being effective

So, being effective means being able to measure what you’ve done so that you can use that information to learn from it. The functional status scores from patient self-report outcome measures that physiotherapists typically collect during routine care are observational data.

These measures can be either paper or computer administered. You can use questionnaires like the Oswestry or computer adaptive testing (CAT) driven surveys, such as the FOTO lumbar CAT measure.

When you’re choosing your outcome measurement system, there are a few things you should consider. These include:

1) A large national patient data base

2) Robust, risk adjusted models to predict expected functional status and number of visits that similar patients should achieve by discharge

3) Functional status computer adaptive testing (CAT) measures (which are more efficient than traditional tools)

4) Benchmarking reports to judge how a clinician is performing compared to other physiotherapists treating like patients

Our research group specifically chose FOTO as our outcome system because it met all of these needs.  I think it is fair to disclose that I am a member of FOTO’s Research Advisory Board (for the past three years). With that said, I have been using FOTO data for over two decades to manage my patients on an everyday basis.

 

Common challenges associated with being effective

Differences in outcomes between your patients and other providers may be due to the fact that your patients received superior treatment. It may also be simply due to the differences in the characteristics of the patients you are managing.

The majority of physiotherapists do not have the capability to apply sophisticated risk adjusted analytical methods to strengthen the validity and interpretation of their patient outcomes. We chose FOTO to manage and risk adjust our outcomes; this allows us to compare apples to apples.

Another challenge our research group learned from using observational data for improvement was that it takes time to understand how to integrate patient self-report data into daily practice. Analyses of providers’ performance using FOTO data between 2010- 2014 taught us that it takes about one to three years of practice to enhance your outcome performance skills.

The point is: don’t be discouraged when you first start to systematically incorporate patient outcome data into your practice.

 

Potential consequences of not using effectiveness in your practice

The short version of not using objective patient self-report data in your practice is that you won’t be as an effective physiotherapist as you could be.

That applies to both choosing what observational data to collect and how you analyze it.

What risk-adjusted analytics can tell you about performance

I collect outcomes data with eight other physiotherapists who work across the US. As a group, we’ve standardized our data and patient self-report outcome collection process.

One of our clinicians (we’ll call him Rob) was always getting better functional outcomes for patients with lumbar impairments using unadjusted or raw data, compared to another clinician (we’ll call her Sara). Both had received the same training and had similar clinical reasoning and manual skills.

However, when we applied risk-adjustment to interpret our outcome data, we found that there were many other factors not related to the clinician’s treatment.

Sara was seeing older patients with more chronic pain conditions. More of her patients had:

  • Lumbar surgery
  • More medical comorbidities
  • A higher caseload of worker’s compensation and litigating patients

All of these factors can negatively influence a clinician’s functional status outcomes.

What was fascinating was that after advanced risk adjustment analyses to control for patient case-mix, Sara’s outcome performance was better than Rob’s. It should be noted that Rob and Sara’s data are encrypted, so no one knows which physiotherapist was which. There are limitations of unadjusted observational data.

The science of risk adjusting observational outcome data is relatively new in physiotherapy practice. The best published physiotherapy risk adjusted models have an accuracy of about 35-40%.

That means that 60% of the time, we cannot precisely identify all unmeasured or potential confounders which may also influence our outcomes. However, with that said, if you aren’t using risk adjusted data, then you can’t compare results.

 

Three things you can do right now to make your clinical practice more effective and efficient

  1. Understand how to integrate these data to guide your patient management. I don’t believe this concept is emphasized enough at university or postgraduate educational levels. Can you remember an instance when a clinical instructor shared their patient self-report outcome data to support the value of interventions being touted as evidence-based?
  1. Choose efficient measures. When getting started, using efficient measures means a reduced time for patients to complete and physiotherapists to score. Saving time during fast-paced and often hectic outpatient environments is a strong clinical advantage for collecting data at the patient’s bedside.
  1. Make a plan to incorporate observational data into your practice today. Start with small steps and within a few weeks, you’ll start to have valuable data to improve your patient care.

Mark Werneke PT, MS, Dip MDT: I am a full-time clinician working at a suburban hospital-based outpatient clinic. I am also a clinical scientist. I am interested in outcome-guided patient management and have been collecting data at the patient’s bedside for the past three decades. I am a cofounder of our research group examining the associations between McKenzie methods and multi-domain patient outcomes. Our group has been fortunate to publish our clinical observations and results in multiple peer-reviewed journals. I have also presented both internationally and nationally on topics related to the biopsychosocial management of patients with low back pain.