Best Practices in Chiropractic Academy Outcomes Assessment Protocols

1. Best Practices in Chiropractic Academy Outcomes Assessment Protocols

2. Outcomes Assessment Proper use of outcomes assessments in your office.

3. Outcomes Assessment How many use outcome measures in your office? Of the participants that do not, is there a reason why? Of the participants that do, which ones do you use and how do you implement them?

4. Survival� To survive, in fact to flourish, in this era of accountability health care providers must be prepared to maintain and be able to provide appropriate documentation and patient records in a clinically efficient and economical manner. (Hansen, 1994).

5. 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).

6. 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)

7. Correlating Correlate the outcome measures you use in your office in your documentation to support the benefit and need of your care.

8. 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).

9. Outcomes Assessment ToolsAvailable on Web Site� Neck Index Headache Oswestry Back Index Spinal Stenosis Low Back Pain Risk Assessment Depression Forms Fear Avoidance Beliefs Questionnaire Hip Knee Patellofemoral Ankle Shoulder Elbow Wrist Carpal Tunnel Syndrome

10. Outcomes Assessment Tools� It is important to remember to utilize the same outcome assessment tool through the course of case management with each patient.

11. Outcome Measure Forms On the initial presentation of the patient (new, new injury or condition) Doctor or staff gives the appropriate form to the patient (Oswestry, Neck index, Knee index) Patient completes the form (only complete the questions that are appropriate)

12. Outcome Measures Doctor or staff scores the form: The score is percentage of the possible maximum scores based on the questions that are answered. If all questions are answered on the Oswestry or Neck Index, then the answers to the questions are added up and multiplied by 2 If only 8 questions are answered then the percentage is based on 40 possible points: Example: 15 points are scored when adding up the questions 15 is divided by 40 multiplied by 100. The score is then documented in the patients file

13. Oswestry - Score Interpretation 0-20% ��Minimal Disability 20-40% �Moderate Disability 40-60% �Severe Disability 60-80% �Crippled 80-100%�Bed Bound or Exaggerating �

14. Outcome Measures The Outcome Measure Form is then given to the patient again at the following intervals: 2 Weeks after initial visit 4 Weeks after initial visit 8 Weeks after initial visit 12 Weeks after initial visit Etc. At Discharge When an exacerbation occurs

15. VAS VAS used at the same time as the Outcomes Option is to ask the patient on every visit

16. Options: VAS Ask the patient to rate pain on a scale from 0 to 10 if 10 was unbearable pain and 0 was no pain Give the patient a picture of a scale with different levels of pain on it-Analog Scale-or just the number 0 to 100 VAS Digital Scale-Digital Scale 0= no pain1-3= mild pain; nagging, annoying, interfering little with ADL's4-6= moderate pain; interfering significantly with ADL's7-10= severe pain; disabling; unable to perform ADL's��

17. Quadruple Visual Analogue Scale (QVAS)� � Four specific factors - Von Korff et al, 1992 CURRENT Pain Level AVERAGE or TYPICAL Pain Level Pain level at its BEST Pain level at its WORST Final Score Ratings are averaged x 10 = TOTAL SCORE� (Range 0 � 100) �

18. When to use Psychological Questionnaires Patient not progressing as anticipated and you have concerns that there is a psychological component to the pain. Work dissatisfaction-work comp case Physical exam findings do not support patient complaints

19. Psychological Questionnaires RISK FACTOR ASSESSMENT QUESTIONNAIRE Risk Factor Assessment �(Re-Exam� Questionnaire)� NEW ZEALAND ACUTE LOW BACK PAIN GUIDE

20. Risk Factor Assessment �Scoring Risk of a Prolonged Recovery � Score Mild���������� -����������� 51 - 71 Moderate�� -������������ 72 - 89 Severe������ -������������ > 89

21. Depression Questionnaire Concerned the patient may have depression? May be more appropriate to just discuss in an appropriate way to determine the state of depression rather then using the questionnaire The Zung Self-Rating Depression Scale

22. The Zung Self-Rating Depression Scale There are ten positively worded and ten negatively worded questions. Each question is scored on a scale of 1 through 4 (based on these replies: "a little of the time," "some of the time," "good part of the time," "most of the time"). Scores on the test range from 25 through 100. The scores fall into four ranges 25-49 Normal Range 50-59 Mildly Depressed 60-69 Moderately Depressed 70 and above Severely Depressed

23. The Zung Self-Rating Depression Scale http://www.depressiontreatmentnow.com/depression_test.html

24. Fear-Avoidance Beliefs Questionnaire Higher scores on the FABQ have been associated with greater disability in patients who have LBP. Although no general thresholds for low, moderate or high fear-avoidance have been identified, the FABQ may still be useful in identifying patients who are at greater risk of disability. It is suggested that physicians review their patients� responses to individual items on the questionnaire and pursue further discussion of items for which patients score 4 or higher.A study of patients who had work-related acute LBP found that those with FABQ work subscale scores higher than 34 had substantial risk (58 percent) of prolonged work restriction, while those with scores of 29 or lower had low risk (3 percent) of prolonged work restriction.3 In a study of patients who had acute LBP and new workers� compensation claims, patients who had high work-related fear-avoidance beliefs, demonstrated by an average score of 5 or 6 on item 10 (�my work makes or would make my pain worse�) and item 11 (�my work might harm my back�), were 4.6 times more likely to be on work disability six months after injury than patients whose average score was lower than 3 on the same questions.2

25. Application of General Health Questionnaires (GHQ)� The application of a GHQ can be used at the following intervals: At the time of the initial presentation for baseline establishment of outcomes assessment. To identify problems for prompt management. At a plateau in care or discharge for outcomes assessment of the treatment benefits or lack thereof. Six months after discharge in order to evaluate the long-term benefits of treatment.

26. SF 36 and SF 12General Health Questionnaire� These 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). �

27. Outcomes Study BPICA has started to perform some initial studies to evaluate the effectiveness of chiropractic care and individual doctors in the management of low back pain patients. We will review these finding at the end of the weekend.

28. QUESTIONS?