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Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach

Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach. Presenters: David Berbrayer , MD, Amy Houtrow , MD, PhD, MPH; Armando Miciano, MD; M. Elizabeth Sandel , MD (Director); Deepthi Saxena , MD. 2014 AAPMR Annual Assembly, San Diego CA, 2014 Nov 15.

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Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach

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  1. Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach Presenters: David Berbrayer, MD, Amy Houtrow, MD, PhD, MPH; Armando Miciano, MD; M. Elizabeth Sandel, MD (Director); DeepthiSaxena, MD 2014 AAPMR Annual Assembly, San Diego CA, 2014 Nov 15

  2. Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach Learning objectives: 
1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics 
2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations 
3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

  3. Outcome Core Set – Chronic Low Back Pain Section Presenter: Armando Miciano, MD Nevada Rehabilitation Institute Las Vegas, NV 2014 AAPMR Annual Assembly, San Diego CA, 2014 Nov 15

  4. Disclosures • Medical Director Spring Mountain Rehab, Las Vegas NV • Practitioner – Nevada Rehabilitation Institute, Las Vegas NV

  5. Acknowledgments – CLBP QTB Subject Matter Experts: 1. David Berbrayer MD (Performance Metrics Committee member) 2. Edwin Capulong MD 3. Kush Goyal MD 4. Martin Grabois MD (Co-leader) 5. Armando Miciano MD (Clinical Practice Guideline Committee member) 6. Joshua Scheidler MD 7. Deborah Venesy MD (Co-leader)

  6. INTRODUCTION • Most common assessment: • Evaluation of underlying impairment & pathology • Specialists performing evaluations for MSK disorders will be best served when they can: • Assess the individual's functional status • Incorporate that information into their decision regarding the individual's current limitations and prognosis • In addition to the evaluation of the underlying impairment and pathology. [1] [1] Greenough CG. Eur Spine J. 2006.

  7. Functional Status • Many of the factors contributing to the evaluation of functional status are necessarily subjective • e.g. pain, physical functioning, and affective status • Nonetheless, the literature suggests that inclusion of functional assessment into the [MSK] disability determination using a patient-centered approach may provide the factors that are most potent with respect to patient prognosis and care planning. [1] [1] Linn RT, Granger CV, et al. Phys Med RehabilClin N Am. 2001.

  8. How should clinicians measure “Patient-centered Outcomes?”INTRODUCTION – Performance Metrics • DEFINITION: The field of developing, evaluating & applying measurement instruments • Undergone considerable progress in MSK medicine [1]. [1] Mooney V, et al. Spine J. 2010 May;10(5):433-40.

  9. INTRODUCTION – Progress in Performance Metrics • How is recovery from low back pain measured? A systematic review of the literature • BACKGROUND: • No accepted definition of what recovery involves or guidance as to how it should be measured. • OBJECTIVE: • To appraise the LBP literature (last 10 years) to review the methods used to measure recovery. • RESEARCH DESIGN: • All prospective studies of subjects with non-specific LBP that measured recovery as an outcome Kamper SJ, et al. Eur Spine J. 2011.

  10. INTRODUCTION – Progress in Performance Metrics • How is recovery from low back pain measured? A systematic review of the literature • RESULTS: • 82 included studies used 66 different measures of recovery • 17 measures used pain as a proxy for recovery, • 7 used disability or function • 17 based on a combination of two or more constructs. • 9 single-item recovery rating scales • 11 studies used a global change scale that included an anchor of ‘completely recovered’ • 3 measures used return to work as the recovery criterion • 2 used time to insurance claim closure • 7 used physical performance Kamper SJ, et al. Eur Spine J. 2011.

  11. INTRODUCTION – Which PRO to use? • How is recovery from low back pain measured? A systematic review of the literature • CONCLUSIONS: • Almost every study that measured recovery from LBP in the last 10 years did so differently • Lack of consistency makes interpretation & comparison of the LBP literature problematic. • That the failure to use a standardized measure of recovery is due to the absence of an established definition Kamper SJ, et al. Eur Spine J. 2011.

  12. Another Challenge • Despite progress in PERFORMANCE METRICS, the appreciation of the complex interrelationship between: • Physical • Psychological • Social effects of MSK disorders is incompletely explored in clinical practice. [1] [1] Mayer T, et al. Spine J. 2003 May-Jun;3(3 Suppl):28S-36S. Review.

  13. LEARNING KEY POINT *THE ICF Model International Classification of Functioning, Disabilities, and Health: ICF. 2001. Source: World Health Organization (2001) International Classification of Functioning, Disability and Health (ICF), Geneva: World Health Organization.

  14. Impairments: problems in body function or structure such as significant deviation or loss • Activity limitations: difficulties an individual may have in executing activities. • Participation restrictions: problems an individual may experience in involvement in life situations. Rondelli, RD.  PM&R. 2009.

  15. Tools in the Quality Toolbox (QTB) • Assessment instruments • Quality metrics • Patient education materials • Checklists • Review articles • Knowledge Now articles • Clinical practice guidelines • Core constructs specific for the health condition

  16. QTB: Review Articles • 1. Chapman JR, Norvell DC, et al. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1; 36(21 Suppl):S54-68. • 2. Cleland J, Gillani R, Bienen EJ, Sadosky A. Assessing dimensionality and responsiveness of outcomes measures for patients with low back pain. Pain Pract. 2011 Jan-Feb; 11(1):57-69. • 3. DeVine J, Norvell DC, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S69-74. • 4. Deyo RA, Dworkin SF, et al. Report of the NIH Task Force on research standards for chronic low back pain. Pain Med. 2014 Aug; 15(8):1249-67. • 5. Freiberger E, et al. Performance-based physical function in older community-dwelling persons: a systematic review of instruments. Age Ageing 2012; 41: 712–721. • 6. Ghogawala Z, Resnick DK, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome following lumbar fusion. J Neurosurg Spine. 2014 Jul; 21(1):7-13. • 7. McCormick JD1, Werner BC, Shimer AL. Patient-reported outcome measures in spine surgery. J Am AcadOrthop Surg. 2013 Feb;21(2):99-107. • 8. Schoenfeld AJ, Bono CM. Measuring spine fracture outcomes: common scales and checklists. Injury. 2011 Mar;42(3):265-70.

  17. QTB: Review Articles

  18. QTB: Review Articles, contd.

  19. Key Psychometric Properties of a Health Status Instrument Spertus JA. Circulation. 2008.

  20. COSMIN taxonomy of relationships of measurement properties Adapted from: Mokkink LB, et al. Qual Life Res. May 2010; 19(4): 539–549.

  21. QTB: PMR Knowledge NOW * • Carayannopoulos A. Discogenic Lumbar Pain. In: PMR Knowledge NOW [Internet]. 2011 Nov 10 [modified 2013 Jan 24]. c2014 AAPMR. Accessed 10/22/14 at: http://me.aapmr.org/kn/article.html?id=176 • Everett CR, Ramirez C, Perkowski M. Lumbar Disc disorders. In: PMR Knowledge NOW [Internet]. 2013 Sep 20. c2014 AAPMR. Accessed 10/22/14 at: http://me.aapmr.org/kn/article.html?id=133 • Nance PW, Chen H. Lumbar stenosis. In: PMR Knowledge NOW [Internet]. 2012 Jul 20 [modified 2013 Jan 23]. c2014 AAPMR. Accessed 10/22/14 at: http://me.aapmr.org/kn/article.html?id=137 • Spires MC. Inflammatory Arthritides. In: PMR Knowledge NOW [Internet]. 2011 Nov 10 [modified 2012 Dec 27]. c2014 AAPMR. Accessed 10/22/14 at: http://me.aapmr.org/kn/article.html?id=82 * Selected ones with discussion on Functional Assessment tools

  22. QTB: Clinical Practice Guidelines • North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. c2012 NASS. Accessed 10/22/14 at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf • North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. c2011 NASS. Accessed 10/22/14 at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf • North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. c2008 NASS. Accessed 10/22/14 at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/Spondylolisthesis.pdf • American Academy of Orthopedic Surgeons (AAOS). Treatment of Symptomatic Osteoporotic Spinal Compression Fractures. 2010. Accessed 10/22/14 at: http://www.aaos.org/research/guidelines/SCFguideline.pdf

  23. QTB: Clinical Practice Guidelines

  24. Constructs for core sets (for choice of assessment instruments) • 1. Symptom quality • 2. Pain-related impairment • 3. Life satisfaction • 4. Global health status • 5. Work productivity [1] Bombardier C. Spine (Phila Pa 1976). 2000.

  25. QTB: Assessment InstrumentsPRO vs. PBA • PRO = Patient-Reported Outcomes – from the “patient” • PBA = Performance Based Assessment - medical search term used also as outcome measures - clinician-derived objective tests

  26. Patient-Reported Outcomes (PRO) • ICF component 1: body function/structure a. Numerical Rating Scale (NRS) – body pain b. NRS – leg pain • ICF component 2: activity a. Generic: 1. Pain Disability Questionnaire (PDQ) b. Disease-specific: 1. Oswestry Disability Index (ODI) 2. Roland Morris Disability Questionnaire (RMDQ) • ICF component 3: participation a. PROMIS-57 v1.0 i. PROMIS-57 Physical function subscale ii. PROMIS-57 Pain Impact b. Work Productivity & Activity Impairment: General Health (WPAI: GH) v2.0

  27. Performance-based Assessment (PBA) a. ICF component 1: body function/structure i. Lumbar Range of motion test ii. Backache Index (BAI) b. ICF component 2: activity i. 6-Minute Walk Test c. ICF component 3: participation i. Short Physical Performance Battery

  28. ICF Conceptual Framework: Outcome Measures used in Practice– Chronic Low Back Pain

  29. ICF Conceptual Framework: Outcome Measures - Low Back Dysfunction

  30. Constructs for Core Sets (for choice of assessment instruments)

  31. Minimal clinically important improvement (MCII) • Definition: • the smallest clinical change that is important to patients, and recognizes the fact that there are some treatment-induced statistically significant improvements that are too small to matter to patients. • Also as Minimal clinical important difference (MCID) Accessed 05/25/14 at: http://www.aaos.org/research/guidelines/SCFguideline.pdf

  32. MCII Accessed 10/23/14 at: http://www.aaos.org/research/guidelines/SCFguideline.pdf

  33. QTB: Quality Metrics • To qualify for the 2014 PQRS incentive payment, Physiatrists must report on at least 9 individual measures covering 3 National Quality Strategy (NQS) domains for at least 50 percent of your Medicare Part B FFS patients seen during the reporting period. • Alternatively, you can report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients. Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

  34. QTB: Quality Metrics I. Measure Group 1. PQRS # 148-151, Back Pain Measures Group II. Individual Measures 1. Patient Safety domain: a. PQRS #130, Documentation of Current Medications in the Medical Record b. PQRS #154, Falls: Risk Assessment 2. Communication and Care Coordination domain: a. PQRS #182, Functional Outcome Assessment b. PQRS #131, Pain Assessment and Follow-Up c. PQRS #155, Falls: Plan of Care d. PQRS #24, Osteoporosis: Communication with the Physician Managing On- going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older e. PQRS #47, Advance Care Plan 3. Clinical Process and Effectiveness domain: a. PQRS #39, Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older b. PQRS #40, Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older c. PQRS #41, Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older 4. Population Health domain: a. PQRS #128, Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up b. PQRS #134, Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

  35. QTB: Quality Metrics I. Measure Group 1. PQRS # 148-151, Back Pain Measures Group II. Individual Measures 1. Patient Safety domain: a. PQRS #130, b. PQRS #154, 2. Communication and Care Coordination domain: a. PQRS #182, b. PQRS #131, c. PQRS #155, d. PQRS #24, e. PQRS #47, 3. Clinical Process and Effectiveness domain: a. PQRS #39, b. PQRS #40, c. PQRS #41, 4. Population Health domain: a. PQRS #128, b. PQRS #134 Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

  36. What we learned today: Learning objectives: 
1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics 
2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations 
3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

  37. Constructs for Core Sets (for choice of assessment instruments)

  38. Summary: Recommended PRO for practical use • Numerical Rating Scale (NRS) – body pain; and, NRS – leg pain • Pain Disability Questionnaire (PDQ) • Oswestry Disability Index (ODI) or Roland-Morris Disability Questionnaire (RMDQ) • PROMIS-57 v1.0 • Work Productivity & Activity Impairment: General Health (WPAI: GH) v2.0

  39. Thank You. • Contact Info: Armando Miciano, M.D. Nevada Rehabilitation Institute, Las Vegas NV www.springmountainrehab.com 702-869-4401 drmiciano@me.com

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