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

Learning objectives:1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

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

Outcome Core Set – Chronic Low Back Pain

Section Presenter: Armando Miciano, MDNevada Rehabilitation Institute

Las Vegas, NV

2014 AAPMR Annual Assembly, San Diego CA, 2014 Nov 15

Medical Director Spring Mountain Rehab, Las Vegas NV

Practitioner – Nevada Rehabilitation Institute, Las Vegas NV

Disclosures

1. David Berbrayer MD (Performance Metrics Committee member)

2. Edwin Capulong MD3. Kush Goyal MD4. Martin Grabois MD (Co-leader)5. Armando Miciano MD (Clinical Practice

Guideline Committee member)6. Joshua Scheidler MD7. Deborah Venesy MD (Co-leader)

Acknowledgments – CLBP QTB Subject Matter Experts:

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]

INTRODUCTION

[1] Greenough CG. Eur Spine J. 2006.

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]

Functional Status

[1] Linn RT, Granger CV, et al. Phys Med Rehabil Clin N Am. 2001.

DEFINITION: The field of developing, evaluating &

applying measurement instruments

Undergone considerable progress in MSK medicine [1].

How should clinicians measure “Patient-centered Outcomes?”

INTRODUCTION – Performance Metrics

[1] Mooney V, et al. Spine J. 2010 May;10(5):433-40.

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

INTRODUCTION – Progress in Performance Metrics

Kamper SJ, et al. Eur Spine J. 2011.

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

INTRODUCTION – Progress in Performance Metrics

Kamper SJ, et al. Eur Spine J. 2011.

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

INTRODUCTION – Which PRO to use?

Kamper SJ, et al. Eur Spine J. 2011.

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]

Another Challenge

[1] Mayer T, et al. Spine J. 2003 May-Jun;3(3 Suppl):28S-36S. Review.

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.

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.

Review articles Knowledge Now articles

Clinical practice guidelines

Core constructs specific for the health condition

Assessment instruments

Quality metrics Patient education materials

Checklists

Tools in the Quality Toolbox (QTB)

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 Acad Orthop 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.

QTB: Review Articles

Outcome Measures Considerations

Chapman JR, et al. Spine. 2011

VAS, NRPSODI, RMDQ.SF-36EQ-5D or SF-6D.Psychosocial tests

validity, reliability, & responsiveness to change

Cleland J, et al.Pain Pract. 2011

Roland Morris Disability Questionnaire, Oswestry Disability Index

the most comprehensively validated measures with respect to responsiveness.

DeVine J, et al. Spine. 2011

VASODISF-12, EQ-5D

Strength of rec: strong

Deyo RA, et al. Pain Med. 2014

PROMIS A Report of the NIH Task Force (Expert Panel)

QTB: Review Articles

Outcome Measures Considerations

Freiberger E, et al. Age Ageing 2012

Short Physical Performance Battery

Physical Performance Test

Continuous Scale Physical Functional Performance.

validity, reliability and responsiveness,

Ghogawala Z, et al. J Neurosurg Spine. 2014

ODISF-36 and the SF-12

For fusion cases

McCormick JD, et al. J Am Acad Orthop Surg. 2013

VAS-back, VAS-legODI, RMDQEQ-5D, SF

ODI & RMDQ with established MCID

Schoenfeld AJ, et al. Injury. 2011

VASODI, RMDQSF-36

QTB: Review Articles, contd.

Measurement Property Description

Validity The measure quantifies what it is intended to (face validity), represents all important content of the construct (content validity), and is empirically demonstrated to be associated with the construct it was designed to measure (criterion validity)

Reliability Reproducible results are obtained when the measure is repeatedly given to stable patients

Responsiveness The measure is sensitive to clinical change

Interpretable A clinical framework is available to interpret cross-sectional and longitudinal changes in scores

Translations exist Linguistically and culturally appropriate translations are available so that multiple patients, from different countries and cultures, can be pooled for analysis

Key Psychometric Properties of a Health Status Instrument

Spertus JA. Circulation. 2008.

COSMIN taxonomy of relationships of measurement properties

Adapted from: Mokkink LB, et al. Qual Life Res. May 2010; 19(4): 539–549.

1. 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

2. 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

3. 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

4. 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

QTB: PMR Knowledge NOW *

* Selected ones with discussion on Functional Assessment tools

1. 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

2. 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

3. 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

4. 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

QTB: Clinical Practice Guidelines

NASS: Lumbar Disc Herniation w/ Radiculopathy

NASS:Spinal Stenosis

NASS:Spondylolisthesis

AAOS:Compression FX

“Refer to a publication entitled Compendiumof Outcome Instruments for Assessment and Research of Spinal Disorders.

“Refer to a publication entitled Compendium of Outcome Instruments for Assessment and Research ofSpinal Disorders.”

The Zurich Claudication Questionnaire (ZCQ)/Swiss Spinal Stenosis Questionnaire (SSS), Oswestry Disability Index (ODI),

Likert Five-Point Pain Scale

36-Item Short Form Health Survey (SF-36)

Pain – VAS (0-100)

Pain – NRS (0-10)

Oswestry Disability Index

Roland-Morris Disability Questionnaire

SF-36 Physical Component Summary

AQoL

EQ-5D

QTB: Clinical Practice Guidelines

1. Symptom quality2. Pain-related impairment 3. Life satisfaction4. Global health status5. Work productivity

Constructs for core sets (for choice of assessment instruments)

[1] Bombardier C. Spine (Phila Pa 1976). 2000.

PRO = Patient-Reported Outcomes – from the “patient”

PBA = Performance Based Assessment - medical search term used also as

outcome measures - clinician-derived objective tests

QTB: Assessment InstrumentsPRO vs. PBA

I. ICF component 1: body function/structurea. Numerical Rating Scale (NRS) – body painb. NRS – leg pain

2. ICF component 2: activitya. Generic:

1. Pain Disability Questionnaire (PDQ)

b. Disease-specific: 1. Oswestry Disability Index (ODI) 2. Roland Morris Disability Questionnaire (RMDQ)

3. ICF component 3: participationa. 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

Patient-Reported Outcomes (PRO)

a. ICF component 1: body function/structurei. Lumbar Range of motion testii. Backache Index (BAI)

b. ICF component 2: activityi. 6-Minute Walk Test

c. ICF component 3: participationi. Short Physical Performance Battery

Performance-based Assessment (PBA)

Body Functions & Structures

PRO:

NRS – body pain;

NRS – leg pain

Activity

PRO:

Generic: PDQ;

Disease-specific:

ODI, RMDQ

Participation

PRO:

PROMIS-57

WPAI:GH

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

Body Functions & Structures

PBA:

Lumbar ROMBackache

Index

Activity

PBA:

6-Minute Walk Test

Participation

PBA:

Short Physical Performance

Battery

ICF Conceptual Framework: Outcome Measures - Low Back Dysfunction

Symptom quality

Pain-related Impairment

Life Satisfaction

Global Health Status

Work Productivity

a. Numerical Rating Scale (NRS) – body pain

b. NRS – leg pain

Generic: i. Pain

Disability Questionnaire

Disease-specific: ii. Oswestry

Disability Index;

ii. Roland Morris Disability Questionnaire

PROMIS-57 - Satisfaction with Social Role

a. PROMIS-57 Physical Function

b. PROMIS-57 Pain Impact

Work Productivity & Activity Impairment: General Health (WPAI: GH)

Constructs for Core Sets (for choice of assessment instruments)

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)

Minimal clinically important improvement (MCII)

Accessed 05/25/14 at: http://www.aaos.org/research/guidelines/SCFguideline.pdf

Outcome Measures MCII (points)

Pain – VAS (0-100) 15

Pain – NRS (0-10) 2

Oswestry Disability Index 10

Roland-Morris Disability Questionnaire

5

PROMIS-57 Not reported

WPAI: GH Not reported

MCII

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

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.

QTB: Quality Metrics

Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

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 Recordb. PQRS #154, Falls: Risk Assessment

2. Communication and Care Coordination domain:a. PQRS #182, Functional Outcome Assessmentb. PQRS #131, Pain Assessment and Follow-Upc. PQRS #155, Falls: Plan of Cared. 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 Oldere. 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 Olderb. PQRS #40, Osteoporosis: Management Following Fracture of Hip, Spine or Distal

Radius for Men and Women Aged 50 Years and Olderc. PQRS #41, Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years

and Older4. 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

QTB: Quality Metrics

Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

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

QTB: Quality Metrics

Accessed 10/23/14 at: http://www.aapmr.org/research/PQRS/Pages/default.aspx

Learning objectives:1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

What we learned today:

Symptom quality

Pain-related Impairment

Life Satisfaction

Global Health Status

Work Productivity

a. Numerical Rating Scale (NRS) – body pain

b. NRS – leg pain

Generic: i. Pain

Disability Questionnaire

Disease-specific: ii. Oswestry

Disability Index;

ii. Roland Morris Disability Questionnaire

PROMIS-57 - Satisfaction with Social Role

a. PROMIS-57 Physical Function

b. PROMIS-57 Pain Impact

Work Productivity & Activity Interference: General Health (WPAI: GH)

Constructs for Core Sets (for choice of assessment instruments)

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

Summary: Recommended PRO for practical use

Contact Info:

Armando Miciano, M.D. Nevada Rehabilitation Institute, Las Vegas NV

www.springmountainrehab.com 702-869-4401

[email protected]

Thank You.