FROM: American Chiropractor 2011 (May): 33 (5): 28–34
by Steven Yeomans, D.C.
Today more than ever, chiropractors are faced with the challenge of running a busy practice and, at the same time, juggling the documenting requirements in light of Medicare audits, proving “medical necessity” to private insurers, and producing documentation that minimizes risk in this litigious world. The requirement of creating a legible, concise account of the patient encounter that includes patient centered functional goals and methods of tracking functional improvements that occur during care, emphasizes the need for the inclusion of outcomes assessment tools in the documentation process. The goal of this article is to provide you with the “knowledge ammunition” needed to accomplish this task without expending volumes of time and effort.
Outcomes assessment tool availability is not a new concept. Back in the 1970’s, long, impractical outcomes tools surfaced that were too cumbersome for routine use in a primary care setting, but shortly thereafter, in 1980, Fairbank introduced the Oswestry (Low Back) Disability Index (ODI). An interesting point is that the original purpose of the ODI was to identify patients that may require “…positive intervention” in the form of psychological care when scores exceeded 60% (defined as “crippled”).
However, it was (also) found to be an effective tool to be used in serial manner to show patient progress over time and identify endpoints of care or plateaus in progress, prompting a change in the treatment planning for the patient. This was followed by other “gold standard” tools including the Roland-Morris Low Back Disability Questionnaire in 1984, and the chiropractic contribution of Vernon and Mior’s Neck Disability Index in 1988.
A gradual increase in the use of these tools occurred in the 1990’s with introduction of many other condition specific tools for headaches, dizziness, carpal tunnel, shoulder pain, hip, knee, and ankle pain, as well as general health tools, and psychometric tools for depression and anxiety assessment. In fact, there are now so many tools available, it may be quite a challenge to decide which ones are most important.
Because chiropractic is generally considered a non-surgical, non-pharmaceutical, form of health delivery with an emphasis in treating neuromusculoskeletal complaints, there are two main domains or areas of importance to track. These include pain, since pain drives patient satisfaction and also drives people into our offices, and functional scales that measure activity tolerance. However, as primary care providers, we have to consider the whole person, not just the biological portion and, hence, tracking psychosocial issues became strongly recommended in the early 1990’s.
It became clear in the literature during the 1990’s and 2000’s that barriers to recovery were not due to a “bad sprain or disc condition” (i.e., the “biological” issues), but rather things like depression, anxiety, coping, and fear-avoidance of activity have consistently been found to impede recovery. In order to embrace this “biopsychosocial model,” the concept of designing one questionnaire to cover all three domains (pain, disability/activity tolerance, and psychosocial issues), a multi-domain, “hybrid” questionnaire was introduced.
First introduced in 1999, is a short, easy to complete (for the patient) and score (for the health care provider) hybrid instrument called the Back-Bournemouth Questionnaire (BQ) was introduced that truly embraced the biopsychosocial model. This was unique, as it tracked these three important domains or categories (anxiety, depression and locus of control).
The importance of this contribution cannot be over emphasized, as this allows the health care provider to quickly identify those that are more likely to fail to respond to treatment due to psychometric barriers to recovery and promotes prompt management options (an emphasis of active care and promotion of self-management) for this more challenging patient. A neck specific version of the BQ was introduced in 2001 (Neck-Bournemouth Questionnaire), again, including the three domains of pain, activity tolerance, and psychosocial factors.
There are seven questions, each of which the patient circles a number on a 0-10 scale (0=low score and 10=highest score). Scoring the tool is simple: total up the patient’s score and divide by the maximum possible, which is usually 70 (if the patient completes all seven questions). The “formula” is:
PT SCORE/MAXIMUM POSSIBLE (70) X 100 = _____% or, for example, 38/70 X 100 = 54%.
Another condition specific tool that I can highly recommend at this time includes the Patient Specific Functional Scale (PSFS). This tool is unique, as the patient selects as many affected activities of daily living (ADL’s), as desired to rate on a 0-10 scale, so it might include sitting more than five minutes, walking up steps, turning the head to check traffic, and work related activities. It can include as few as one item or more (there is no limit). This is as “patient centered” as possible, since the patient is not prompted to answer specific questions about any one complaint or condition, and it is GREAT for patient specific goal setting. Scoring is simple, as the patient’s total is divided by the maximum possible score (70 when all 7 items are completed) times 100 (use the same scoring method which was reported for the Back or Neck Bournemouth Questionnaire).”
These tools can be repeated once every 1-2 weeks in the acute care stage to 1x/month in the subacute phase of care. When no change is noted in the score, the healthcare provider is prompted to modify the treatment plan by either changing the approach, adding a different service, discharge with residuals or, possibly, co-manage or refer for complementary services. That’s the concept of outcomes management which, in my experience, requires three specific steps:
Identify and use outcomes assessment tools that match your patient’s needs.
Score the questionnaire and place that score on a “scorecard” of some sort so the changes that take place can be quickly identified.
Based on the change (or lack thereof) in the score, make clinic treatment plan decisions to optimize patient condition resolution and patient independence that may include self-care.
HOW TO IMPLEMENT AN EVIDENCE-BASED DOCUMENTATION SYSTEM INTO A BUSY CLINICAL SETTING
Hold a CA staff meeting explaining the importance of outcome assessment tools (OATs) prior to or shortly after implementing the tools (warn them about probable patient resistance of completing paper work).
a) Stress the point to patients: “Insurers are beginning to require proof for the need of care. By completing and scoring these forms, we can most effectively prove this to the insurer.”
b) Discuss other important reasons for using OATs.
“If you’re injured in the future, we will be able to compare your present status to your past, to prove that further injury has occurred. After completing care, we will both know if you’ve returned to a pre-accident level of function.” This is especially important in car accident cases, personal injury cases, new insurance—not willing to cover pre-existing conditions, etc.).
Give the new patient a clipboard including all your intake forms on their first visit. DO NOT allow them to sit in your front office filling out forms for more than 15 minutes (pre-appointment time period—due to poor attention span which reduces the quality of the information).
The clipboard follows the patient around from exam room to treatment room to X-ray room, to PT room. In most cases, patients will complete the forms prior to the conclusion of their first visit. They may take home the remaining forms if they do not complete them all (expect about a 50% return rate, in which case, re-administer uncompleted forms at the 2nd visit). When you enter to examine the patient, THANK them for taking care when completing the forms, and explain the importance of tracking care accurately—to promote patient compliance.
Possible Outcome Assessment scenarios:
I. A plateau (Max. Therapeutic Benefit OR MTB) short of pre-injury resolution has been reached:
a. Refer for further tests & services.
b. Wean care to justify supportive care (determine if patient’s condition deteriorates with reduced care frequency).
c. Discharge with or without Permanent Partial Disability (PPD) ONLY if applicable.
d. Explain to patient, care may be required when home-based therapies are non-satisfying.
II. A plateau has not been established (frequent remission/exacerbations).
Consider additional forms of care including:
a. Home-based exercise program.
b. If already implemented, in-office rehab with pre- and post- Quantitative Functional Capacity Evaluation (QFCE) to objectively support the “medical necessity.”
c. Co-treatment with allied health care providers, especially if no in-office rehab available.
d. Patient’s Outcomes Assessment Tools (OATs) scores are worsening.
1. Review patient’s history for exacerbations.
2. Discuss with patient outside/homework physical demands & tolerance.
3. Consider ergonomic factors/work station evaluation.
4. Consider poor patient compliance.
5. Consider inappropriate care (iatrogenic cause).
e. Prove the long-term benefits of chiropractic care by sending the patient the same OATs forms at a 6- and/or 12-month point post-discharge. This will also serve as an excellent patient recall/reminder, if their condition is unstable/failing/recurrent (see Table 2).
Outcomes Assessment (SUBJECTIVE)
Overview: Which tool(S) to utilize?
a. An immediate practical challenge for the clinician is to determine which instrument or instruments would be most optimal in assessing specific outcomes.
b. Table 1 offers an abridged summary of the goals of the outcomes assessment tool and several instruments from wich one may choose. As you can see, up to 4 tools in total are recommended to be used initially. However, this recommendation has been modified over the years and currently, I suggest that only the pain and condition specific/hybrid tools be considered. Omitting the General Health tool is wise as it is not sensitive / responsive to short-term changes in patient status. Also, I recommend a pain diagram be photocopied onto the opposite side of the Bournemouth Questionnaires. I usually ask the 4 QVAS (Quadruple Visual Analogue Scale) questions verbally, as I’m taking the patient’s history initially and on daily office visits, so that eliminates the need for a separate form (one less form for the patient to complete). Hence, the Patient Specific Functional Scale (PSFS) and the Neck/Back Bournemouth Questionnaires (BQ’s) (with the pain diagram photocopied on the back side) are my primary outcome measures utilized currently. Once an instrument is chosen, it should be utilized throughout the remainder of the patient's care, since these instruments are not interchangeable. Care should be exercised in avoiding duplication of instruments and goals.
General Categories of Questionnaires:
Refer to tables 1 & 2
Table 1 is a partial list of categories of outcomes assessment instruments and their respective goals.
* Only parts of the questionnaire relate to the categories.
** These are physical examination procedures, not questionnaire tests.
WHEN SHOULD THE TOOLS BE USED?
NOTE: Once an instrument is selected for use in the clinical setting, deciding when it should be used is another challenge. To assist in answering this question, case management may be broken down into the following stages:
1. Initial/Base line
3. At times of exacerbation
4. At the conclusion or discharge of the case
TABLE 2 offers suggestions for when these various instruments could be applied. This is a summary of the OATs and when to apply them An "X" represents when the instrument category could be used during case management. Make sure to stay with your initial or baseline choice for all follow-up evaluations, as the instruments are not interchangeable.