Embracing Outcomes: Actionable Steps to Start Measuring Patient Success

“I’m fine.” How many times have patients walked through the door and said this? Taken at face value, “I’m fine” could be interpreted as “I’m good,” “I’m just okay,” “I’m not great,” or “I’m not fine.” Without further probing, we may miss an opportunity to make a meaningful improvement in the patient’s life. In clinical care, it can be difficult to fully uncover how a patient is feeling during a short interaction in the exam room. Outcome measures allow clinicians to dig deeper into how their patients are doing and track their progress over time. Outcome measures come in many shapes and sizes. There are subjective outcomes, such as patient stories, and there are objective outcomes that are carefully measured through patient-reported outcome measures (PROMs), performance tests, and instruments to measure activity outside the clinic. Patient stories provide context and meaning to changes we see in objective measures, filling in the gaps with the “why” behind changes in their care. Patient stories are vital to understanding an individual’s journey, however, all details aren’t always disclosed and cannot be easily measured over time. PROMs are objective questionnaires administered to patients to measure various domains of patient health. For example, the Prosthetic Limb Users Survey of Mobility (PLUS-M) or Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF) measure a patient’s ability to ambulate. PROMs typically consist of four to 20 questions with five response options to inquire about difficulty, frequency, or intensity, depending on the measure. Generally, these measures are quick to administer and have been rigorously validated against various performance measures. Performance measures are short evaluations performed in the clinic, such as a 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), or Two-Minute Walk Test (2MWT). These tests are well validated and can measure a patient’s walking speed, fall risk, and endurance, respectively. However, they typically require a large amount of space to complete, and the outcomes can be time-intensive to collect. Instrumented measures capture data about patients outside the clinic. These may be trackers to monitor step count or wear time and can be implemented through a device that a patient already wears such as a smart watch, smartphone, or pedometer. If patients already use these devices, it can be relatively easy to bring measures into patient conversations and document them in clinical notes; however, if patients do not have these devices, the start-up costs and logistics may be difficult to manage. So which outcomes are best for your patients? In an ideal world, we’d utilize both subjective and objective measures, as each type of outcome measure provides a different perspective for assessing health, function, or well-being. We want to strive to improve all areas of our patients’ lives. By solely focusing on performance measures or instrumented measures, we may optimize performance, but are we optimizing health? Patient-reported outcomes are a great first step when beginning an outcomes journey. They are measurable, valid, quick, and responsive to change in patient care. Using Outcomes for Individual Patient Care “If you can’t measure it, you can’t improve it.” – Peter Drucker Every patient interaction is an opportunity to improve a patient’s outcomes. However, this is only possible when we know how a patient is doing. Conversations with patients are a great place to start, but the challenge is synthesizing this data into an action plan. Did the patient reveal all the necessary information for making a meaningful change in his or her care? When patients say, “I’m fine,” but we see their PROMIS-PF T-score has dropped ten points since their last visit, we can use this as a starting point. For example, a patient conversation may look like this: “Mr. Smith, I see you reported that your physical function has decreased since I last saw you three months ago. Have you noticed any changes in your mobility?” “Oh. Yeah. I’ve been having a lot of pain on the front of my shin near the bottom of my limb. But I guess that’s just my life now. It starts to hurt a lot when I’m out walking my dog or at the grocery store, so I haven’t been doing that as often.” “I’m sorry to hear that. Let’s try to add some additional padding or add relief in that area. If you have pain like this in the future, come see me so we can make a change.” As in this example, patients may not be able to articulate how they are feeling or think that nothing can be done. Measurable outcomes can uncover underlying issues that can be resolved, resulting in better patient care. Additionally, regularly collecting patient outcomes can help individual patients with insurance authorization. Having data can be extremely impactful to demonstrate improvements in function to justify third-party payer approvals. It’s the difference between “This patient has K3 potential,” and “This patient has K3 potential, their self-reported mobility has increased from 43.3 to 48.4 over the past six months, and their daily step count has increased from 4,000 to 6,000 average steps per day.” In this case, the additional data can be used to justify a change in care. Having longitudinal data over time can make authorizations easier. Using Outcomes for Patient Care on the Population Level “Great things are done by a series of small things brought together.” – Vincent Van Gogh Hanger has spent more than eight years dedicating time and resources to advance evidence-based practice through clinical outcomes. This involves standardizing which outcomes to collect from our patients, how often the outcomes are collected, and how to use them to make a meaningful difference in patient care on the population level, as well as on an individual level. [caption id="attachment_251605" align="alignleft" width="324"] Chart courtesy of Hanger Institute for Clinical Research and Education.[/caption] The Hanger Institute for Clinical Research and Education has published over 30 peer-reviewed articles since its inception. These articles span a range of patient care, including the relationship between mobility and falls, patient well-being, differences in componentry, impact of device receipt, and clinical practice guidelines. The articles include data from hundreds and sometimes thousands of patients. When thinking about aggregate outcomes, we can see the large-scale effect of O&P care and tease out differences across levels of injury, etiology, and device type. We can utilize this information to empower clinical decision-making and payer policy. In 2022, Michigan Medicaid lagged behind adjacent states in O&P coverage. Commonly utilized Healthcare Common Procedure Coding System codes describing hip orthoses, elbow orthoses, alignable systems, ultralight materials, flexible inner sockets, multiaxial rotation units, vertical loading pylons, and microprocessor knees were not covered. In addition, the only K3 foot in the fee schedule was L-5980. It was common for Michigan Medicaid to respond to authorization requests stating that other codes were considered equivalent or comparable to L-5980. In response to this claim, the Michigan O&P Association cited Hanger’s MAAT V study to argue that L-5980 is not equivalent to other K3 feet L-Codes. MAAT V demonstrated significant differences across L-Codes for K3 feet. Because of this research, additional L-Codes were added to the fee schedule in 2023. This change in policy was only possible due to clinicians and patients dedicating time to collecting outcomes. Outcomes can help patients on an individual level, but collected over time and with a large number of individuals, outcomes can help patients on a population level. Tips and Tricks to Start Collecting Outcomes “A journey of a thousand miles begins with one step.” – Lao Tzu Choose an outcome measure. Depending on your patient population, select an appropriate measure to track the domain(s) of health that are most important to that population. The PLUS-M 1 and Orthotic Patient-Reported Outcomes-Mobility (OPRO-M) 2 are mobility measures specific to prosthesis and orthosis users, respectively. Alternatively, there are general measures from PROMIS to measure physical, mental, and social health categories for any patient population. 3 PROMIS measures can also be customized to better suit the patients you see. For example, the PROMIS-9 UE was developed to measure physical function specifically for patients with upper-limb amputations. 4 The easiest measures to start with are PROMs; however, performance measures such as the TUG, 10MWT, or 2MWT, or instrumented measures such as step count or wear time, may also be appropriate. Because PROMs are patient-reported measures, it is typically easiest to start with these to reduce clinician time with outcomes collection and, more importantly, capture the patient’s firsthand experience/feedback. Collect longitudinal outcomes. For the greatest impact, collect outcomes before and after a change in care. This is typically at an evaluation appointment, then at a two-week or one-month follow-up appointment. As outcomes become routine, try collecting outcomes for all follow-up appointments or at predefined times, such as three-month and six-month follow-ups. Collecting longitudinal outcomes at regular intervals can document patient changes over time. For example, if a patient would be a good candidate for a microprocessor knee, collecting longitudinal data on his or her mobility, quality of life, and falls will be beneficial when submitting an approval request through the patient’s insurance provider. This information will also be vital after receipt of the microprocessor knee to demonstrate to the payer (and even the patient) progress with the technology. Start with paper outcomes. Paper outcome measures allow for low start-up cost and can make it easier to start the process. Getting started can be as easy as printing out the selected outcome measures, attaching them to a clipboard, and placing them in patient rooms. Encourage patients to fill out the papers while they are waiting. Digital outcome measures and integration into patient electronic health records can be a later step. Build a team of outcomes champions. If your clinic regularly trains residents, utilize their talents to assist with collecting outcomes. Residents can assist with collecting outcomes, digitalizing paper outcome measures, synthesizing data, and running analyses. If your clinic does not have many residents, consider reaching out to local university students (keeping in mind HIPAA compliance). Students in statistics, biology, or engineering programs may love the opportunity to work with real-world data. Empower patients to complete outcomes. An outcome measure may feel like another form to complete during an appointment, but it is essential to communicate the importance of the measures to patients. Explain why outcomes are essential for their care—outcomes can help with insurance coverage, goal setting, tracking progress, and celebrating milestones. And explain why outcomes are essential for the care of other patients and that outcomes can facilitate changing insurance policies, defining goals, and understanding the impact O&P care has on patient health. Taking the time to describe the power of outcomes ensures the data being collected is high quality. Starting to collect outcomes can feel like a daunting task, but the result is worth it. Patient care can only be improved if we have a measurable starting point and a goal to aim toward. Every patient outcome is an opportunity to improve clinical care for that individual patient and every patient that walks through the door. Bretta L. Fylstra, PhD, is a research scientist with the Hanger Institute for Clinical Research and Education. She can be contacted at bfylstra@hanger.com. References https://plus-m.org https://www.healthmeasures.net/index.php https://hangerclinic.com/wp-content/uploads/scoring-instrument-9-item-PROMIS.pdf

Embracing Outcomes: Actionable Steps to Start Measuring Patient Success

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