Using feedback on patient health outcomes to improve orthopaedic physical therapist practice: a quality improvement study.

OBJECTIVE: Measuring health outcomes plays an important role in patient-centred healthcare. When aggregated across patients, outcomes can provide data for quality improvement (QI). However, most physical therapists are not familiar with QI methods based on patient outcomes. This mixed-methods study aimed to develop and evaluate a QI programme in outpatient physical therapy care based on routinely collected health outcomes of patients with low-back pain and neck pain. METHODS: The QI programme was conducted by three teams of 5-6 physical therapists from outpatient settings. Plan-do-study-act cycles were used based on team-selected goals. Monthly feedback reports of process and outcomes of care, including pre-post treatment changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI), guided the QI efforts. Primary outcomes were pre-QI and post-QI changes in knowledge and attitudes towards outcome measures through a survey, and administered and self-reported compliance with using the ODI and NDI. Semistructured interviews and a focus group were conducted to evaluate the perceived value of the programme. RESULTS: Post-QI, the survey showed improvements in two items related to the role of patients and implementation of outcome measures. Registered pre-QI and post-QI completion rates were high at intake (ODI:91% pre, 88% post; NDI:75% pre, 84% post), while completion rates at discharge improved post-QI (ODI:14% pre, 66% post; NDI: 32% pre, 50% post). Perceived benefits of the QI programme included clinician and institutional accountability to processes and strategies aimed at continuous improvement in patient care. An important facilitator for programme participation was autonomy in project selection and development, while a main barrier was the time required to set up the QI project. CONCLUSION: A QI programme based on the feedback of routinely collected health outcomes of patients with low back pain and neck pain was feasible and well accepted by three pilot teams of physical therapists.

Identifying requisite learning health system competencies: a scoping review.

OBJECTIVES: Learning health systems (LHS) integrate knowledge and practice through cycles of continuous quality improvement and learning to increase healthcare quality. LHS have been conceptualised through multiple frameworks and models. Our aim is to identify and describe the requisite individual competencies (knowledge, skills and attitudes) and system competencies (capacities, characteristics and capabilities) described in existing literature in relation to operationalising LHS. METHODS: A scoping review was conducted with descriptive and thematic analysis to identify and map competencies of LHS for individuals/patients, health system workers and systems. Articles until April 2020 were included based on a systematic literature search and selection process. Themes were developed using a consensus process until agreement was reached among team members. RESULTS: Eighty-nine articles were included with most studies conducted in the USA (68 articles). The largest number of publications represented competencies at the system level, followed by health system worker competencies. Themes identified at the individual/patient level were knowledge and skills to understand and share information with an established system and the ability to interact with the technology used to collect data. Themes at the health system worker level were skills in evidence-based practice, leadership and teamwork skills, analytical and technological skills required to use a 'digital ecosystem', data-science knowledge and skill and self-reflective capacity. Researchers embedded within LHS require a specific set of competencies. Themes identified at the system level were data, infrastructure and standardisation; integration of data and workflow; and culture and climate supporting ongoing learning. CONCLUSION: The identified individual stakeholder competencies within LHS and the system capabilities of LHS provide a solid base for the further development and evaluation of LHS. International collaboration for stimulating LHS will assist in further establishing the knowledge base for LHS.

Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US.

BACKGROUND: Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs. METHODS: Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics. RESULTS: Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205). CONCLUSION: The first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.

Accrediting Graduate Programs in Healthcare Quality and Safety.

The number of master's degree programs in healthcare quality and safety (HQS) has increased significantly over the past decade. Academic accreditation provides assurance that educational programs are of a high quality and meet the needs of students, employers, and the general public. Under the guidance of the Commission on Accreditation of Healthcare Management Education, faculty from 9 universities collaborated in the development of criteria and related content domains to be used in the accreditation of graduate programs in HQS. Thirteen content domains were identified. Four of the content domains, safety and error science, improvement science and quality principles, evidence-based practice, and measurement and process improvement are thought to be foundational domains for graduate education in HQS. This article describes the development of the content domains and accompanying standards for accreditation of graduate programs in HQS.

Learning health systems from an academic perspective: establishing a collaboratory within a school of medicine and health sciences.

Learning Health Systems (LHSs) seek continuous improvement through the translation and integration of internally and externally generated knowledge across stakeholders within and external to the organization, yet current approaches are primarily described from the healthcare delivery perspective, leaving teaching and research responsibilities underexposed. Academic medical centers offer a unique perspective on LHSs because their mission includes teaching, research, and healthcare. This introduces an opportunity to enact, educate, and study processes and outcomes of LHSs within a single system. Little information is available to describe these processes and outcomes, resulting in a knowledge gap regarding the role of education and research in the quality improvement cycles and learning of LHSs. To close this knowledge gap, The George Washington University School of Medicine and Health Sciences initiated the Health Research and Education Collaboratory (GW Collaboratory) in 2017. The GW Collaboratory was established to study mechanisms supporting continuous quality improvement and learning in health systems within an academic medical center. We envision the GW Collaboratory as interconnected knowledge nodes facilitating collaboration among clinicians, patients, researchers, and educators to study the knowledge generation, dissemination, application, and evaluation required for continuous quality improvement and learning. We employ a project-based approach to foster communities of learning focused on exploring specific health problems of interest. We propose the GW Collaboratory as one model by which academic medical centers can contribute to the science of LHS.

The use of safe patient handling and mobility equipment in rehabilitation.

BACKGROUND: Increasingly, occupational and physical therapists are using safe patient handling and mobility (SPHM) equipment, such as mechanical lifts, in rehabilitation. However, there is little guidance in the literature on how SPHM equipment can be used to assist patients to reach rehabilitation goals. The purpose of this projectwas to document and categorize common and innovative ways rehabilitation therapists use SPHM equipment in their clinical practice. OBJECTIVE: This article investigates common and innovative uses of SPHM equipment in rehabilitation practice. METHODS: Occupational, physical and kinesio therapist employed at the Veterans Health Administration wrote narratives and took photos describing rehabilitation therapy activities where they used SPHM equipment in their clinical practice. The authors used a systematic process to review and categorize the narratives and subsequent photos by using the World Health Organization's International Classification of Functioning, Disability and Health (ICF). RESULTS: Thirty narratives (13 innovative and 17 common) were coded into four categories on the ICF section of mobility. The most common category was "changing and maintaining basic body position"(21) followed by "walking and moving" (5). The category "carrying, moving and handling objects" garnered two narratives and there were no narratives for "using transportation." CONCLUSIONS: Project findings may serve as a guide for therapists who would like to enhance their use of SPHM equipment in rehabilitation. Additional research is needed to expand the use of SPHM in rehabilitation practice and evaluate the impact on patient rehabilitation outcomes and therapist safety outcomes.

Comparing student outcomes in traditional vs intensive, online graduate programs in health professional education.

BACKGROUND: Health professions' education programs are undergoing enormous changes, including increasing use of online and intensive, or time reduced, courses. Although evidence is mounting for online and intensive course formats as separate designs, literature investigating online and intensive formats in health professional education is lacking. The purpose of the study was to compare student outcomes (final grades and course evaluation ratings) for equivalent courses in semester long (15-week) versus intensive (7-week) online formats in graduate health sciences courses. METHODS: This retrospective, observational study compared satisfaction and performance scores of students enrolled in three graduate health sciences programs in a large, urban US university. Descriptive statistics, chi square analysis, and independent t-tests were used to describe student samples and determine differences in student satisfaction and performance. RESULTS: The results demonstrated no significant differences for four applicable items on the final student course evaluations (p values range from 0.127 to 1.00) between semester long and intensive course formats. Similarly, student performance scores for final assignment and final grades showed no significant differences (p = 0.35 and 0.690 respectively) between semester long and intensive course formats. CONCLUSION: Findings from this study suggest that 7-week and 15-week online courses can be equally effective with regard to student satisfaction and performance outcomes. While further study is recommended, academic programs should consider intensive online course formats as an alternative to semester long online course formats.

Validation of the 2-Minute Walk Test with the 6-Minute Walk Test and Other Functional Measures in Persons with Multiple Sclerosis.

BACKGROUND: Persons with multiple sclerosis (MS) commonly have difficulty walking. The 6-Minute Walk Test (6MWT) assesses functional capacity but may be considered burdensome for persons with MS, especially those with higher disability levels. The 2-Minute Walk Test (2MWT) may be an alternative measure to the 6MWT. The purpose of this study was to investigate the validity of the 2MWT in persons with MS. METHODS: Twenty-eight ambulatory persons with MS aged 18 to 64 years participated in this cross-sectional study. Participants completed five measures of walking performance (2MWT, 6MWT, usual and fast gait speed, and Timed Up and Go test) and two functional measures (Berg Balance Scale and five-times sit-to-stand test) during a testing session. Participants were classified into two subgroups based on Disease Steps scale classification. RESULTS: The 2MWT was significantly correlated with the 6MWT (r = 0.947), usual gait speed (r = 0.920), fast gait speed (r = 0.942), the Timed Up and Go test (r = -0.911), and other functional measures. The 2MWT explained 89% of the variance seen during the 6MWT. The distances completed on the 2MWT and 6MWT accurately distinguished the subgroups. CONCLUSIONS: This study demonstrated good construct and discriminant validity of the 2MWT in persons with MS, providing an efficient and practical alternative to the 6MWT. Validation of the 2MWT with other functional measures further supports these findings.

Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs.

OBJECTIVE: To compare differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist (PT) at the first point of care, at any time during the episode or not at all. DATA SOURCES: Commercial health insurance claims data, 2009-2013. STUDY DESIGN: Retrospective analyses using two-stage residual inclusion instrumental variable models to estimate rates for opioid prescriptions, imaging services, emergency department visits, hospitalization, and health care costs. DATA EXTRACTION: Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period. PRINCIPAL FINDINGS: Compared to patients who saw a PT later or never, patients who saw a PT first had lower probability of having an opioid prescription (89.4 percent), any advanced imaging services (27.9 percent), and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization (all p < .001). These patients also had significantly lower out-of-pocket costs, and costs appeared to shift away from outpatient and pharmacy toward provider settings. CONCLUSIONS: When LBP patients saw a PT first, there was lower utilization of high-cost medical services as well as lower opioid use, and cost shifts reflecting the change in utilization.

Design for success: Identifying a process for transitioning to an intensive online course delivery model in health professions education.

Intensive courses (ICs), or accelerated courses, are gaining popularity in medical and health professions education, particularly as programs adopt e-learning models to negotiate challenges of flexibility, space, cost, and time. In 2014, the Department of Clinical Research and Leadership (CRL) at the George Washington University School of Medicine and Health Sciences began the process of transitioning two online 15-week graduate programs to an IC model. Within a year, a third program also transitioned to this model. A literature review yielded little guidance on the process of transitioning from 15-week, traditional models of delivery to IC models, particularly in online learning environments. Correspondingly, this paper describes the process by which CRL transitioned three online graduate programs to an IC model and details best practices for course design and facilitation resulting from our iterative redesign process. Finally, we present lessons-learned for the benefit of other medical and health professions' programs contemplating similar transitions. ABBREVIATIONS: CRL: Department of Clinical Research and Leadership; HSCI: Health Sciences; IC: Intensive course; PD: Program director; QM: Quality Matters.

A prospective model of care for breast cancer rehabilitation: function.

A significant proportion of adult breast cancer survivors experience deficits in function and restriction in participation in life roles that may remain many years after diagnosis. Function is a complex construct that takes into account the interactions between an individual, their health condition, and the social and personal context in which they live. Research to date on limitations in activities of daily living, upper extremity function, and functional capacity in breast cancer survivors illustrates the need for prospective measurement of function using measures that are sensitive to the unique issues of breast cancer survivors and the need for the development of effective rehabilitation interventions to improve function. Limitations in function have a significant impact on quality of life, but less is known about the implications on return to work and survival, as well as the impact of other comorbidities and aging on the function limitations in breast cancer survivors. This review provides a rationale for the integration of measures of function into breast cancer care to more fully appreciate the functional limitations associated with breast cancer diagnosis and treatment and to aid in the development of better rehabilitation care for breast cancer survivors.

Myths and facts about safe patient handling in rehabilitation.

As the incidence of injuries associated with patient-handling tasks remains high in the rehabilitation community, interdisciplinary discussions on optimal methods for preventing injuries and ensuring good care continue. A national task force consisting of representatives from the Association of Rehabilitation Nurses, the American Physical Therapy Association, and the Veterans Health Administration identified myths that have been promulgated on both sides of the discussion, focusing especially on rehabilitation practices. The purpose of this article is to dispel these myths by using evidence-based methods. Evidence should be applied in discussions of safe patient handling, and although concern about patient outcomes is critical, there is no evidence that the use of patient-handling technology undermines rehabilitation goals and strong evidence that these practices enhance the safety of rehabilitation care providers. Further research on the impact of safe patient-handling practices on rehabilitation goals and continued communication between rehabilitation providers are recommended.

Development and testing of a self-report instrument to measure actions: outpatient physical therapy improvement in movement assessment log (OPTIMAL).

BACKGROUND AND PURPOSE: Physical therapy is faced with the challenge of producing evidence that physical therapy interventions are effective. The fundamental question confronting physical therapy is whether or not physical therapy interventions make a contribution to function, health, and well-being. The individual's ability to perform actions can serve as a theoretical construct related to movement and health around which physical therapy interventions can be assessed. To this end, the aims of this study were: (1) to develop a self-report instrument to assess ability to perform mobility actions in an adult outpatient population and (2) to assess the psychometric properties of such an instrument in the appropriate population. SUBJECTS AND METHODS: An instrument was developed to assess difficulty and confidence related to 24 actions. Descriptive statistics and measures of reliability, validity, and responsiveness were computed. A total of 391 patients participated in the study. RESULTS: The coefficient for reliability was in the required range, and measures of validity and responsiveness were established as well. Three factors were identified. DISCUSSION AND CONCLUSION: The instrument provides the beginning of documentation of outcomes in movement to identify the unique contributions of physical therapist practice.