Patient Reported Outcomes Can Measure Value: A Clinician’s Perspective

Physical therapy adds value to the healthcare system. As defined in our first post on effectiveness, value can be defined as improving our patient’s quality of life and function (i.e., effectiveness) while minimizing treatment costs and healthcare visits (i.e., efficiency).¹ 

After decades of collecting outcomes, I would like to share with you my clinical thoughts for enhancing treatment effectiveness and value by collecting and integrating patient self-report outcome (PRO) data to guide patient management during routine clinical practice.  

Whose Value do we measure? 

Although there appears to be growing consensus among stakeholders in healthcare that value is necessary for improving quality of care and controlling costs, whose value should we be measuring? Different stakeholders have different views for measuring value. For instance, the payer may define value as the fewest number of treatment visits, the employer describes value as an employee who forgoes sick time and continues to work full time/full duty, a physical therapist may document value as improved range of motion or increased muscle strength, or the patient may view value based on changes in his or her quality of life. Clinical practice guidelines, policy makers, and physical therapy associations have unanimously defined value using the patient’s perspective. Sackett’s operational definition of evidence-based medicine clearly prioritizes the patients’ perceptions to define value i.e., “integration of the best research evidence with clinical expertise applied to patient values to optimize patient outcomes and quality of life to achieve the highest level of excellence in practice.”² The bottom line is that the patient plays the central role in the delivery of care and is a driving motivation for clinical education and research. 

What Measures Should Physical Therapists Use to Demonstrate Value of Care?  

The most common outcome measures utilized by physical therapists during clinical practice to justify value of their treatments are impairment and physical performance data. A principle physical therapy treatment tenet focuses on the patient’s impaired movement & motor control which are responsible for limitations in patients’ physical function; optimal care addresses these impairments. If physical therapy interventions focus on resolving the patients’ impairment, then can it be assumed that impairment and performance measures should provide the best tools to document value and patient outcomes?  The evidence suggests otherwise. Both impairment and physical performance may not adequately capture the breadth of health concepts associated with a patient’s perceived functional ability, can be time consuming to measure, and/or are often associated with inadequate reliability/validity data. Despite the evidence, many physical therapists cite restoration of function as primary treatment goals, yet never measure function. Too often, impairment measures are used as a proxy to infer function for evaluating treatment and value of care.   

If traditional impairment tools may not be optimal for measuring the patient’s function; what measures should we be using during every day care? There is strong support in the literature for using PRO measures. PRO is now considered a gold standard for measuring patient outcomes during routine clinical practice and are endorsed by World Health Organization, Centers for Medicare and Medicaid Services, National Quality Forum, Institute of Medicine, and other policy makers, payers, professional associations, and clinical practice guidelines. PRO data play a key role in providing best research evidence from randomized control trials and well-designed observational studies. Clinically, PROs are objective measures capturing a wide range of a patient’s health concepts and physical abilities in short amount of time. 

As healthcare changes from a volume based to value based focus, physical therapists will need to reconsider their traditional focus on impairment. Physical therapists will need to consider how to easily report patients’ function and quality of health without increasing burden and costs. Outside stakeholders will be requiring proof of value of the services provided. Since the patient is the one centralized component of the service, PRO is the solution. 

 

This post originally appeared in the 2016 issue of Advance for Physical Therapy and Rehab Medicine, 27 (3), 6-7. 

References: 

1. Porter, ME. (2010) What is Value in Health Care? NEngl J Med, 363 (26), 6-7. doi:10.1056/NEJMp1415160. 

2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. (1996) Evidence based medicine what it is and what it isn’t. BmjClinRes Ed, 312, 71-72. http://www.bmj.com/content/312/7023/71.full. 

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