I sometimes wonder if being able to quickly predict outcomes of care will be of high importance as payment models change.
It seems that it is hugely valuable to be able to quickly know if a patient is a good fit for services. By good fit, I guess I’m being somewhat vague because I don’t really know how to be politically correct as I think of how to word my thoughts. Does every patient deserve a chance to improve? If yes, how much of a chance should be granted?
Years ago, I used to believe it was reasonable to give everyone a chance. Now I am beginning to think differently. The pressure to gain outcomes is becoming stronger and stronger. And as we are evaluated for attaining outcomes, there isn’t any pressure on patients nor on the payer to be of assistance in helping achieve the final outcome. We should all be in this together. It doesn’t seem to me that everyone involved has the same amount of skin in the game – and onus is left to the clinicians. This bothers me. It feels like we will become quickly judgmental in determining who should receive services when if we had a bit more time and visits the person just might attain anticipated improvement.
So, as I see more and more research trying to determine prognostic factors, a bulk of the factors reside within the patient and are not related to the physical impairments we are able to observe and measure. It seems that the psychological component plays a major role with regard to how much functional improvement will happen. This means we need to be very intentional with our words and very astute. I wonder if we will be more direct in discussing the factors affecting the patient’s outcomes with the patient. We may need to do more frequent assessment with patient reported outcome measures to determine if the patient is having psychological changes that favor better outcomes. We may also need to determine what amount of time or number of visits are adequate to capture if the patient is demonstrating psychological changes.
You’ll find the abstract to the recent study below.
What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review.
Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.
(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients’ upper extremity injuries?
We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the “upper extremity”, “outcome measurement”, and “impairment, psychological, social or symptomatic” variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.
Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.
Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.
Clin Orthop Relat Res. 2018 Nov;476(11):2190-2215. doi: 10.1097/CORR.0000000000000427.
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