1. Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach
Presenters:
David Berbrayer, MD,
Amy Houtrow, MD, PhD, MPH;
Armando Miciano, MD;
M. Elizabeth Sandel, MD (Director);
Deepthi Saxena, MD
2014 AAPMR Annual Assembly,
San Diego CA, 2014 Nov 15

2. Selecting Outcome Metrics for Your Outpatient Practice: An ICF-Based Approach
Learning objectives:

1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics

2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations

3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

3. Outcome Core Set – Chronic Low Back Pain
Section Presenter: Armando Miciano, MD
Nevada Rehabilitation Institute
Las Vegas, NV
2014 AAPMR Annual Assembly, San Diego CA, Nov 15

4. Disclosures Medical Director Spring Mountain Rehab, Las Vegas NV
Practitioner –
Nevada Rehabilitation Institute, Las Vegas NV

5. Acknowledgments – CLBP QTB Subject Matter Experts:
1. David Berbrayer MD (Performance Metrics Committee member)
2. Edwin Capulong MD
3. Kush Goyal MD
4. Martin Grabois MD (Co-leader)
5. Armando Miciano MD (Clinical Practice Guideline Committee member)
6. Joshua Scheidler MD
7. Deborah Venesy MD (Co-leader)

6. INTRODUCTION Most common assessment:
Evaluation of underlying impairment & pathology
Specialists performing evaluations for MSK disorders will be best served when they can:
Assess the individual's functional status
Incorporate that information into their decision regarding the individual's current limitations and prognosis
In addition to the evaluation of the underlying impairment and pathology. [1]
[1] Greenough CG. Eur Spine J

7. Functional Status
Many of the factors contributing to the evaluation of functional status are necessarily subjective
e.g. pain, physical functioning, and affective status
Nonetheless, the literature suggests that inclusion of functional assessment into the [MSK] disability determination using a patient-centered approach may provide the factors that are most potent with respect to patient prognosis and care planning. [1]
[1] Linn RT, Granger CV, et al. Phys Med Rehabil Clin N Am

8. How should clinicians measure “Patient-centered Outcomes
How should clinicians measure “Patient-centered Outcomes?” INTRODUCTION – Performance Metrics
DEFINITION:
The field of developing, evaluating & applying measurement instruments
Undergone considerable progress in MSK medicine [1].
[1] Mooney V, et al. Spine J May;10(5):

9. INTRODUCTION – Progress in Performance Metrics
How is recovery from low back pain measured?
A systematic review of the literature
BACKGROUND:
No accepted definition of what recovery involves or guidance as to how it should be measured.
OBJECTIVE:
To appraise the LBP literature (last 10 years) to review the methods used to measure recovery.
RESEARCH DESIGN:
All prospective studies of subjects with non-specific LBP that measured recovery as an outcome
Kamper SJ, et al. Eur Spine J

10. INTRODUCTION – Progress in Performance Metrics
How is recovery from low back pain measured? A systematic review of the literature
RESULTS:
82 included studies used 66 different measures of recovery
17 measures used pain as a proxy for recovery,
7 used disability or function
17 based on a combination of two or more constructs.
9 single-item recovery rating scales
11 studies used a global change scale that included an anchor of ‘completely recovered’
3 measures used return to work as the recovery criterion
2 used time to insurance claim closure
7 used physical performance
Kamper SJ, et al. Eur Spine J

11. INTRODUCTION – Which PRO to use?
How is recovery from low back pain measured? A systematic review of the literature
CONCLUSIONS:
Almost every study that measured recovery from LBP in the last 10 years did so differently
Lack of consistency makes interpretation & comparison of the LBP literature problematic.
That the failure to use a standardized measure of recovery is due to the absence of an established definition
“Absence of established definition” >>> soln: ICF
Kamper SJ, et al. Eur Spine J

12. Another Challenge
Despite progress in PERFORMANCE METRICS, the appreciation of the complex interrelationship between:
Physical
Psychological
Social effects
of MSK disorders is incompletely explored in clinical practice. [1]
[1] Mayer T, et al. Spine J May-Jun;3(3 Suppl):28S-36S. Review.

13. LEARNING KEY POINT * THE ICF Model
The WHO then replaced the ICIDH with the ICF to be more comprehensive, recognizing three key components of disablement: body functions and body structures, activity, and participation.
Body functions and body structures are “physiological functions and body parts respectively.”
Activity is “the execution of a task by an individual (typically within their personal sphere).”
Finally, participation is “involvement in life situation (typically within a social sphere)
International Classification of Functioning, Disabilities, and Health: ICF
Source: World Health Organization (2001) International Classification of Functioning, Disability and Health (ICF), Geneva: World Health Organization.

14. Activity limitations:
Impairments:
problems in body function or structure such as significant deviation or loss
Activity limitations:
difficulties an individual may have in executing activities.
Participation restrictions:
problems an individual may experience in involvement in life situations.
How do literature reports apply the ICF ???
Rondelli, RD.  PM&R

15. Tools in the Quality Toolbox (QTB)
Review articles
Knowledge Now articles
Clinical practice guidelines
Core constructs specific for the health condition
Assessment instruments
Quality metrics
Patient education materials
Checklists

16. QTB: Review Articles
1. Chapman JR, Norvell DC, et al. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976) Oct 1; 36(21 Suppl):S54-68.
2. Cleland J, Gillani R, Bienen EJ, Sadosky A. Assessing dimensionality and responsiveness of outcomes measures for patients with low back pain. Pain Pract Jan-Feb; 11(1):57-69.
3. DeVine J, Norvell DC, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine (Phila Pa 1976) Oct 1;36(21 Suppl):S69-74.
4. Deyo RA, Dworkin SF, et al. Report of the NIH Task Force on research standards for chronic low back pain. Pain Med Aug; 15(8):
5. Freiberger E, et al. Performance-based physical function in older community-dwelling persons: a systematic review of instruments. Age Ageing 2012; 41: 712–721.
6. Ghogawala Z, Resnick DK, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome following lumbar fusion. J Neurosurg Spine Jul; 21(1):7-13.
7. McCormick JD1, Werner BC, Shimer AL. Patient-reported outcome measures in spine surgery. J Am Acad Orthop Surg Feb;21(2):
8. Schoenfeld AJ, Bono CM. Measuring spine fracture outcomes: common scales and checklists. Injury Mar;42(3):

17. QTB: Review Articles Outcome Measures Considerations
Chapman JR, et al.
Spine. 2011
VAS, NRPS
ODI, RMDQ.
SF-36
EQ-5D or SF-6D.
Psychosocial tests
validity, reliability, & responsiveness to change
Cleland J, et al.
Pain Pract. 2011
Roland Morris Disability Questionnaire,
Oswestry Disability Index
the most comprehensively validated measures with respect to responsiveness.
DeVine J, et al.
VAS
ODI
SF-12, EQ-5D
Strength of rec: strong
Deyo RA, et al.
Pain Med. 2014
PROMIS
A Report of the NIH Task Force (Expert Panel)

18. QTB: Review Articles, contd.
Outcome Measures
Considerations
Freiberger E, et al.
Age Ageing 2012
Short Physical Performance Battery
Physical Performance Test
Continuous Scale Physical Functional Performance.
validity, reliability and responsiveness,
Ghogawala Z, et al.
J Neurosurg Spine. 2014
ODI
SF-36 and the SF-12
For fusion cases
McCormick JD, et al.
J Am Acad Orthop Surg. 2013
VAS-back, VAS-leg
ODI, RMDQ
EQ-5D, SF
ODI & RMDQ with established MCID
Schoenfeld AJ, et al.
Injury. 2011
VAS
SF-36

19. Key Psychometric Properties of a Health Status Instrument
Measurement Property
Description
Validity
The measure quantifies what it is intended to (face validity), represents all important content of the construct (content validity), and is empirically demonstrated to be associated with the construct it was designed to measure (criterion validity)
Reliability
Reproducible results are obtained when the measure is repeatedly given to stable patients
Responsiveness
The measure is sensitive to clinical change
Interpretable
A clinical framework is available to interpret cross-sectional and longitudinal changes in scores
Translations exist
Linguistically and culturally appropriate translations are available so that multiple patients, from different countries and cultures, can be pooled for analysis
Spertus JA. Circulation

20. COSMIN taxonomy of relationships of measurement properties
Adapted from: Mokkink LB, et al. Qual Life Res. May 2010; 19(4): 539–549.

21. QTB: PMR Knowledge NOW *
Carayannopoulos A. Discogenic Lumbar Pain. In: PMR Knowledge NOW [Internet] Nov 10 [modified 2013 Jan 24]. c2014 AAPMR. Accessed 10/22/14 at:
Everett CR, Ramirez C, Perkowski M. Lumbar Disc disorders. In: PMR Knowledge NOW [Internet] Sep 20. c2014 AAPMR. Accessed 10/22/14 at:
Nance PW, Chen H. Lumbar stenosis. In: PMR Knowledge NOW [Internet] Jul 20 [modified 2013 Jan 23]. c2014 AAPMR. Accessed 10/22/14 at:
Spires MC. Inflammatory Arthritides. In: PMR Knowledge NOW [Internet] Nov 10 [modified 2012 Dec 27]. c2014 AAPMR. Accessed 10/22/14 at:
* Selected ones with discussion on Functional Assessment tools

22. QTB: Clinical Practice Guidelines
North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. c2012 NASS. Accessed 10/22/14 at: rDiscHerniation.pdf
North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. c2011 NASS. Accessed 10/22/14 at: rStenosis.pdf
North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. c2008 NASS. Accessed 10/22/14 at: ylolisthesis.pdf
American Academy of Orthopedic Surgeons (AAOS). Treatment of Symptomatic Osteoporotic Spinal Compression Fractures Accessed 10/22/14 at:

23. QTB: Clinical Practice Guidelines
NASS:
Lumbar Disc Herniation w/ Radiculopathy
Spinal Stenosis
Spondylolisthesis
AAOS:
Compression FX
“Refer to a publication entitled Compendium
of Outcome Instruments for Assessment and Research of Spinal Disorders.
“Refer to a publication entitled Compendium of Outcome Instruments for Assessment and Research of
Spinal Disorders.”
The Zurich Claudication Questionnaire (ZCQ)/Swiss Spinal Stenosis Questionnaire (SSS),
Oswestry Disability Index (ODI),
Likert Five-Point Pain Scale
36-Item Short Form Health Survey (SF-36)
Pain – VAS (0-100)
Pain – NRS (0-10)
Oswestry Disability Index
Roland-Morris Disability Questionnaire
SF-36 Physical Component Summary
AQoL
EQ-5D

24. Constructs for core sets (for choice of assessment instruments)
1. Symptom quality
2. Pain-related impairment
3. Life satisfaction
4. Global health status
5. Work productivity
[1] Bombardier C. Spine (Phila Pa 1976)

25. QTB: Assessment Instruments PRO vs. PBA
= Patient-Reported Outcomes
– from the “patient”
PBA
= Performance Based Assessment
- medical search term used also as outcome measures
- clinician-derived objective tests

26. Patient-Reported Outcomes (PRO)
ICF component 1: body function/structure
a. Numerical Rating Scale (NRS) – body pain
b. NRS – leg pain
ICF component 2: activity
a. Generic:
1. Pain Disability Questionnaire (PDQ)
b. Disease-specific:
1. Oswestry Disability Index (ODI)
2. Roland Morris Disability Questionnaire (RMDQ)
ICF component 3: participation
a. PROMIS-57 v1.0
i. PROMIS-57 Physical function subscale
ii. PROMIS-57 Pain Impact
b. Work Productivity & Activity Impairment: General Health (WPAI: GH) v2.0

27. Performance-based Assessment (PBA)
a. ICF component 1: body function/structure
i. Lumbar Range of motion test
ii. Backache Index (BAI)
b. ICF component 2: activity
i. 6-Minute Walk Test
c. ICF component 3: participation
i. Short Physical Performance Battery

28. Body Functions & Structures
ICF Conceptual Framework: Outcome Measures used in Practice– Chronic Low Back Pain
Body Functions & Structures
PRO:
NRS – body pain;
NRS – leg pain
Activity
Generic:
PDQ;
Disease-specific:
ODI, RMDQ
Participation
PROMIS-57
WPAI:GH
PRO and PBA used in my practice setting

29. ICF Conceptual Framework: Outcome Measures - Low Back Dysfunction
Body Functions & Structures
PBA:
Lumbar ROM
Backache Index
Activity
6-Minute Walk Test
Participation
Short Physical Performance Battery
PRO and PBA used in my practice setting

30. Constructs for Core Sets (for choice of assessment instruments)
Symptom quality
Pain-related Impairment
Life Satisfaction
Global Health Status
Work Productivity
Numerical Rating Scale (NRS) – body pain
b. NRS – leg pain
Generic:
Pain Disability Questionnaire
Disease-specific:
Oswestry Disability Index;
ii. Roland Morris Disability Questionnaire
PROMIS-57 - Satisfaction with Social Role
PROMIS-57 Physical Function
PROMIS-57 Pain Impact
Work Productivity & Activity Impairment: General Health (WPAI: GH)

31. Minimal clinically important improvement (MCII)
Definition:
the smallest clinical change that is important to patients, and recognizes the fact that there are some treatment-induced statistically significant improvements that are too small to matter to patients.
Also as Minimal clinical important difference (MCID)
Accessed 05/25/14 at:

32. MCII Pain – VAS (0-100) 15 Pain – NRS (0-10) 2
Outcome Measures
MCII (points)
Pain – VAS (0-100) 15
Pain – NRS (0-10) 2
Oswestry Disability Index 10
Roland-Morris Disability Questionnaire 5
PROMIS-57
Not reported
WPAI: GH
Accessed 10/23/14 at:

33. QTB: Quality Metrics
To qualify for the 2014 PQRS incentive payment, Physiatrists must report on at least 9 individual measures covering 3 National Quality Strategy (NQS) domains for at least 50 percent of your Medicare Part B FFS patients seen during the reporting period.
Alternatively, you can report at least 1 measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B FFS patients.
Accessed 10/23/14 at:

34. QTB: Quality Metrics I. Measure Group
1. PQRS # , Back Pain Measures Group
II. Individual Measures
1. Patient Safety domain:
a. PQRS #130, Documentation of Current Medications in the Medical Record
b. PQRS #154, Falls: Risk Assessment
2. Communication and Care Coordination domain:
a. PQRS #182, Functional Outcome Assessment
b. PQRS #131, Pain Assessment and Follow-Up
c. PQRS #155, Falls: Plan of Care
d. PQRS #24, Osteoporosis: Communication with the Physician Managing On going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
e. PQRS #47, Advance Care Plan
3. Clinical Process and Effectiveness domain:
a. PQRS #39, Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
b. PQRS #40, Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
c. PQRS #41, Osteoporosis: Pharmacologic Therapy for Men and Women Aged Years and Older
4. Population Health domain:
a. PQRS #128, Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
b. PQRS #134, Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Accessed 10/23/14 at:

35. QTB: Quality Metrics I. Measure Group
1. PQRS # , Back Pain Measures Group
II. Individual Measures
1. Patient Safety domain:
a. PQRS #130,
b. PQRS #154,
2. Communication and Care Coordination domain:
a. PQRS #182,
b. PQRS #131,
c. PQRS #155,
d. PQRS #24,
e. PQRS #47,
3. Clinical Process and Effectiveness domain:
a. PQRS #39,
b. PQRS #40,
c. PQRS #41,
4. Population Health domain:
a. PQRS #128,
b. PQRS #134
Accessed 10/23/14 at:

36. What we learned today: Learning objectives:

1. Define foundational concepts of the ICF that serve as a guide for the choice of PM&R outcome metrics

2. Understand variety of resources available for selection of outcome metrics for PM&R patient populations

3. Incorporate outcome measurement into outpatient practices for a variety of patient populations to enhance physiatric care using core sets of measures

37. Constructs for Core Sets (for choice of assessment instruments)
Symptom quality
Pain-related Impairment
Life Satisfaction
Global Health Status
Work Productivity
Numerical Rating Scale (NRS) – body pain
b. NRS – leg pain
Generic:
Pain Disability Questionnaire
Disease-specific:
Oswestry Disability Index;
Roland Morris Disability Questionnaire
PROMIS-57 - Satisfaction with Social Role
PROMIS-57 Physical Function
PROMIS-57 Pain Impact
Work Productivity & Activity Interference: General Health (WPAI: GH)

38. Summary: Recommended PRO for practical use
Numerical Rating Scale (NRS) – body pain; and,
NRS – leg pain
Pain Disability Questionnaire (PDQ)
Oswestry Disability Index (ODI) or
Roland-Morris Disability Questionnaire (RMDQ)
PROMIS-57 v1.0
Work Productivity & Activity Impairment: General Health (WPAI: GH) v2.0

39. Nevada Rehabilitation Institute, Las Vegas NV
Thank You.
Contact Info:
Armando Miciano, M.D.
Nevada Rehabilitation Institute, Las Vegas NV