International performance improvement expert H. James Harrington said, “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”
Using outcomes instruments is an effective and relatively easy method for measuring and understanding a patient’s response to treatment. With a clearer understanding of patient responses to therapy interventions, therapists can make better clinical decisions—and thus, improve patient outcomes.
I have consistently used the following outcomes instruments in my clinic for the past 12 years:
- Disabilities of the Arm, Shoulder, and Hand (DASH),
- Oswestry Disability Index (ODI),
- Neck Disability Index (NDI),
- Knee Outcome Survey (KOS), and
- Lower Extremity Functional Scale (LEFS).
I also track patients’ pain levels using the numeric pain rating scale (NPRS). Additionally, I have found value in assessing my patients’ perceptions of their progress using the Global Rating of Change Scale (GROC). The GROC is a 15-point scale that ranges from -7 (a very great deal worse) to 0 (about the same) to +7 (a very great deal better). Each patient completes the appropriate outcome form—along with NPRS and GROC—at every visit.
Classifying patients also is a key part of my outcomes tracking and reporting process, because it allows me to create homogenous groups. This, in turn, enables me to make more accurate comparisons when assessing results among therapists and clinics. I use this treatment-based classification system (proposed by Fritz et al) for neck pain and this one (introduced by Delitto et al ) for back pain. For conditions of the peripheral joints, I use a pathoanatomic classification informed by my PT diagnosis.
While I am certainly not an expert in outcomes and research, I have found that using these outcomes tools in the clinic has helped me to accomplish three specific things:
1. Assess patients’ responses to treatment interventions.
Administering outcomes allows me to assess not only changes that occur from visit to visit, but also changes in the patient’s response to treatment over several visits. In other words, with the help of outcomes tracking, I can see and assess trends.
Additionally, by analyzing aggregate data of all my patients with a particular condition—back pain, for example—I gain important information about my average improvements in outcomes, pain, and GROC per episode of care and per visit for that specific body region.
2. Guide decision-making.
If my patient’s outcome score, NPRS, and GROC all show improvement that meets or exceeds the minimum clinically important difference (MCID), I know my treatment is effective, and I can confidently continue the therapy program. I also am able to objectively determine when the patient is ready for discharge. On the other hand, if the outcome measures are essentially unchanged, or if they’ve improved minimally since the initial visit, this is a clear prompt to reassess the patient, determine reasons for the lack of improvement, and then make important adjustments in my interventions and treatment plan. I can then assess the patient’s response to my adjusted intervention—and the cycle continues until discharge.
One practical clinical method that has helped me to improve patient results is looking carefully at some of the patient’s answers on the outcome form, selecting a specific activity that the patient has difficulty with, and addressing it directly. For example, if a patient indicates on the ODI that his sleep is substantially limited due to pain, I will identify potential reasons for the poor sleep, implement strategies to improve sleep—including education regarding effective sleeping postures—and then assess the results of that specific intervention on the ODI sleep question at subsequent visits.
Another way that tracking outcomes and establishing reports improves decision-making: it provides clinicians with real feedback about their results. So, in addition to identifying trends in a patient’s progress, therapists also are able to assess trends over time to evaluate their individual effectiveness in treating patients with specific conditions (e.g., neck pain). If a therapist’s outcomes in treating neck pain are worsening over time, this is an alert to the therapist. He or she can then reflect on potential reasons for the downward trend and create a plan for improvement. Additionally, comparing outcomes for therapists in the same clinic can provide meaningful information and promote improvement. For example, if therapist A has significantly better outcomes in treating neck pain than therapist B, it could be very beneficial for therapist B to learn skills from therapist A and/or complete continuing education courses in the area of evaluating and treating neck pain. Therapist B can then assess his or her outcomes at a future date to see what kind of impact the improvement plan had.
Obviously, there are a lot of potential clinical scenarios in which this applies, but simply put, measuring outcomes improves results—both for our patients and the clinicians treating them.
3. Provide valuable feedback to each patient regarding his or her progress.
Over the years, I’ve found that many patients want and appreciate therapist feedback regarding their recovery. On a regular basis, I share with my patients their outcomes, NPRS, and GROC scores, because I believe that this valuable and timely feedback improves patient engagement and motivation for improvement.
Using outcomes has helped me make better clinical decisions—and that has helped my patients’ overall outcomes and satisfaction rates. How has implementing outcomes tracking helped you and your patients? I’d love to hear your stories. Share them in the comment section below.
About the Author
Brian Rodriguez, PT, DPT, OCS, is the owner of Utah Physical Therapy Specialists. He graduated from the University of Utah in 1990 with a bachelor’s degree in physical therapy. In 1996, he completed an orthopedic physical therapy residency program with the Kelsey Institute for Physical Rehabilitation Studies. In 1997, he became board-certified in orthopedic physical therapy with the American Board of Physical Therapy Specialties. In 2008, Brian completed his Doctor of Physical Therapy degree from the University of Utah. Brian’s entire career has focused on evaluating and treating orthopedic conditions including post-surgical cases. Brian is married with three children and enjoys fitness.