Original articleMonitoring the change: Current trends in outcome measure usage in physiotherapy
Introduction
As the emphasis on evidence-based medicine in health services delivery grows (Jette et al., 2003) health professionals are increasingly expected to demonstrate improved treatment outcomes. The World Health Organisation International Classification of Functioning (ICF) conceptualizes dysfunction as impairments, activity limitations and participation restrictions (WHO, 2001). It is now widely accepted that measurement of outcomes should occur across those domains and over the past 10–20 years, patient-report health outcome measures have been developed and increasingly used for measuring a wide range of health and rehabilitation outcomes (Garratt et al., 2002).
Entry-level professional competencies for physiotherapists include the ability to select relevant, achievable and measurable treatment goals and the use of valid and reliable tests and measures to evaluate the results of treatment (ACOPRA, 2002). Physiotherapists, particularly in orthopaedic practice, have traditionally focused on the measurement of impairments such as pain, range of motion and muscle strength, but have not utilized standardized measures of activity and participation (Jette et al., 1994; Kay et al., 2001; Vanderkooy et al., 1999; van der Valk et al., 1995). Two European surveys of rehabilitation health professionals, including physiotherapists, suggest a pattern across professions, countries and health care settings that the use of standardized measures of function in low back pain rehabilitation is not routine and most assessments are at the impairment level (Haigh et al., 2001; Torenbeek et al., 2001).
In 2003, a number of initiatives occurred in Victoria to encourage physiotherapists to use standardized measures of activity and participation. The Australian Physiotherapy Association (APA) adopted a national position statement on treatment justification that re-stated the professional requirement to measure outcomes using valid and reliable instruments. The Transport Accident Commission (TAC)1 produced a “Clinical Justification Model”, a decision algorithm that included a requirement to use standardized outcome measures to assess activities/participation and monitor outcomes for individual patients. A new treatment notification plan was adopted by the TAC that required practitioners to submit standardized or customized outcome measures with all new treatment plans proposed. Flanagan et al. (2003) discussed the use of outcome measures to assess the management of long term patients on a case by case basis. The implementation of the clinical justification model was supported by a series of lectures and education seminars offered by the APA and TAC, educational material (including copies of a range of standardized questionnaires) was made available in hard copy and on the TAC and APA websites, and peer contact was made with physiotherapy treatment providers to assist them implement the clinical justification model. Peer contact was performed by Physiotherapy consultants employed by the TAC, and the results over the corresponding period to this study were internally audited.
These strategies aimed to increase the use of standardized measures of activity/participation by physiotherapy providers of services to TAC clients. The primary aim of this study was to survey the use of outcome measures over the 6 month period during which these strategies were implemented. Secondary aims were to determine physiotherapists’ attitudes toward outcomes measurement, and the perceived barriers to their use.
Section snippets
Method
A longitudinal mailed survey was conducted in March and September 2003. Simple random samples of 300 private practitioners were drawn from the register of 1092 physiotherapists who had treated Transport Accident Commission clients in Victoria in the preceding year. Ethical approval for the study was provided by the Faculty Human Ethics Committee, Faculty of Health Sciences, La Trobe University. A simultaneous internal audit on the use of outcome measures by physiotherapists was conducted by the
Analysis
A test of the difference between the proportion of respondents using each test in March and September was calculated (Bland, 1995), and two types of analyses were done. The response categories of Sometimes, Frequently and Always were collapsed for comparison of change in reported use. The second analysis grouped the categories Frequently and Always to examine change in common practice. Differences were not tested where any proportion was less than 10%.
For the five items relating to barriers the
Results
There were 154 and 164 completed forms received in the March and September surveys, a return rate of 51% and 55%, respectively. The average age was 40.6 years (SD 8.3) and the average time since graduation 17.1 years (SD 8.6). The sample was similar in age to the average age of 38.7 years for Victorian Physiotherapists in 1998. However, there were significantly more rural practitioners (27.4% compared to 17%) and more males (58.5% compared to 27%) (AIHW, 2001).2
Discussion
The results showed that the use of outcome measures amongst TAC physiotherapy providers had increased significantly over the period. This was confirmed by findings of the TACs internal audit over the same period. During this audit, physiotherapy consultants contacted physiotherapy treatment providers to discuss the use of outcome measures in assisting with treatment plans. An increase in the usage of outcome measures was found, rising from 30% in March to 66% in September.
Significant increases
Conclusion
This study found a significant increase in the use of a number of standardized outcome measures by physiotherapists over a 6 month period. The changes observed were likely influenced by active education initiatives, professional support, and peak body position statements. Mandatory reporting of outcome measures, implemented by TAC during the period and monitored by peer review, also played a key role. Most of the physiotherapists surveyed supported the use of valid and reliable instruments,
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