Clinical Value of StandardizationOPTA2018...Stewart WF, Ricci JA, Chee E, et al. Cost of lost productive work time among US workers with depression.JAMA. 2003;289:3135‐3144 Haden

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Clinical Value of Standardization and How it Leads to Quality Improvements-

Bringing Big Data to Small Actionable Space

Tara Jo Manal PT, DPT, FAPTABoard Certified Orthopedic Clinical Specialist

Board Certified Sports Clinical SpecialistDirector of Clinical Services and Residency Training

Associate ProfessorUniversity of Delaware Physical Therapy Department

Newark, DE www.udptclinic.com

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The Wall Street Journal LISA MILLER 1994

“My left knee sometimes hurts, especially going up and down stairs, after a long run or while I am on the Stairmaster. The pain is a short twinge. I have had the pain since I was 14 years old. I am in good health, active, 31 years old. What should I do?”

Acute RehabilitationAverage Length of StayFacility A = 34 daysFacility B = 74 days

Whiteneck G, Gassaway J, Dijkers M, et al. Inpatient treatmentime across disciplines in spinal cord injury rehabilitation. TheJournal of Spinal Cord Medicine. 2011;34(2):133‐148. doi:10.1179/107902611X12971826988011.

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By NASA ‐ Earth's Vital Signs, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9565093

Unwarranted Variation

Care variation unexplained by condition or patient preferences

By NASA ‐ Earth's Vital Signs, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9565093

Fearon 2009 Maley

Variability in our outcomes cannot continue to be

influenced by our current lack of discipline in the application of

established standardized patterns of care.

“consistent care with demonstrated outcomes”

Manal Maley 2017http://www.apta.org/NEXT/2017

/MaleyLecture/

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Insurance Restrictions Scheduling

Equipment Failure

Electronic Medical Record

Missed Deadlines Wardrobe Malfunction

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You can be part of the solution‐ highly trained local clinical champions to lead the Revolution

• Clinical Chaos• Human Factor• Schedules• Colleagues• Technical Factors• Equipment• Resources• Patient Factors• Condition complications• Physical Therapy Care

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#CombatClinicalChaos

Remove the disorganization and confusion we create when we fail to standardize our physical therapy

care….

• Necessary Questions• Indicated Tests• Self‐Report/Performance‐Based Measures• Synthesize and Interpret• Risk Assessment• Classify• Matched Intervention• Shared Decision Making

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The Gap between evidence and decision making

• 12‐17 year gap from bench to bedside

• KT‐ Fills the gap between knowledge and practice • Also called Knowledge to Action

(K2A)

Mycustomer.com

Research

Practice

K2A

Knowledge

Action

Green LW, Fam Pract 2008; 25 (Supp 1):i20‐24

http://extra.upmc.com/100108/8.html

Knowledge Translation (KT)Gaps between knowledge and care delivery• patients, health care providers and policy‐makersKT‐ uses high quality knowledge in processes of decision makingMoving knowledge into action involves applying research to patient care • Assists clinicians in best practice• Reduces unwanted variability • Improves outcomes for patients• Is efficient and cost effective

Straus Defining Knowledge Translation CMAJ August 4, 2009 vol. 181 no. 3‐4 pt 165‐168

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Why Does the Gap Exist?Knowledge creation and dissemination are not enough to ensure use in the field.Interventions not described in ways that can be replicatedToo much information, too little timeLack of skills and confidence in critical appraisalInadequate analysis and resources aimed at eliminating barriers

Glasziou P, Meats E, Heneghan C, et al. What is missing from descriptions of treatments in trials and reviews?BMJ

2008;336:1472–4Evenson et al Implementation Science 2010

“Without access to provider training and/or resources, we cannot expect this evidence to be implemented in practice with optimal effects”

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Knowledge‐to‐Action Process

Graham ID, Logan J, Harrison MB, et al J of Cont Education for Health Professions. 2006; 26: 13‐24.

Need to have the Knowledge

Depressive Symptoms

Incidence is 5.5%‐60% of population depending on definitionPrimary care physicians failed to recognize 50‐75% of cases of depressionHalf of lost productivity in US is attributed to depression ($44 Million) 2nd to ischemic heart disease for disability adjusted life years by 2020

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Agency for Healthcare Research and Quality. US Preventive Services Task Forcehttp://www.ahrq.gov/clinic/uspstfix.htm

Katon W, Schulbergare. Gen Hosp Psychiatry 1992;14:237‐47.

Stewart WF, Ricci JA, Chee E, et al. Cost of lost productive work time among US workers with depression. JAMA. 2003;289:3135‐3144

Haden A, Campanini B, eds. The World Health Report 2001—Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001:30

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Poll Question 1How confident are you that you would recognize MILD depression in a patient/client you are evaluating?

a. Very confident b. Moderately confidentc. Somewhat confidentd. Not confident

Question 2How confident are you that you would recognize EXTREME depression in a patient/client you are evaluating?

a. Very confident b. Moderately confidentc. Somewhat confidentd. Not confident

Depressive Symptoms

Brief 2‐item screening test from the Primary Care Evaluation of Mental Disorders ProcedureThe questions: • (1) "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and

• (2) "During the past month, have you often been bothered by little interest or pleasure in doing things?"

The screening test is scored by counting the number of "yes" responses (range=0–2).

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Info.pacificquest.org

2 Questions Alone Sens. 96% Spec.78%

Haggman, PTJ, 2004Arroll B BMJ. 2005;331(7521):884

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Solid Line‐2 questions Dashed Line‐PT judgment19

Why Close the Gap?Failures to use best evidence can..• Increase costs (waste)• Provide less effective care• Result in reduced patient outcomes

• Cause potential harm• Create poor policy‐making

Closing the Gap improves our patients lives demonstrates our value and enhances professionalism

McGlynn The quality of health care delivered to adults in the US NEJM 2003;348:2635‐45

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“Wrong-site surgery is one of the most seriousand talked about safety failures—

But it could be said that any surgery that hasn’t been proven to benefit the patient is a wrong-

site surgery.” Jack Wennberg MD, Dartmouth University

Applying this concept to physical therapy, any therapy that hasn't been proven to benefit the patient

is “wrong site therapy”

Knowledge SynthesisHave to begin with knowledgePrimary literature consumption is not feasible on a large scale for impacting clinical behaviorsAn internist must read 34 primary literature articles daily to stay current in the fieldSynthesis Documents are excellent resources

Straus Defining Knowledge TranslationCMAJ August 4, 2009 vol. 181 no. 3‐4

Clinical Practice

Guidelines Systematic Reviews

PTNow Stroke Engine

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Synthesis DocumentsClinical Practice Guidelines (CPG)‐Statements that include recommendations intended to optimize patient care that are informed by systematic review of evidence and assessment of benefits and harms of alternative care optionsCochrane ReviewsAPTA and Section EDGE documents

Clinical Practice GuidelinesIdentify best evidence based summary statementsList things to screenTests and Measures to performSub classification of patients when indicatedMatched Treatment InterventionsPrognosis/Outcomes

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Appraisal Rating•Agree II tool

Highlights

•Have 10 min‐Focus here

Check your Practice•Do you need to make a change?

#GetWiththeGuidelines

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Web Based Resources

Rehabilitation Measures Database

Translate to the PractitionerDon’t just tell me what to do‐ give me the resources

Your patient:• 26 year‐old male• Running and felt a “pop” L Achilles

tendon 3 days ago• Walks with pronounced limp• Substantial swelling and discoloration in

the posterior heel.

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What if it is not a rupture?Achilles Tendinopathy Guidelines Journal Club

• Read Guidelines• Identify Tests/measures not used in clinic

• Lab Review of new items• Created new evaluation form• Follow up with chart reviews of ankle patients

• Create training list for new hires

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Now we have the knowledge………

Do we have a problem with the implementation of the

knowledge?

Need an X‐ray with All Neck Injuries?

One easy mnemonic for the criteria NSAID:•Neuro Deficit•Spinal Tenderness (Midline)•Altered mental Status/Level of Consciousness•Intoxication•Distracting Injury

Painful Distracting Injury: Including, but not limited to long bone fracture, visceral injury requiring surgical consultation, large laceration, degloving injury, crush injury, large burns, or any injury causing acute functional impairment Stiell et al Canadian CT Head and Spine Study group CJEM 2002

Hoffman JR Ann Emerg Med 1992,1998 NEJM 2000

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Is Clinical Judgment Always Better?

Canadian C‐spine RuleSensitivity 99‐100%Specificity 44%

Physician JudgmentSensitivity 93% (missed 5 cases)Specificity 53.9%• Banderia et alAnnals of Emerg Med 2003

NEXUS Criteria : 93% Sensitivity; 12% specificityStiell et al Acad Emerg Med 2000

NEXUS:

Patient insists on x‐ray‐ 60.4%

Worried about legal ramification 37.7%

X‐rays may help person in court, insurance etc 18%

Too difficult to use remember in real time 9.5%

I don’t know what it is 7.5%

This rule has not been proven to work 1%

Canadian:

Too difficult to remember real time 36%

I don’t know what it is 36%

Worried about legal ramifications 22%

X‐rays may help person in court, ins etc 8%

This rule has not been proven to work 4%

S Weiner. The Actual Application of the NEXUS and Canadian C‐Spine Rules by Emergency Physicians. The Internet Journal of Emergency Medicine. 2008 Volume 5 Number 2

What to do with all this informationNeed Trigger that results in team wanting to “change” practice or implement something new• Question in practice arises• Evidence for something is created or found

Group meetingFocus GroupJournal Club

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“Failure to Progress” 20‐23%Benchmark Goal 17%

www.udptclinic.com

Observations: In Chart Reviews

• Pain reduction over time followed a typical course• Self‐reported function worsened • Why?

• Treatment was not pain limited‐could the progression be more aggressive?• Care Process Model followed in some areas not in others

o NMES never performedo Lowering bike seat now followedo Long duration knee flexion stretch not documentedo Strength progression weako No strengthening to hipo Balance and Agility training limited and not progressedo Patient was not educated in nor practiced safe kneeling

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SCORECARDPassive Stretch

NMES

Measure ROM

Progress Strength

Kneeling Education

Performance Measure

X

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2014

2014= 31 patients

2015= 38 patients

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Chart reviews for Practice changeProvide helpful reminders related to actual patients• No change in weights on patient in 3 visits

o Assess each exercise and change accordingly• ROM has not increased and no change in treatment plan implementedo Assess home complianceo Assess for mobilizationo Implement new stretching strategy

• Swelling was increased from trace to 2+o Rest 2 days back on crutcheso Reduce in clinic and home program by 1 level

Criteria for Audit Successo Baseline use of knowledge was lowo Feedback is provided by colleague or supervisor

o More than one audit loop (inspect what you expect)

o Multimodal feedback (verbal/written)o Explicit action recommendations

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Determine your change goals and change toleranceWhat is your ultimate goal?• Assess current baseline of practice‐o By condition?o By frequency?

• Identify unwanted variation in practice

• Protocol development

• Create process for ongoing changeo i.e. Journal clubs linked to practice changes or KT team

What is your teams tolerance for change?• Minimum criteria

o Take BP on patients with cardiac/stroke history or BP meds

o Take BP on all evals• Maximum criteria

o Treat on protocol 85% time‐ 100% time

Poll

How would you rate the tolerance to change in your current climate?A. High‐ eager to adopt new methods and proceduresB. Medium‐ willing to change daily practice but only a few procedures per yearC. Low‐ even when requested, compliance to change is poor

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1 year ‐Create Flow Sheet and Support Documents

MD Letter, Action Flow sheet

Create Habit and Compliance

Assess Compliance‐ 6 months

>95% data collected Failure to Act 55% of time

Just Measure BP on All Patients

Train Aides Buy Automated cuff

1 year ‐Create Flow Sheet and Support Documents

MD Letter, Action Flow sheet

Create Habit and Compliance

Assess Compliance “Chart Review”‐ 6 months

>95% data collected Failure to Act 55% of time

Just Measure BP on All Patients

Train Aides Buy Automated cuff

5 year Compliance88% collection day 1( 100%‐64%)

High Change Tolerant Facility

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0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

B1 B2 B3 B4 B5 P1 P2 P3 P4

Therapists by Week

BC

BS

CJ

DA

EB

JH

RB

Baseline Post Intervention

0.000.100.200.300.400.500.600.700.800.901.00

B1 B2 B3 B4 B5 P1 P2 P3 P4

Clinic A Aggregate by Week

p‐hatp‐barLCLUCL


0.00

0.100.200.300.400.500.600.700.800.901.00

B1 B2 B3 B4 B5 P1 P2 P3 P4

Clinic B Aggregate by Week

p‐hatp‐barLCLUCL


So far: 180pts with 96 BP’s (49 require some response)….Need compliance for measurement before can have sufficient responses to assess adherence to algorithm

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Do not be quick to adopt if you are not quick to drop…………….• Early adopters have high change tolerance and adopt new procedures/pathways quickly

• When evidence changes they also need to be dropping

Do Not Treat just because you used to…

Michaleff et al Lancet 2014Gorelick Adv Tech Biol Med 2015

Lateral epicondylitis injectionWhiplash

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Adapt knowledge to local contextWhat needs to be adjusted to fit into your practice setting and area?• Example: Guidelines may span care for a condition from acute through chronic‐you need to edit to match just acute care components for your inpatient hospital setting


Adapt Knowledge to your practice

Clinical ExampleMeasurement of BMI and explanation on all evaluationsProblem: BMI guidelines for older adults and children differ from standard guidelines Our practice sees 12‐100 year olds

Adaptation: 3 sets of guidelines• Aides calculate BMI• Therapists Explain• Pedometers with goals• Nutrition/Gym Referrals

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_dis.htm

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Barrier and Facilitator IdentificationSystem Level‐• Financial incentives/disincentives

Organization Level• Lack/Abundance EquipmentTeam Level• Insufficient/available resourcesPractitioner Level• Variations in knowledge, attitudes and skills appraising and using evidence

Patient Level• Low to high adherence to recommendations

What challenges and opportunities exist for

knowledge use

System LevelCongenital Torticollis GuidelineShared with payer

Moved to covered service by payer

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Organizational level‐Patient Positioning Recommendations

Barriers to Training FamilyTherapist knowledge# Pillows available in acute care

SolutionsPhoto with text handoutPurchase and Location for pillows to be housed on acute care floors

Team LevelSkill sets variety• Requires matched task assignmentLevel of enthusiasm• Resistance to change• Fatigue to demands

Group dynamics• Common expectations• Common goals• Common understanding

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Practitioner LevelPractice HabitsKnowledge in Area• Mastery of Facts and ConceptsNecessary Skills

BE A LOCAL CHAMPION!!

Patient LevelChallenge

Patient demands for unnecessary service

Lack of Compliance

Failure to Progress

Patient Barrier Assessment

StrategyEducation• Choosing Wisely campaign

Motivational Interviewing• APTA resources

Measures of confounding variables• Co‐morbidities• Fear avoidance

Need Tools/Resources

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Educate and Provide Resources to Family

Poll For the knowledge to practice gap in your facility, which level do you think you have the greatest barriers?a. Systemb. Organizationc. Teamd. Practitionere. Patient

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Just Do It!Intervene

How are your patients doing?

• Chart Reviews• Best Cases• Worst Cases• Reason for variation

• Peer Review

• National Comparisons• Identify Milestones

• Self Report Forms• Body region specific

• NDI, DASH, Oswestry• Disease specific

• Toronto Extremity Salvage Score

• Activity Related• PSFS

• Impairments• Strength, ROM, etc.

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Judgement Influenced by…

• Lack of Long term follow up

• Lack of outcome measures

• Lack of data for comparison

• Back inference

• Measurement ends at DC

• Patient reports “feeling better”

• How do your patients compare to others nationally, internationally

• Patient improved so what I did is necessary and my assumptions are true

• All patients from my clinic• If asked 90% of our patients meet Return to sport Testing at 6 months

• In Reality……• 58% Passed• 41% Failed

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Do Not Reject Clinical Practice Guidelines and Milestone Based Progressions as “cookbook”

• Your patient complains of headache that occur with neck movements and neck pain.

• They are limited in cervical range of motion and corresponding joint play

• Palpation of posterior cervical muscles reproduce headache

• Which test likely to provide info you will use for treatment?

• A. Spurling A• B. ULTT A• C. Cranial cervical flexion test• D. Cervical extensor endurance test

• E. This is why I don’t treat c‐spine patients

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Neck pain with Headaches

• Unilateral headache produced or aggravated by neck movement or position

• Headache produced/aggravated by opposite side posterior cervical muscle and joints

• Cervical Active Range of Motion• Limited

• Segmental mobility• Limited

• Cranial Cervical Flexion Test• Weak and poor control

By Daniel Schwen ‐ Own work, CC BY‐SA 4.0, https://commons.wikimedia.org/w/index.php?curid=7647000

Established MeasuresEstablished Measures

Robust ProceduresRobust Procedures

Standardized Care PathwaysStandardized Care Pathways

Reliable OutcomesReliable Outcomes

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Impairment/Treatment Delivery

Task RepetitionExercise IntensityStrength ChangesPain Reduction

Self Report

OswestryWOMACBalance Confidence Patient‐Specific Functional Scale

Performance

6‐Minute walkY BalanceAMPROSteps/Day

Benchmark Published Standards

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Rules, Guidelines, Self Report, Impairment and Performance Based Measures Lead the Way• Can be done on individual, practice or health systems level

• Can demonstrate improvement• Can reinforce treatment direction

• Can provide ability to compare• Individual progress• Group performance• National/International performance

• Contribute to Database

• Resolves many of the issues noted

• Lays foundation for practice change

YOU are our clinical leaders

• Clinical culture change requires…..

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Practice Improvement

Success

Get With the Guidelines

Procedural Reliability

Reduce Failure to Progress

Benchmark