PROMs and other Outcome Measures in Musculoskeletal and Rehabilitation Medicine

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1 PROMs and other Outcome Measures in Musculoskeletal and Rehabilitation Medicine John Etherington OBE Director of Defence Rehabilitation National Clinical Director Rehabilitation and Recovering in the Community 17 June 2015

2 Outcome Measures - determine Safety Effectiveness Patient engagement Military perspective Civilian relevance

3 Military Peculiarities Different models of care Geographically disperse Disparate injuries and conditions High functional expectations Occupational focus NHS relevance

Catterick Lichfield Cranwell Devonport Halton

4 WHERE? Defence Medical Rehabilitation Programme DMRP: The Role of the RI Hohne (Germany) Gutersloh (Germany) Edinburgh Aldergrove Catterick Lichfield Cranwell Devonport Halton Honington Aldershot Tidworth Portsmouth Colchester Headley Court Primary Intermediate Secondary

Instructor Injury 12-15 patients Health Psychology

5 Structure Rehabilitation Programme GRADED PROGRAMME OF EXERCISE Consultant-led Exercise Rehabilitation Instructor Injury patients Health Psychology Physio SLT Prosthetics OT Nursing SW MHT Group Therapy

6 MSK Conditions

7 Complex Injuries

8 Factors in Choosing Outcome Measures Variety diagnoses Occupationally related Varied occupations MDT input Ceiling effect

9 Approach Standardised measures of health EQ5D SF36 HAD GHQ Measures specific to diagnosis Lower limb injury - LEFS Amputation - AMP Q, 6MWD Neurological injury - MPAI 4

10 Mechanism Examine literature Face, Contextual validity Trial in our context Practicality / utility Validation Mandate - through the EPR

18 The Functional Activity Assessment Military Vocational Outcomes CODE FAA 1 FAA 2 FAA 3 FAA 4 FAA 5 GRADE Fully Fit Fit for Trade and fit for restricted General or Military Duties Unfit for Trade but fit for restricted General or Military Duties Unfit for all but Sedentary Duties Off All Duties

19 FAA validation 180/200 patients completed questionnaires at outpatient clinic 91/180 Line Manager replied 149/180 Clinicians The Functional Activity Assessment: a validated PROM unreliable in the hands of clinicians A Roberts, J Etherington JRAMC 159(4)

20 Frequency FAA validation Clinician FAA Self-assessed FAA Line Manager FAA FAA 1 FAA 2 FAA 3 FAA 4 FAA 5 Figure 1. Frequency of FAA scores

21 3 points = normal range SF-36

22 3 points = normal range SF-36

23 3 points = normal range SF-36

24 Agreement between patient, clinician and line manager on FAA score 1. Moderate agreement between clinician and pt 2. Moderate agreement between clinician and LM 3. Better agreement between pt and LM Why? Clinician bias towards FAA 2 / v.few rated FAA 1 Table 1. Cross-tabulation of FAA scores

25 Correlations 141 service personnel FAA significantly correlated with all SF-36 scores (component & subscale) Heavy physical workload sum score Years in service Higher levels of occupational ability associated with Better health Lower physical workload Older age A New Functional outcome assessment tool for military rehabilitation A Roberts, J Etherington PM&R 3 (6),

26 Regression model Accounted for 49% of the variability in FAA score 3 variables retained in model Role-Physical subscale score (43%) Physical-Functioning (3%) Years in service (3%)

27 Role-physical subscale and FAA Accounted for 49% of the variability in FAA score 3 variables retained in model Role-Physical subscale score (43%) Physical-Functioning (3%) Years in service (3%)

28 Efficacy of Interdisciplinary Rehabilitation on Functional and Mental Health Outcomes in UK Military Amputees Pete Ladlow MSc Research Scientist Academic Dept of Military Rehabilitation, University of Bath 65 Amputees Mean age 28 95% Male 23 Bilateral 8 Triple

29 Injury Severity Injury Characteristics Unilateral Amputee Groups Unilateral Non-Op Bilateral Triple Total Amputees Injury Severity: NISS (m ± SD) 28 ± 11.3 N/A 44 ± ± ± 15 NISS (95% CI) N/A

30 Functional Outcomes 6 Minute Walk Test (6MWT) Amputee Mobility Predictor with Prosthesis (AMP-Pro) DMRC Mobility Outcome DMRC Activities of Daily Living (ADL) Outcome

31 Walking Requirements for Community Integration Community ambulation metres (Robinett and Vondran (1988) Healthy age-matched groups 459 to 738 metres (Chetta et al 2006)

6-MWT and AMP-Pro Unilateral Amputee Groups Unilateral Non-Op Bilateral Triple Total Amputees 6MWD (metres) (m ± SD) * 544 ± 98.5 544 ± 114.4 445 ± 103.6 387 ± 99.1 489 ± 116.

32 6-MWT and AMP-Pro Unilateral Amputee Groups Unilateral Non-Op Bilateral Triple Total Amputees 6MWD (metres) (m ± SD) * 544 ± ± ± ± ± MWD (metres) (95% CI) AMP-Pro: Score (max 47) (m ± SD) Ɨ 44 ± ± ± ± 9 43 ± 5.1 Score (max 47) (95% CI) % of all amputees attained AMP-Pro functional mobility score typical of an active adult or athlete. 91% of all amputees attained at least a functional mobility score typical of a community walker.

33 DMRC Mobility Outcome

34 Mental Health Outcomes Patient Health Questionnaire - Depression (PHQ-9) General Anxiety Disorder (GAD-7) DMRC - Pain Status

35 Mental Health Outcomes PHQ-9 General Population * DMRC Amputees Number Mean ± SD 2.9 ± ± 4.5 Major Depression: Moderate ( 10) (%) Mod to Severe ( 15) (%) * (Kocalevent et al 2013) GAD-7 General Population * DMRC Amputees Number Mean ± SD 2.95 ± ± 4 Major GAD Moderate to Severe ( 10) (%) Severe ( 15) (%) * (Lowe et al 2008)

36 % of Patients Pain Status Outcome Unilateral Operational Unilateral Non-Op Bilateral Operational Triple Operational Injury Group No Pain Controlled Pain Uncontrolled Pain

37 3 year study on TBI inpatients n = 91 Follow up data on 79 patients at 4 months Vocational Independence Scale Competitive 55% Unemployed 6% Sheltered 1% Supported 11% Transitional 27% Community Employment: 92% Supported + Transitional + Competitive Dharm-Datta S, Gough M, McGilloway E, 2014

38 Rehabilitation for Economic Growth Rehabilitation can be a net contributor to NHS and Society

39 Measuring the Right Outcome NHS embrace broader societal outcomes work, wellness injury and illness prevention. Improving outcomes will generate national financial savings by reducing: Welfare costs Impact on the justice and education system Outcome-based commissioning Ambitious outcomes RTW

DEFENCE MEDICAL SERVICES REHABILITATION

DEFENCE MEDICAL SERVICES REHABILITATION The aim s of this presentation are to inform you of the Role of the Remedial Instructor (RI) Outline of the 3 week in patient treatment programme Background Injuries