Time for quality of manual physical therapy Where do we stand now and are we moving in the right direction? Prof. Rob A.B. Oostendorp (1942) Physiotherapist (1964) Manual physiotherapist (1972) Defence of doctoral thesis (1988) Professor of Manual Therapy (1989) Professor of Allied Health Sciences (2000)
Points of view How can professionals improve quality of care? Quality of care / quality problem / key problem / defining quality of care / quality indicators (process, outcome, structure) Clinical guidelines / recommendations / quality indicators. Where do we stand now? Adherence to clinical guidelines low back pain: Relationship between adherence and outcome Conclusion: Are we moving in the right direction?
I. QUALITY OF CARE KEY PROBLEM - DEFINITION
The quality problem Many patients (estimated 30-50%) do not receive recommended (evidence-based) care in line with guidelines recommendations and/or according to best practices 30-55% of tests ordered, medications prescribed, or treatments performed are not evidence-based, unnecessary, and/or potentially harmful Many patients are being harmed by services delivered by health care providers because of the occurence of errors and adverse events, many of which are preventable Large, unexplained differences in quality of service delivered among providers are noted Improvement of quality, even after implementing well-developed programs is slow
Key problem? Why do professionals not follow the guidelines recommendations despite the important convincing arguments? What is the most effective approach to solve this problem? Do we have a logic model for the problem?
Defining Quality of Care: Mission Impossible? More than 40 definitions (Donabedian, 1966-1980) Degree of excellence of care in relation to actual medical knowledge (read manual physical therapy knowledge), identified by quality tracers based on outcomes of care, as well as on structure and process (Silimper et al., 2002; Grol et al., 2004).
Interaction between indicators structure process outcome patient treatment functioning, QoL
Defining Quality of Care A Basic Idea: STEEEP All health care should be Safe, Timely, Effective, Efficient, Equitable, and Patient-centered: Patients should not be harmed by the care that is intended to help them (safe) Unnecessary waits and harmful delays should be reduced (timely) Care should be based on sound scientific knowledge (effective) Care shouldn't be wasteful (efficient) It shouldn't vary in quality because of patient characteristics (equitable) Care should be responsive to individual preferences, needs, and values (patient-centered)
Elements of quality of care Recognize patients at risk (red flags) Make the appropriate functional diagnosis ( medical diagnosis) Start the appropriate treatment Perform an appropriate evaluation Schedule the appropriate follow-up Stimulate the appropriate compliance / adherence to treatment In essence: The right things to do!
II. CLINICAL GUIDELINES RECOMMENDATIONS QUALITY INDICATORS
Development, implementation and evaluation of guidelines Definition of guidelines: Systematically developed statements to assist practitioner and patient decision prospectively for specific clinical circumstance (Grimshaw et al, 1993; Campbell et al, 2004) Guidelines are based on consensus, practice, and research evidence Many clinical guidelines, e.g. Low back Pain (Australia, Canada, Denmark, Netherlands, Norwegian, New Zealand, UK and US) Levels of guidelines recommendations: Level I: recommendation: It has shown that.. Level II: recommendation: It is likely that. Level III: recommendation: There are indications that Level IV: recommendation: The expert group recommends.
Dutch clinical guidelines 15 clinical guidelines (10 translated in English): www.kngf.nl 8 clinical guidelines relevant to manual physical therapy: Osteoarthritis hip and knee Ankle sprain injury (2): Acute and chronic Osteoporosis Whiplash Lumbosacral radicular syndrome Low back pain (2): Physiotherapy and manual therapy Guidelines recommendations on different levels Quality indicators (self regulation, external pressure)
Development of quality indicators Definition: A measurable element of practice performance for which there is evidence or consensus that it can be used to assess the quality, and hence the change in quality, of care provided (Lawrence & Olesen, 1997) Standard: The level of compliance with an indicator (target standard) (Donabedian, 1978;Eccles et al, 1996; Grol et al, 2005) Types Process (information on the care process) Outcome (information on the outcomes of care provided) Structure (organization and conditions of care process) Quality indicators are formulated in percentages
Development of quality indicators based on guidelines recommendations using an iterated rating procedure Methodology Flowcharts of KNGF-guidelines Low Back Pain and KNGF-guidelines Manual Therapy for diagnosis and management of Low Back Pain Key recommendations Diagnostic process indicators Therapeutic process indicators Outcome indicators
IIa. METHODOLOGY OF DEVELOPMENT OF QUALITY INDICATORS
Round1: Pre-selection Round 2: Rating Aim Undertaken by Criteria used Selecting key recommendations Rating key recommendations Small group (3 persons) Expert panel (8-10 persons) Patients health status, cost Patients health status, cost, sensitivity of change, availability of data Round 3: Reliability Determining interand intrarater reliability Expert panel for rating Research team for analyses Kappa, rho Round 4: Potential indicators Getting set of potential indicators Research team Cut-off score Agreement Round 5: Reflection Acceptability of indicators Research team Professionals Face validity
IIb. FLOWCHART DIAGNOSTIC AND THERAPEUTIC PROCESS IN GUIDELINES LBP
Guideline driven indicators Overview of selection of key recommendations of diagnostic process in low back pain
Overview of selection of key recommendations of therapeutic process in low back pain
Guidelines recommendations: Diagnostic process in LBP Diagnostic process number process indicators (level of evidence I-II-III-IV) Referral data 1 Contact physician in case of insufficient information (IV) History taking 7 request for help (IV), ICF (III), measurement instruments (II), red flags (IV), yellow flags (IV), course (IV), supplementary treatment (IV) Classification patient profile Examination objectives 2 Patient profile (II), contact in case of red flags (IV) 1 Examination objectives are consistent with objectives of profile (IV) Examination 1 Tests in accordance with objectives (II-IV) Analysis - conclusion Level of evidence: I: systematic review or > 2 high-quality controlled diagnostic studies; II: 2 high-quality controlled diagnostic studies; III: 1 high-quality diagnostic study or noncontrolled; IV: expert opinion. 3 Indication treatment (IV), prognosis (III), referral to physician if insufficient or no result is expected (IV)
Guidelines recommendations: Therapeutic process in LBP Level of evidence: I: systematic review or > 2 high-quality randomized controlled trials (RCTs); II: 2 high-quality RCTs studies; III: 1 high-quality non-controlled study; IV: expert opinion. Therapeutic process number process indicators (level of evidence I-II-III-IV) Treatment plan 2 Treatment plan fits with analysis of patient profile (III), participation of patient in treatment plan (III) Treatment 2 Treatment fits with treatment objectives (I-II), number of sessions fits with patient profile (IV) Evaluation 4 Systematic evaluation of treatment objectives (IV), adoption of changing treatment objectives (IV), contact with physician in case of insufficient or no result (IV), final evaluation including recommended measure instruments (II) Closure 2 Documentation fits with the Dutch guidelines for patient recording (IV), arrangement for aftercare (IV)
Guidelines recommendations: Outcome indicators in LBP Level of function: Pain intensity Visual Analogue Scale (VAS): 0 (no pain) 100 (unbearable pain); average pain previous week, maximal pain previous week, minimal pain previous week Level of functioning: Daily activities and specific activities Quebec Back Pain Disability Scale (QBPDS): 20 items; score 0 100 Patient-Specific Functional Scale (PSFS): Selection of three to five activities with limitations that patients aim to improve; score 0 (no trouble) 100 (impossible) Number of treatment sessions
Where do we stand now? Development, implementation, and evaluation of clinical guidelines Level of guidelines recommendations based on evidence Development of quality indicators based on guidelines recommendations Right direction?
III. ADHERENCE TO GUIDELINES RECOMMENDATIONS LBP. PROSPECTIVE COHORT STUDY (Rutten et al., 2008)
Adherence to clinical guidelines for LBP in (manual) physical therapy Participants (manual) physical therapist (n=233) Characteristics Response 42.1% (n=98) Mean age 42.4 y (SD=9.86) 64.1% male Patients with LBP n=242; incomplete records n=93 Mean age 48.2 y (SD=14.0) 49.2% female Complete data process indicators Complete data outcome indicators (pre and post) n=149 (n=74 PT; n=75 MPT) n=149 (n=74 PT; n=75 MPT)
IIIa. Results Adherence to Guidelines Recommendations LBP DIAGNOSTIC THERAPEUTIC PROCESS INDICATORS
Mean percentages of adherence to the guidelines recommendations for LBP: Diagnostic process indicators (n=149) Diagnostic process (number of indicators) Percentage adherence (SD) Referral (1) 2.1 (14.1) History taking (7) 60.0 (10.5) Patient profile (2) 98.0 (9.9) Examination objectives (1) 30.3 (46.1) Examination (1) 42.9 (49.7) Analysis conclusion (3) 91.7 (14.4) No significant difference in guidelines adherence between physiotherapists (n= 74) and manual physiotherapists (n=75)
Mean percentages of adherence to the guidelines recommendations for LBP: Therapeutic process indicators (n=149) Therapeutic process (number of indicators) Percentage adherence (SD) Treatment plan (4) 46.3 (32.9) Treatment (2) 50.7 (39.4) Evaluation (4) 88.8 (19.4) Closure (2) 74.8 (31.1) No significant difference in guidelines adherence between physiotherapists (n= 74) and manual physiotherapists (n=75)
Overall adherence to the guidelines recommendations for LBP (n=149) Overall adherence 66.6% (SD=8.55) range 44 88% (0 100%) 55% or lower 8.1% 56 65% 39.5% 66 75% 32.2% 76 85% 21.1% Target Standard > 65% No significant difference in guidelines adherence in patients with acute, subacute and chronic LBP No significant difference in guidelines adherence between physiotherapists (n= 74) and manual physiotherapists (n=75)
IIIb. Results Adherence to Guidelines Recommendations LBP OUTCOME INDICATORS
Guidelines recommendations: Outcome indicators LBP: minimal important change Outcome Instrument Mean difference Mean percentage of change* Pain VAS (0 100) >15 (range 6 18) >30 Daily activities Specific activities QBPDS (10 100) >20 >30 VAS (0 100) >15 >30 Minimal Important Change (MIC) taking into account the baseline score (Ostelo et al., 2008)
Outcome indicators LBP (n=149) * = p<0.05; mean difference VAS >15, QBPDS >20; PSFS >15; mean percentage of change >30% Measurement scale mean initial score (SD) mean end score (SD) mean difference (SD) mean percentage of change (SD) VAS average pain 58.02 (21,40) 22.54 (22.77) 36.13* (28.78) 55.67 (51.05) VAS maximal pain 75.46 (18.18) 37.98 (33.12) 37.79* (37.33) 44.60 (57.74) VAS minimal pain 25.60 (22.24) 11.06 (15.22) 14.69* (24.30) 19.11 (32.51) VAS-PSFS activity 1 65.74 (21.27) 19.20 (23.01) 47.36* (31.54) 66.54 (40.69) activity 2 64.98 (22.69) 17.56 (22.01) 46.63* (30.63) 66.73 (45.64) activity 3 63.44 (23.29) 17.29 (21.95) 46.43* (29.60) 67.84 (45.36) QBPDS 41.44 (16.36) 21.01 (14.98) 20.31* (18.37) 46.03 (36.54)
Outcome Indicator LBP (n=149) Number of treatment sessions Number treatment sessions Mean (SD) Total group (n=149) 6.7 (3.2) Acute LBP (n=69) 6.3 (3.0) Subacute LBP (n=32) 6.6 (3.4) Chronic LBP (n=48) 7.3 (3.1) No significant difference in number of treatment sessions between physiotherapists (n= 74) and manual physiotherapists (n=75)
IV. RELATIONSHIP BETWEEN ADHERENCE AND OUTCOME
Outcome Guidelines adherence total group (n = 149) acute low back pain # (n = 69) subacute low back pain ## (n=32) chronic low back pain ### (n = 48) VAS average pain -0.15-0.06-0.14-0.45** VAS maximum pain -0.18* -0.08-0.17-0.42* VAS minimum pain -0.25** -0.25* -0.25-0.50** PSFS activity 1-0.12-0.13-0.16-0.13 PSFS activity 2-0.19* -0.23-0.11-0.28 PSFS activity 3-0.11-0.19-0.00-0.21 QBPDS -0.22** -0.20-0.15-0.38* Number of treatment sessions -0.31** -0.30* -0.28-0.37* # <6 w; ## 6-12w; ### >12w; Spearman s r; * p<0.05; ** p<0.01
Correlation between guidelines adherence and outcome Guidelines adherence acute en subacute LBP and outcome 11 coefficients < - 0.20 (slight) 5 coefficients < - 0.40 (fair) 2 / 16 correlations significant Guidelines adherence chronic LBP and outcome 1 coefficient < - 0.20 (slight) 4 coefficients < - 0.40 (fair) 3 coefficients < - 0.60 (moderate) 5 / 8 correlations significant
Where do we stand now? Are we moving in the right direction? V. CONCLUSION
Conclusion Where do we stand now? Development, implementation, and evaluation Clinical guidelines (also in preparation) Methodology of key guidelines recommendations (flowchart) Quality indicators based on key recommendations in clinical guidelines with regard to LBP (methodology) Adherence to guidelines LBP Process indicators overall sufficient (66%); Range Diagnostic process 30 98% Range Therapeutic process 46 88% Outcome indicators: Pain and activities > MIC (30%); number of treatment sessions (6 to 7) No difference in percentages of process and outcome indicators between physiotherapists and manual physiotherapists Negative correlation (slight to moderate) between adherence to guidelines and outcome indicators
Are we moving in the right direction? Yes, but. Upgrading guidelines: New recommendations or changing level of evidence of guidelines recommendations Upgrading quality indicators based on key guidelines recommendations Development of web-based registration in daily practice; Database, transparency of care, and feedback on individual clinician s quality of care Increase of standard for the level of compliance with diagnostic and therapeutic process indicators to > 75% (target standard) Development of core sets of outcome instruments based on ICF Unsolved problem: Small correlation between process and outcome indicators Implementation strategies based on negative determinants of MPTs and patients
Are we moving in the right direction? Yes, but. More attention should be directed towards the level of evidence related to implementation strategies Dissemination of innovations and implementation of guidelines through multimodal strategies based on derteminants General strategies: Scientific journals, popular journals, direct personal mailing, internet, e-mail, computerized databases (Medline, PUBMED, Cochrane, PEDRO etc), video messages, etc. Personal strategies: Conferences, courses, local meetings, regular professional meetings, peer contacts, outreach visitors or trained facilitators, use of opinion leaders, telephone advice, etc.
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