Clinical Outcomes

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Clinical Outcomes

• Mary Haven
• Research Methodologies in Allied Health

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Objectives

• After listening to lecture and participating
• in class discussion the student will
• be able to

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Objectives

• Name at least four measures of clinical outcomes
• Explain the output from a SF-36 assessment
• Formulate at least six questions for a patient
  satisfaction survey
• Discuss how the perspective of the evaluator can
  influence selection of outcome measures

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Quality and Outcomes

• The best measure of quality is not how well or
  how frequently a medical service is given, but
  how closely the result approaches the fundamental
  objectives of prolonging life, relieving
  distress, restoring function, and preventing
  disability. Lembcke,
  1952

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Why go to the Patient?

• achieving and producing health and satisfaction
  is the ultimate validator of the quality of
  care.
• Donabedian (1986)

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Outcome Definitions

• Changes in health status that can be attributed
  to care
• What comes out after you put something in
• Measureable events which occur as a result of the
  structure and process of health care

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Group Activities

• Identify a chronically ill patient, take the
  SF-36 from her/his perspective
• Design an outcomes research project to convince a
  hospital administrator that your professions
  expertise is critical for quality patient care
• Design an outcomes research project to measure a
  new intervention in your field

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Titles of Outcomes Articles

• A comparison of physical therapy, chiropractic
  manipulation and provision of an educational
  booklet for the treatment of lower back pain
• Severity-adjusted mortality and length of stay in
  teaching and nonteaching hospitals

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Quality of Life after Knee Replacement

• Previous studies focused on
• Improvements in joint mechanisms
• Post-operative complications
• Patient assessments
• Pain
• Physical function of the knee
• Physical function
• Satisfaction with result
• Context of overall health

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Types of Outcomes to Measure

• Mortality
• Morbidity
• Physiological/Physical
• Patient Satisfaction
• Patient Compliance
• Health Related Quality of Life
• Costs

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Mortality and Morbidity

• The traditional province of the physician
• Severity index necessary

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Physiological/Physical

• Often the domain of the allied health
  professional to be the practitioner who measures
  these variables
• Laboratory values
• Functional status
• Blood gases, coagulation tests
• Radiologic/ultrasound/CT/MRI/nuclear images

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Patient Satisfaction

• Examine a patient satisfaction survey from your
  institution
• Difficult to measure
• Demanded of provider groups by contracting
  entities
• Surveys easier than phone or individual interviews

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Health Related Quality of Life

• Patient perceptions are crucial
• Ability to engage in activities of daily life
• Self-care
• Role function
• Social function
• Perceived well-being
• Lets consider what the patients want

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Health Related Quality of LifeMeasures

• SF-36, http//www.sf-36.org/demos/SF-36v2.html
• COOP charts
• Duke-UNC Health Profile
• Sickness Impact Profile
• McMaster Health Index Questionnaire
• Nottingham Health Profile
• Quality of Well-Being Scale

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Types of Outcomes to Measure

• Costs
• From whose perspective?
• Patient
• Institution
• Society

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Cost-Effectiveness

• Dollars/life saved
• Dollars/case of disease prevented
• Dollars/year-life gained

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Cost-Benefit Analysis
Net social benefit of a program

• Radiation Safety Program
• 10 million/human life saved
• EPA
• 7.6 million/human life saved
• Childhood immunization
• No cost, saves money
• Harvard School of Public Health

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Cost-Utility

• Measure of effect per quality-adjusted life years
  (QALYs) gained
• Program Reported cost/QAL (1993)
• PKU screening lt0
• Coronary artery bypass 3,500
• NICU, 500-999g 6,300
• Hemodialysis 54,000

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Community Acquired Pneumonia Dr. Brent James
With guideline
Without guideline
patients admitted 39 29 Average length of
stay 6.4 days 4.3 days Time to antibiotic 2.1
hrs 1.5 hrs Average cost/case 2752 1424
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Wilson-Cleary Model for Outcomes Research
Patient Characteristics
Biologic/ Physiologic Variables
General Health Perceptions
Symptom Status
Functional Status
Overall QOL
Environment Characteristics
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Strengths of Outcomes Research

• Addresses a broad range of questions
• Takes into account patient preferences and the
  social utility of treatment outcomes
• More generalizable to community providers,
  patients, practices
• More immediate structural applications

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Limitations of Outcomes Research

• May not be able to prove causation
• May not adequately characterize treatments
• May not be able to control all biases,
  confounders and interactions
• Findings may be more vulnerable to
  misinterpretation and abuse

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Public Release of Medical Outcomes Data in NY

• Data on risk adjusted mortality after CABG
  surgery made public since 1989
• Hospitals and surgeons identified
• Data used to stimulate improvement
• Statewide risk-adjusted mortality fell 41 in
  first 4 years (1989-92)

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Randomized controlled trial of rehabilitation in
CRD

• Subjects 39 men with dyspnea on exertion
• Randomized to treatment and non-treat.
• Treatment was rehab 6 wk.
• Subjects who received rehab felt better and
  improved 12 min walking and max. oxygen uptake
  initially and after 4 mos.

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Coronary risk factors in Type II diabetes
response to low-intensity aerobic exercise.

• Subjects were NIDDM, 9 female, 7 male
• Randomly assigned to treatment
• VO2 max, ht, wt, BP, pulse, treadmill test,
  blood glucose, total triglycerides and
  cholesterol
• Increase in VO2 max, decrease in BP, resting
  pulse, total triglycerides

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Occupational therapy helps elderly in study, OWH
1997

• Teach elderly people how to keep up their daily
  activities
• Improves physical and mental health
• Helps them live independently
• Saves money by delaying reliance on expensive
  nursing home care

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