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THE CLINICAL APPLICATION OF OUTCOMES ASSESSMENT

This text offers both the seasoned as well as the new health care provider the ability to access outcomes assessment instruments of both subjective and objective types for immediate implementation into the clinical setting. See the table of contents for an overview of sections and chapters and the forward written by Stanley Bigos, MD. Please forward any questions to me.

Table of contents:

THE CLINICAL APPLICATION OF OUTCOMES ASSESSMENT
TABLE OF CONTENTS
INTRODUCTION
FORWARD: Stanley Bigos

SECTION I Outcomes Assessment Overview
CHAPTER 1 Why Outcomes? Why Now? (Dan Hansen, B. Mootz, S. Mior)
CHAPTER 2 Attributes to Look for in Outcome Measures (H Vernon, C Hagino)
CHAPTER 3 Subjective versus Objective, Qualitative versus Quantitative, and Provocative Testing: What does it all mean? (SY)
CHAPTER 4 Classification of Outcomes Assessment instruments (SY)

SECTION II Subjective OA Tools (These chapters will include an appendix of tools)
CHAPTER 5 General Health Questionnaires (SY)
CHAPTER 6 Assessment of Pain (SY)
CHAPTER 7 Condition-specific Outcome Assessment Tools (SY)
CHAPTER 8 Measuring Psychosocial Outcomes in Clinical Practice
(David Williams/Michael Feuerstein, MD)
CHAPTER 9 Patient Satisfaction and Experience (Tom Zastowney, Ph.D)
CHAPTER 10 Predicting Outcome in Low Back Pain (Jeff Fitzthum, DC, MD)

SECTION III Objective OA Tools
CHAPTER 11 High-tech verses Low-technology (David Stude, DC, Gunnar Andersson)
CHAPTER 12 Strength and Endurance Testing (Hennu Alaranta, MD, Ph.D.)
CHAPTER 13 Spinal Orthopedic and Neurological Testing (SY)
CHAPTER 14 Spinal Range of Motion: Is This a Valid Form of Outcomes Assessment? (SY)
CHAPTER 15 Outcome measures for the Upper and Lower Extremities (Jeffery Wilder)
CHAPTER 16 Measuring Physical Performance (SY)
CHAPTER 17 Functional Capacity Assessments and Low Back Pain (Bruce Hoffman-12)
CHAPTER 18 Cardiovascular Fitness Testing (William Defoyd, DC)

SECTION IV Application of OA to Clinical Practice
CHAPTER 19 Case Management in an Evidence-based Practice (SY)
CHAPTER 20 Integrating Outcomes Assessment into Clinical Documentation and Establishing an "Outcomes Based Practice" (Jeffery Wilder, DC)
CHAPTER 21 Identification of the Patient at Risk for Persistent or Recurrent Low Back Trouble (Craig Liebenson/SY)

SECTION V Practical reality: Commonly Asked Questions regarding Outcomes Assessment
CHAPTER 22 Putting Outcomes-based Management Into Practice (SY-0)
CHAPTER 23 Clinical Outcome Data Bases - Ed E. Dobrzykowski
CHAPTER 24 Positioning for the future: Using Outcomes Management To Enhance Customer Service (Robert D. Mootz, Daniel T. Hansen, Silvano Mior) - 0)

Forward:

The priests of Asklepios took an oath to put their patients' needs before their own and provide the best recommendations to their patients and colleagues. They did so to avoid the fate of Asklepios, slain by Zeus for becoming greedy and presumptuous. This became Hippocrates' Oath that physicians take today to protect us from the wrath of society or the gods for bad results. Our present day oath is defined further by the 1910 medical report by Abraham Flexner which pushed medical recommendations to be based upon science rather than a "mysterious process". Both of these historical issues still define the modern professional clinician and his or her link to being protected by being a good Samaritan. Unfortunately, today's professional faces a great challenge to balance the many aspects of what is considered appropriate care. The clinician must provide care that enhances the patient's self-reliance, while we are expected to maintain quality in a cost-conscious way. This not only opens the door but makes imperative the need for evidence based practice to become a reality. Health care delivery and financing, not to mention the expectations of the healthcare provider by both patients and health purchaser seem to be in an overwhelming, continuous state of flux. As the administrative side of practice requires more resources than ever before, the clinician sees reimbursement shrinking. Consumers demand the latest and greatest. Doctors desire to be as accurate as possible in diagnosis while anxiety over professional liability can often be at odds with the current state of the literature, payer policies, or government regulation.

Traditionally we have relied upon assumption-based science which provides so called "objective" indicators of physiology and function, only to learn that many of these tests and examination findings have limited value, are not reproducible, and at times even fail to accomplish what we expect. Our understanding is further complicated by new, more expensive medical technologies that are evolving at breakneck speed, based on either intuitive thinking or assumptions that require great leaps of faith to be applicable to our patients. Then, according to our oath, we must continue to try to guard against our fascination with technology from leading to further mysterious processes. Only outcomes management can provide particular attention to patient response in innovative and meaningful ways. Paying attention to a patient's health status, changes in their functional ability, auditing physiological indicators, and also the patient's satisfaction are becoming second nature to being a modern professional. However, in the state of today's health care system, it can be difficult to systematically balance all of these components. A reasonable use of outcomes assessment appears to be the only means to live within our oath and the expectations of our patients and society. Outcomes can provide needed tools to more effectively focus patients on meaningful treatment goals. Moreover, outcomes tracking can be integral to assuring the quality and relevance of the work you do with your patients. Outcomes management is essentially a toolbox that helps practitioners focus on what is important to the patient's life, rather than just the indirect clinical indicators we have been trained to rely upon for making many of our treatment decisions.

I hope you will find this book helpful in your professional practice. A section on pain-driven (self-report) outcomes is complemented by a section on provider-driven (including examination) outcomes, and pulled together with section on applying outcomes management in the real world of practice. This book is timely and brings the issue of outcomes management into focus within a single resource that has utility for any practitioner who works with musculoskeletal disorders. The information comes from a multidisciplinary cast of contributors who have been developing outcome management in the real world situations. There are clinical, academic and policy perspectives to consider, and while scholarly, the book remains relevant and practical. Its principal aim is to help newcomer and experienced practitioner alike to enhance clinical efficiency. There is an emphasis on simple and economic tracking mechanisms with the goal of returning patients to self-reliance as quickly as possible (something important to both patients and "the system" in general) being underscored. Although outcomes management has a learning curve, it is not a steep one. I think you will find that this book a resource to help ease the transition from business-as-usual to getting ahead of the curve by providing an appropriate context for gathering information from your patients. Since the AHCPR Guidelines on acute low back problems came out in 1994, I have often been accused of chiding my professional colleagues about specific interventions that might not really matter or even making a patient worse. We must begin to focus on function and results while avoiding the deconditioning inactivity. Overresting can physically and emotionally devastate the lives of our patients and their families. By sensibly incorporating meaningful outcome tracking in practice we as professionals may just be able to find out what we are really doing and what we can do better. Otherwise, we may provoke the return to those days prior to the Asklepion oath where Hammurabi's Code of 1700 b.c. states "Should a physician drain an abscess and the patient dies, cut off the hands of the physician." and technological advancement. Only through outcomes research can we be on firm ground to meet the many challenges that face today's clinician. Outcomes research not only keeps us in compliance with our oath but can avoid the temptations of shiny new technology returning us to the "mysterious processes" begun in the dark ages.

Stanley J. Bigos, MD
Professor of Orthopaedics & Environmental Health

University of Washington
Harborview Medical Center
325 9th Avenue, Box 359798
Seattle, WA 98104