Clinical Outcomes Mary Haven Research Methodologies in Allied Health.
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Transcript of Clinical Outcomes Mary Haven Research Methodologies in Allied Health.
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Clinical Outcomes
Mary HavenResearch Methodologies in Allied Health
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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
• Measurable 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 profession’s 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• Radiographs, 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
• Let’s consider what the patients want
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Health Related Quality of Life Measures
• 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$7.6 million/human life saved
•Childhood immunizationNo cost, saves money
Harvard School of Public Health
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Cost-Utility
Measure of effect per quality-adjusted life years (QALY’s) gained
Program Reported cost/QAL (1993$)
PKU screening <0Coronary artery bypass $3,500NICU, 500-999g $6,300Hemodialysis $54,000
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Community Acquired Pneumonia Dr. Brent James
% patients admitted 39% 29%Average length of stay 6.4 days 4.3 daysTime to antibiotic 2.1 hrs 1.5 hrsAverage cost/case $2752 $1424
Without guideline
With guideline
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Wilson-Cleary Model for Outcomes Research
PatientCharacteristics
EnvironmentCharacteristics
Biologic/ Physiologic
Variables
SymptomStatus
FunctionalStatus
GeneralHealth
Perceptions
OverallQOL
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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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• 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)
Public Release of Medical Outcomes Data in NY
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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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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 profession’s expertise is critical for quality patient care
• Design an outcomes research project to measure a new intervention in your filed