FOTO Rehab Outcomes

Outcomes are Not Created Equal - Part II

As you are researching your rehabilitation options for capturing the change that happens throughout the course of an episode of care, please realize that all outcome tools are not equal. FOTO Team touched upon this outcomes inequality in Part I and I'd like to go into a bit more depth.


The art and science of patient reported outcomes has advanced over the years. Just as the science and clinical interventions in rehabilitation have evolved and changed over the years, so has the science of patient reported outcomes. As you come to understand the benefits of merging technology into patient reported outcomes, it is doubtful that you'll favor your currently familiar paper and pencil options, like for example Disabilities of the Arm, Shoulder and Hand (DASH).

Science has evolved to include the power of technology in capturing patient reported outcomes. Computer adaptive testing (CAT) is no longer the wave of the future. It is here and it is now. For those who are unfamiliar with it, it feels scary because the clinician can't see the process. How does a computer capture how well your patient perceives his or her ability to function?

Patient reported outcomes fall into two categories: paper and pencil tools or CAT. The paper and pencil tools HAVE merged with technology. For example the Oswestry Disability Index, the DASH, the Neck Disability Index, and the Lower Extremity Functional Scale (LEFS) can be completed on a computer or a tablet. All technology has done is saved a tree and saved your time scoring the responses. The tool is the same and nothing has been changed with the psychometric properties of these tests by using technology as the medium for distribution.

Luckily, the legacy tools (those paper and pencil tools you've loved for years) created an initial starting point of sorts for CAT. Think of what the original paper and pencil tools looked like. The patient responded to 15-20 items, right? CAT is really not much different with regard to available items within it. Although all CATs are not the same, what they all have in common are a whole lot of items listed within them. Often times, the number of items listed within a specific CAT is much greater than the paper and pencil tools. The reason for this is because the goal of the CAT is to individualize the functional ability for each patient.

How does CAT individualize a patient reported outcome? CAT is smart! Seriously, common sense is built into the technology. Common sense is not applied when it comes to paper and pencil tools. Let's pretend you have a patient who recently had surgery and is using crutches in a non-weight bearing status. With a paper and pencil tool like the Lower Extremity Functional Scale, the patient will have to respond to all the nonsensical items of hopping, walking a mile, running on even ground, running on uneven ground, and running while making sharp turns. CAT has common sense built into its processes so that this very same patient would not be responding to all those items that obviously are not possible at that time. (That does not mean that higher level activities would not be asked by the CAT, the CAT does need to reach a stopping point based on responses indicating an inability to perform an item or two.) The common sense approach highly individualizes your patient's experience while more accurately scoring your patient's function.

Speaking of scoring function, the interpretation of the score when using a CAT is exquisite. In all seriousness, I totally love this aspect. The specialness is for two reasons: 1) (This reason is personal, skip to #2 for a more meaty reason.) Many years ago Dennis Hart and I had an online debate about CAT scores. Anyone who knows me knows that I'm not bashful in saying what I think or discussing an issue of which I am passionate. I hated the CAT interpretation of the score - really, really! At the time, the score was left to being only a number. What does a number mean? What does it mean for the patient? And then, this research started being published! I still remember the email I sent to Dennis - I SO appreciated it. I can only describe the scoring interpretation as brilliance. 2) Item mapping within CAT to create functional staging

I'm sure you are loving the idea of individualizing both your patient's experience and obtaining a more accurate score. Hopefully you find it beneficial to have a clear interpretation of a score. Earlier in the post I mentioned the CAT has a lot more items within it than the paper and pencil tools. So now you are probably wondering how much time will using a CAT versus paper and pencil take? Here's another beauty of a CAT. A single CAT takes approximately 1-2 minutes to complete - that's it! Paper and pencil (EVEN if they are distributed using a technology medium) tend to take about 5-10 minutes to complete depending on the patient reported outcome. The reason for the time difference goes back to CATs being smart. The response your patient provides determines the next item to give to your patient. A CAT does not require a response to every single item within the test to determine a functional score.

How can CAT be dynamic? This is a two-fold question. The process itself is dynamic due to how individualized it is based on the response from your patient. Interestingly, it is also dynamic in another way. Let's pretend that the majority of the population in the world had a huge change; the vast majority either had a single or double lower extremity amputation above the knee or below the knee or were paralyzed from the waist down. We obviously know the LEFS has the potential to be quite poor for these types of problems. With a bit of time and research, a CAT can be adapted to an increased need for new items in the test bank. A CAT has the flexibility to grow and expand. 

If a CAT seems to fit your needs, you have two options in the rehabilitation world: Activity Measure for Post Acute Care (AM-PAC) and FOTO.

Until next time,