With more and more attention being directed toward outcomes, do we have a good working definition of functional outcomes?
What is meant by functional outcomes? Functional outcomes define results of care focused on the patient's physical ability. When patients receive rehabilitative services, they are likely concerned about results that matter to them. Sharing typical results with them helps set realistic expectations.
If you consider the stages of life, you can appreciate that physical ability entails a broad spectrum. A broad spectrum of physical abilities adds a layer of difficulty in measuring functional outcomes. The two main ways to determine a patient's physical ability is to either ask about abilities or to observe physical ability.
Functional outcomes determined by asking a patient about physical ability are captured by patient reported outcome measures. When using this process, the patient self-reports physical ability through some sort of process that involves rating ability to perform a specific task. Back in the 1970's this involved paper and pencil questionnaires. Over the years, science and technology have led to computer adaptive testing which is the preferred method due to higher accuracy and "smart" intuitiveness that adapts to the patient's response. A score has immediate meaning because computer adaptive testing will rely on functional staging to define and describe the patient's physical ability.
Functional outcomes determined by observing physical ability is called performance testing. Performance testing provides a snapshot of physical ability for a specific task. Typically performance testing will involve timing the performance of a task, counting the completed repetitions of a specific task performed during an allotted amount of time, or observing a sequence of movement patterns and scoring the performance. With this type of testing, the clinician is rating or scoring the physical ability.
Neither measurement process is perfect. Each has advantages and disadvantages.
Let me share my thoughts on patient reported outcome measures. When using computer adaptive testing, this option for determining functional outcomes is fast and easy. On the down side, a clinician may disagree with the final score. The most difficult thing to remember with any patient reported outcome measure is that the score reflects the patient's perception. Although this is difficult to grasp when there seems to be a disconnect between reality and patient perception, the positive to remember is that patient perception changes. As the patient's perception changes, a good patient reported outcome measure will capture that change. From a clinical perspective, tracking change assists with clinical decision making, improves dialogue with the patient and increases patient engagement. When using patient reported outcomes, a huge advantage is the ability to risk adjust patients to provide a prediction on the outcome of care.
Predictive analytics are important for both patient engagement and determining quality benchmarks. It is no longer enough to just measure functional outcomes. Risk adjusted aggregated data is required to provide meaning to the quality of care.
Performance testing has an advantage in providing concrete physical ability for the specific task observed. Typically with performance testing there are cut-off points that assist with clinical decision making. The main examples I can think of include return to sport, risk of injury, and risk of falling. In some cases, such as comfortable gait speed, the result can be mapped to a particular level of function or a prediction of falling or mortality. For some performance tests, normative data is available for certain ages or populations. This leads to the interpretation of some performance testing as resulting in below, above or normal performance. A key component in performance testing is using the appropriate performance test for the right population. Not considering the population in which the test was designed increases the risk of floor and ceiling effects. I'm not aware of performance test results having the ability to be risk adjusted. This reduces the capability for results to be fairly compared between clinicians.
Functional outcomes are becoming more and more relevant for rehabilitation providers. Clinicians focus on maintaining or improving physical ability.
Until next time,