ATP Series

Evidence & Outcomes

Will Evidence-Based Practices & Outcomes Measures Drive Complex Rehab Success?

Evidence-Based Practices & Outcomes

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You have so many complex rehab technology success stories. A grad student who now zips to class in an ultralight chair with power assist. A mom who takes her power chair to the office and weight shifts every hour. A dad who uses seat elevation to cook dinner. A first-grader who mastered her new head array.

Such successes are life changing. They are also hard to quantify in a spreadsheet. Pharmaceutical companies report that a drug lowered cholesterol in x number of trial participants, but it’s tough to prove that a custom-fit wheelchair cushion kept a consumer free of pressure injuries. Thus, funding and referral sources ask, “Does complex rehab technology (CRT) work?”

Efforts to justify CRT take many forms, from RESNA position papers to academic research (see the Functional Mobility Assessment [FMA] sidebar). In light of this push to measure CRT outcomes, we asked clinicians and ATPs: How critical are measurable, evidence-based outcomes to your decision making when choosing seating and mobility strategies and equipment?

Here’s what they said.

“A Unique System”

Delia “Dee Dee” Freney, OTR/L, ATP, occupational therapist
Continuing Care Service Center DME
Kaiser Permanente

First of all, we work for Kaiser. It’s a unique system. As DME therapists, we do High Mobility (CRT) clinics with an RTS [rehab technology supplier], submit the clinical report and approve (as funders) the recommended CRT. There are times where there are
co-pay funders such as MediCal/Medicaid, but for the most part, we are somewhat a “closed” system.

Even though we are first-level reviewers, there are often nextlevel reviewers who look at what is being approved and [deny] CRT. For example, most funding will not cover seat elevators and power assist. As clinicians, we document functional reasons these items would benefit the patient based on medical reasons such as transfers for seat elevators and shoulder pain and arthritis for power assist.

We’ve used RESNA position papers for tilt and recline to support our recommendations for adding these features to power wheelchairs and recently viewed the application of seat elevating devices for wheelchair users. As clinicians for an HMO, measurable, evidence-based outcomes support our recommendations for the clinical decisions we’ve made rather than influence our decisions.

More measurable, evidence-based outcome studies are important and critical to enable therapists, providers and funders to justify CRT for end users to enhance their lives with the best technology available and to be as independent as possible.

Perhaps evidence-based outcome studies would be helpful for new therapists coming into our world in making decisions for CRT.

Problem-Solving + Creativity

Michelle L. Lange, OTR/L, ABDA, ATP/SMS
Access to Independence, Inc.

I believe it is important to use outcome measures to track whether our recommendations have actually met a client’s goals. If we have no measure of the effectiveness of our interventions, we are less likely to modify — and hopefully improve — those strategies.

Yet on the other hand, I routinely encounter professionals who request evidence-based articles or assessments to help them determine the best interventions. I work with complex clients who are each unique individuals. It is unlikely that a journal article is going to specifically inform me as to where to place a switch for access to a communication device for a child with cerebral palsy. I still must rely on basic assessment, problem-solving, and a degree of creativity.

The Best, Not the Cheapest

Stacey Mullis OTR/L, ATP, director of clinical education
Comfort Company

When I look at our current climate, I think it is becoming necessary to have evidence-based outcomes in mind when choosing equipment. The IMPACT ACT of 2014 has brought increased transparency by requiring post-acute care providers to report standardized patient assessment data on quality of care and resource use. CMS [Centers for Medicare & Medicaid Services] then is publicly reporting on these quality measures, two of which can be related to seating and wheeled mobility: Percent of residents or patients with pressure ulcers that are new or worsened; all-cause unplanned readmission measure for 30 days post-discharge from long-term care hospitals.

This type of legislation highlights the emphasis being placed on evidence-based practice and quality of care. By providing evidence-based outcomes that show how proper equipment reduces the incidence of wounds and re-hospitalizations by improving function and productivity, we are justifying the need for selecting the best equipment for the individual, not cheapest. We then have data to demonstrate how providing the right equipment ultimately saves money.

Evidence As Advocacy

Philip Wegman, ATP, CRTS
Aspirus Home Medical Equipment

Patient outcome measurements and evidence-based practice are gaining steam in the industry — for good reason. Historically, the assumption of most funding agencies has been that CRT clients don’t need things the rest of us take for granted (being able to reach into a cupboard, or even standing, for example). That attitude, along with a general ignorance of the CRT industry, has led to inadequate funding — or no funding — for equipment that can keep people independent, healthier and living at home. Evidence-based practice and outcome measurements are the key to educating funding sources and others of the benefits of CRT.

Each client is unique. So our approach should be unique and client centered. Measuring outcomes by evidence of benefit starts at the initial evaluation by performing a Functional Mobility Assessment. Interview and document the client’s needs, desires and goals. This approach creates a team spirit between clinician, ATP/SMS and the end user. More importantly, it empowers the client to make decisions regarding his/her own care. With this baseline the client can be tracked after delivery to verify goals have been met. Poor marks on the FMA clearly show the need for a different approach. Documenting improved functional status can do much to establish the benefits of traditionally non-funded items, such as power seat elevators and standing devices.

Outcome measurements and evidence-based practice are one of the best ways we can protect access to CRT, and advocate for appropriate funding.

Collaboration Needed

Steve Mitchell, OTR/L, ATP
Cleveland VA SCI/D Service, Multidisciplinary ALS Clinic

Evidence-based practice is in healthcare what continuous product improvement is to a CRT manufacturer. The future of many of these products will depend on our collective willingness to adopt both approaches. Successful clinical outcomes require clinically effective products.

Standardized outcome instruments like the FMA can give us some idea about how well we are doing. Recently, we began administering the FMA and are contributing to the database. As one of the first [Spinal Cord Injury] Centers in the VA to start providing data, I am certainly interested to see what the “evidence” tells us over time.

I also know the usefulness of the data of a standardized outcome measure will always have limits in complex rehab. Limited sample sizes, complex needs and high heterogeneity among users guarantee it. The irony is that the harder we try to control variables and get “the numbers” needed to do a largescale, well-controlled scientific study, the less likely it will provide useful information. This applies to both clinicians adopting evidence-based practice or a manufacturer who uses continuous product improvement. Neither can get all the information they need unless they get the input and expertise of the other.

Lastly, we will never see meaningful peer-reviewed evidence published about the effectiveness of these products unless we share practice-based evidence. Oftentimes a less formal analysis of the practice-based evidence we can all collect in our individual settings can have a much greater effect on our clinical outcomes. When we identify common problems or potential solutions, we need to share those things in a responsible, qualified manner — not just to help someone else, but to allow others to examine, validate, propose alternatives or build upon what we’ve found.

The Importance to Manufacturers

Nancy Perlich, COTA, ATP, funding specialist
EasyStand/Altimate Medical

Measurable, evidence-based decision-making is of utmost importance whenever manufacturing or choosing any CRT. The more we know as a manufacturer (testing, consumer and clinical surveys, research, etc.), the more appropriate and defined products we can produce for the best outcome for the consumer. When clinicians use evidence-based outcomes and consumer-centered clinical reasoning, they add support to their choice of CRT and weight to their documentation that payors should understand, respect and pay for.

Lori Potts, PT
Rifton

Any clinician who has worked with children (or adults) with neuromotor impairments knows the importance of appropriate CRT. The therapy community has long recognized the importance of research-based evidence to validate and promote what we have known through our own experience, and when evidence-based research is available, it certainly impacts our clinical decision making.

However, particularly in pediatrics, there is a dearth of research. Many clinicians, myself included, rely on what is considered the lowest level of evidence, basing our decisions on outcomes of case studies and clinical experience. It is important to note that CMS seems to be placing greater emphasis on evidence-based practice when formulating coverage policies for DME. As clinicians and manufacturers, we need to advocate and collaborate for more and better research.

Elizabeth Cole, MSPT, ATP, director of clinical applications
ROHO/Permobil

One of our goals as an industry is to raise awareness that CRT products have features, technology and complexity that go beyond what is provided by DME. We want to show that these “high-end” products are not just for luxury or convenience, but that they provide medical and functional benefits not achievable with standard products. Being able to demonstrate their efficacy through outcomes measures and scientific evidence is critical to achieving this recognition, not only from funding sources that pay for them, but also from clinicians and suppliers who prescribe and provide them, and legislators who help us change policy.

The technology of CRT products available today is more sophisticated and complex than ever. Add that to the myriad choices of different makes and models of products, and the selection of the best wheelchair and seating for each individual can be a daunting task. I think it has become increasingly important for those involved in the selection of seating and mobility solutions to understand not only what works, but how and why it works. It’s important to understand the science behind the technology.

As an industry, we should be able to show that outcomes are improved when CRT is appropriately prescribed and provided. We should be able to demonstrate the decrease in incidence of things like pressure injuries, postural deformities, physiological complications, pain and hospital readmissions. Funding sources should be able to see overall cost-saving benefits. Clinicians and suppliers should be able to see the efficacy of their choices. And the consumers should be able to see the increase in independence, health and quality of life.

Ginger Walls, PT, MS, NCS, ATP/SMS, regional clinical education manager
Permobil

As a clinician, when recommending seating, positioning and mobility solutions for clients, I rely on a combination of three things: evidence from the research available; my clinical experience; and the needs/goals/preferences of the client.

Clinical experience is important because we learn from all our clients and interactions with the CRT team over the years.

Paying attention to new research, evidence about outcomes, and new technology is important because it informs our practice and helps us to consider why we are recommending what we do, as well as when to implement evidence into our practice and maybe try something different.

For example, if we are recommending a power wheelchair and a power seating system with tilt, recline and elevating legrests for a client who is at risk of pressure injuries and needs power seating to perform weight shifts, then we should also understand the evidence about power seat function utilization, compare it to our clinical experience, and make client recommendations accordingly. We know both from our clinical experience and from evidence that wheelchair users rarely access positions of tilt and recline necessary to achieve adequate pressure relief. We also know from evidence that users who receive smartphone basedcoaching on when to do pressure reliefs, what position to go to, and how long to stay there, improve their outcomes significantly in being able to follow an appropriate weight-shifting regimen.

If we understand from our client that they want to be as active, healthy, and independent as possible, stay in the wheelchair longer, get more things done, and mitigate risk for skin problems, then the recommendations are a good fit for the client as well.

Jennith Bernstein, PT, DPT, ATP, regional clinical education manager
Permobil

Achieving best practices when making equipment recommendations requires a combination of current research, clinical experience and client goals. Evidence-based solutions are essential to innovate practice patterns and equipment applications. When evidence is translated into a clinical tool that can be used in a treatment setting, the team can make a more informed decision to achieve optimal equipment recommendations for each individual.

A Balanced Approach

Missy Ball, MT, PT, ATP
PhysioBall Therapy

I value research and the insights it can provide the clinician, for example, with regard to best ergonomic setups for independent ambulation with least shoulder girdle damage, or tilt and recline applications to minimize or prevent pressure injury, improve functionality and comfort.

But I also value clinical expertise and judgment. Seating has evolved as a result of clinicians, equipment suppliers and manufacturers working jointly to meet a need and improve on it where possible. As a physical therapist, one of my roles is to analyze the movement and function of a client and promote improvement where possible. My clinical skills (knowledge of movement, observation and handling techniques) and past experience play a large part in a wheelchair evaluation. Through the use of these, I can make an informed decision regarding the specifics of seating details needed to aid the client, particularly with regard to the neurologically involved client, such as cerebral palsy or traumatic brain injury. The more multifaceted the problem of movement, the more difficult to design and measure specific parameters in the research. Possibly the reason for less research in seating and mobility in these areas. Hence, research and clinical expertise are both needed.

Angie Kiger, M.Ed, CTRS, ATP/SMS, clinical education specialist
Sunrise Medical

I think people can get too caught up in evidence. I don’t care how somebody mapped on a cushion in your study. I need to know how [my] actual end user is going to map on it, and also how they are going to use it.

I look at evidence if I’m trying to get funding, because the funding world doesn’t necessarily understand clinical best practice. They don’t understand how the person looks, and they don’t care how [a product] works. They want numbers. So I will pull up evidence for that. I know evidence has been very helpful in getting standers approved. Also, you will run across families who have tried everything and are tired of theories. They’re being told, try this, try that. More intellectual users will want to know why you’re recommending that.

Lauren E. Rosen, PT, MPT, MSMS, ATP/SMS, Motion Analysis Center Program coordinator
St. Joseph’s Children’s Hospital

When there are available, measurable, evidence-based outcomes for the patient I’m seeing, I feel it is very important to use them. Outcomes measures let me know if I’m truly making a difference in my interventions. Also, I’m part of the project collecting data on outcomes so that we can better establish the efficacy of what we do. This should help with funding as well as buy-in from referral sources and patients.

Unfortunately, there are no good measurable outcome tools for some patient populations. These would be dependent clients. In most cases our intervention is simply to better position them and prevent pressure injuries. For those clients, I wish we had better tools that could show positive benefits of our interventions.

That said, with the use of G codes in the adult population and the likelihood that they are coming to pediatrics once funding starts to pay based on those codes, we need to find better tools for all populations that are going to show the benefits of what we do. If we, as therapists, don’t show that we make a difference, the ability to work with this population may go away.

John Zona, ATP, CRTS, rehab & seating specialist
Reliant Medical Group
Durable Medical Equipment, Inc.

I would not say [evidence] is “critical” for determining product [choices], but it helps. In my clinics we strive to choose the best equipment to meet the needs of the patient. We ask, “What do you like and dislike about the old piece of equipment you have, and what are your goals with the new piece of equipment?”

Pitt’s Functional Mobility Assessment is by far the best I have seen as far as outcome measures go, but with any outcome measure, suppliers always want the highest ratings, and many times you can’t obtain high ratings if you can’t supply (usually because of insurance coverage) something they really feel they need (and you do also).

For instance, seat elevators are rarely covered (they should be) and that can skew the whole assessment, which is still very important to track, but has nothing to do with the supplier doing a good job or not.

One of the questions asks about transferring from one surface to another. Without a seat elevator, that may be very difficult or even impossible. That will get a “completely disagree” answer. That one item can skew many questions.

I think the outcome measures try, for the most part, to prove that rehab suppliers and clinicians are doing good work, making patients more comfortable, functional and healthier. Good seating can keep patients out of the hospital, which is very expensive and can be dangerous.

This article originally appeared in the March 2017 issue of Mobility Management.

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