CRT Trends: Big Data

Quality Assurance & the FMA: What Clients Say About CRT

Does Complex Rehab Technology Improve Function?

• Jul 01, 2018

Does complex rehab technology (CRT) work? Do the interventions of clinicians, rehabilitation technology suppliers and highly customized, individually fitted seating and wheeled mobility systems improve outcomes for clients with severe, permanent and sometimes progressive conditions that impact mobility?

If you’re among the professionals working daily with this population, you undoubtedly say yes. You’ve seen how positioning systems, wheelchairs and electronics make it possible for clients to live at home, work or go to school, and be involved in their communities.

But can you prove it to referral or funding sources? Do you have something to offer beyond personal experiences and anecdotes from colleagues?

With quality assurance results from the Functional Mobility Assessment (FMA) now being published, the answer is yes.

What Is the FMA?

In the June issue of Mobility Management, we reviewed the FMA, a 10-question survey that asks adults to rate their ability to perform various activities (e.g., reaching for objects, transferring, leaving their homes) before and after they started using their wheelchairs. Participants give responses on a scale of 1 (Completely Disagree) to 6 (Completely Agree), and they’re asked to complete the survey multiple times, to track whether their answers change over time, especially after being provided with properly chosen and fit equipment.

The FMA was developed by a team at the University of Pittsburgh, including Mark Schmeler, Ph.D., OTR/L, ATP, Associate Professor, Department of Rehabilitation Science & Technology. U.S. Rehab, a division of The VGM Group, has worldwide rights from Pittsburgh to “commercialize and collect data with the FMA,” according to U.S. Rehab President Greg Packer.

A paper on FMA outcomes was published this year, but Schmeler said, “This report is not yet research. This is quality-assurance work. VGM has members who are businesses, and they need quality-assurance metrics to be certified, just like Uber drivers need a rating. Quality-assurance metrics are part of society and part of what we do.”

Participating U.S. Rehab members have been collecting FMA numbers for years, and they use those scores to determine which clients need closer follow-up after wheelchair delivery.

Who Is Using the FMA?

The FMA information contained here came from almost 1,200 surveys of adults. (A family-centered version of the FMA can be administered to children and anyone else who would have trouble accurately self-reporting.)

Schmeler said the FMA has about 40 different diagnoses for clients to select from, but the results here focused on the top 10 most commonly reported conditions of people using CRT. The most common primary diagnosis was Stroke/Cerebral Vascular Accident, which was reported by 17.53 percent of respondents. That was followed by Other Neuromuscular or Congenital Disease (14.9 percent); Cerebral Palsy (9.91 percent); Multiple Sclerosis (9.74 percent); Spinal Cord Injury/Paraplegia (8.55 percent); Spinal Cord Injury/Quadriplegia (5.93 percent); Osteoarthritis (4.49 percent); Amputation (3.64 percent); Morbid Obesity (3.39 percent); and Spina Bifida (2.88 percent).

After that, the percentages for other diagnoses drop to 1 to 2 percent, Schmeler said: “We know we’ve hit saturation on diagnosis. We’re 99 percent sure that the majority of people who need complex rehab have a stroke, followed by neuromuscular disease, followed by cerebral palsy, followed by multiple sclerosis.”

Respondents were evenly split by gender (51.18 percent female, 48.82 percent male), and the average age of respondents in the sample was 59 years, though respondents ranged in age from 18 to more than 100 years old.

Survey respondents listed a number of primary insurance carriers (Chart 1), from Medicare (55.75 percent, the most common response) to Medicaid, Medicare Managed Care, Private Insurance/Fee for Service, Private Insurance/HMO, Medicaid Managed Care, Worker’s Comp, Private Pay, Vocational Rehab, and Veterans Affairs (VA).

Examining the CRT Effect

Chart 2 shows survey participants’ answers to the FMA questions that asked about the ease of performing 10 common, mobility-related activities before and after having a wheelchair.

“If I were to administer the FMA to you,” Schmeler explained, “I’d say, ‘On a scale of 1 to 6 — 6 being Completely Agree, 1 being Completely Disagree — your current means of mobility allows you to carry out your daily routine. It lets you do what you want to do when you want to do it.’”

Determining which activities to ask about was a process in itself, Schmeler added.

“Those 10 items are based on an analysis of about 2,000 goals that we had to systematically review in medical records,” he said. “Every time you see a patient for a wheelchair, you have to ask them what their goals and priorities are. So these are the top 10 priorities. This is what patients tell us is important; it is a patient-centered outcome. And patient-centered outcomes is the top priority in healthcare. That was what the Affordable Care Act did: It said, “We are going to shift away from randomized clinical trials using measures deemed important to clinicians,’ to ‘Not just what’s important to clinicians or researchers, but what’s important to patients.’”

In Chart 2, the Baseline numbers (in blue) show how patients answered prior to using a wheelchair. The Follow-Up numbers (in green) show their scores once they began using their wheelchairs. Patients were asked how well their comfort needs were being met; how well they performed daily routines; how well their health needs were being met; how efficient their mobility was indoors; how well they could operate equipment; how efficient their mobility was outdoors; how well they could perform personal care tasks; how well they could reach; how well they could transfer from surface to surface; and how well they could operate and use transportation.

In Chart 3, the Baseline numbers (in blue) show patient outcomes in those same 10 categories when no Assistive
Technology Professional (ATP) was involved in the seating and mobility provision process. The numbers in green show patient outcomes when ATPs were involved in the provision process.

Future Ramifications of CRT Outcomes

Currently, scores show that patients were more functional with wheelchairs than without them, and that involving an ATP in the provision process also resulted in higher scores than when ATPs were not involved.

Participating patients are asked for their perceptions multiple times. “We contact the patient, on average, five times in the first year,” Packer said of participating U.S. Rehab members. “If [a patient’s] score drops by a certain percentage, we’re contacting the clinician as well as the provider to reassess the issue. We make sure there has been patient contact by the provider to make an equipment adjustment or to change out a cushion or whatever needs to be taken care of. Once that’s done, we put [the client] back into the system for the next call.”

As time goes on and the amount of survey data grows, Schmeler said the FMA team will look for further indications of CRT’s impact.

“We’re looking at other factors in our uniform data set regarding whether we start to see changes in employment, living situations, transportation,” he said. “These are all variables that could be monetized, so when we get to a mass of 10,000 cases and we start doing discrete analyses, we can say within a certain level of confidence that if a person has C4-C5 quadriplegia, based on large data, this is the best chair for them. Not only will it change their self-reported mobility-related activities of daily living, but we’ve cut pressure sores by x percent. We’ve cut falls by x percent.

“Patients are no longer using ambulances to go to doctors’ appointments; they’re using public transportation, they’re using wheelchair-accessible Uber. These are all things that cost society less money. And when you look at the funding sources for this population, to me it’s alarming that almost 70 percent is on Medicare or Medicaid. That is the most expensive health insurance that tends to be less focused on preventive care. We want to see people go onto responsible managed care plans, but likewise need to educate these plans with outcomes.”

Having outcomes measures could also impact future funding policy.

“We’ve just started to scratch the surface on seat elevators,” Schmeler said. “We noticed an increase in satisfaction with reach and transfers, and we’re seeing a decrease in falls. One fall plus one visit to the emergency department is the cost of a wheelchair.”

So beyond affirming that CRT improves clients’ lives, and that ATP involvement in the equipment provision process improves functional outcomes, data gleaned from the FMA could impact clients’ overall health, and even affect coverage and funding policies.

“It’s a big public health project,” Schmeler acknowledged, “and we have two public health professionals on this team. They look at large populations and what’s happening to them.”

In Mobility Management August: A look at what FMA scores say about CRT wheelchair provision and Secondary Health Conditions. For more info on the FMA, go to www.FMA.USRehab.com, or contact Mark Schmeler at schmeler@pitt.edu or Greg Packer at greg.packer@usrehab.com.

This article originally appeared in the July 2018 issue of Mobility Management.