AROC Clinical Benchmarking Workshop Review

Craig Evans and Tony Fitzsimons19th March 2010

What is AROC?

“Australasian Rehabilitation Outcomes Centre” – University of Wollongong

• Provide a national benchmarking system to improve clinical outcomes

• Collect outcome information - rehab centres across Australia (155) and NZ (12); ~ 1200 amputee rehab episodes

• Annual Reports (The AROC Annual Report: the state of rehabilitation in Australia in 2008 – http://chsd.uow.edu.au/Publications/2009_pubs/son_2008.pdf)

So what happened at the workshop?

• Greg Bowring – Practice guidelines for amputee management– VA/DoD Clinical Practice guideline for Rehabilitation of

Lower Limb Amputation (http://www.healthquality.va.gov/amputation/amp_sum_508.pdf)

VA – Amputation Rehabilitation Health-Related Outcomes and confounders

Current Guideline Outcome Measures

Models of Care

Highly variable between centres making benchmarking a difficult task!

Model Variation Factors• Availability of staff /teams• Inpatient rehabilitation admission criteria• Geographic location (metro/regional/remote)• Ability to slot clients into community services• Lack of local specialty expertise• Ability to access funding for home mods• “Parking” patients• Timing of prosthetic clinics and visits• Timing and type of prosthetic intervention.• Ability/funding to access technology to assist in healing, pain management,

& prosthetic phases• Prosthetic funding models• Patient Type changing

AROC Data

• Inclusions – full data sets• Exclusions – Ambulatory, outpatients, mortality

AROC Impairment Codes

Amputation of limbo 5.1 – Single Upper Extremity Above Elbowo 5.2 - Single Upper Extremity Below Elbowo 5.3 - Single Lower Extremity Above Kneeo 5.4 - Single Lower Extremity Below Kneeo 5.5 - Double Lower Extremity Above Kneeo 5.6 - Double Lower Extremity Above/Below Kneeo 5.7 - Double Lower Extremity Below Kneeo 5.8 – Partial Foot Amputationo 5.9 – Other Amputation

AN-SNAP Version 2 Classes

• Amputation of Limb– 2-224 Motor 72-91– 2-225 Motor 14-71*

*Cohort groups too broad. Smaller Cohort groups = smaller samples Functional vs “adequate sample” groups

SYNATIX Data Collection Form

Examples of Data Presentation

Hurdles to achieving outcome benchmarks

• Consequences of prolonged immobility• Presence of medical co-morbidities• Cognitive function• Adjustment issues• Learning capacity• Inappropriate accommodation• Intransigent attitudes

Agreed Stages of Amputee Management

New AN-SNAP Codes?FIM admission Motor

Count (n) Avg FIM change Avg LOS

14-40 91 23.66 47.96

41-60 242 21.01 41.17

61-71 206 12.63 34.54

72+ 111 5.74 23.74

Ceiling effect in higher FIM scores

New Data Collection

• Date of Surgery• Date ready for casting• Date of first prosthetic fitting – reason for delay• Clinically ready for discharge• Discharge Delay Reason

• Home mods• Equipment • Community support• ACAT / Residential Care availability

New Outcome Measures

• Ambulatory Data – FIM not sensitive enough• 6 min walk test• TUG• ?? 10mWT, Amppro, 4SST, K-classification, LCI, mobility aide and

assistance

• Other• Clinical Frailty index• MMSE ? – as a screening tool

What does it mean for us?

• Data collection

• What else should we be collecting that could make a difference or improve our practice?