Restorative Services Authorization/Denial

and Outcomes Assessment

9th Annual Labor Commission/Workers Compensation Educational ConferenceSeptember 29, 2011

RSA“Spine”

OUTCOMESOutcomes Assessment

Collection and recording of information relative to health processes

Outcomes Management Using information in a way that

enhances patient care (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical

Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)

“Medical Necessity”The fully developed clinical record defines the

“medical necessity” of the case in the eyes of the insurer.

4 Steps to Become Outcomes BasedUtilize subjective/objective toolsScore the tools at the initial visit to establish baseline

measuresRepeat the instrument after 2-4 week intervals to

track the effects of treatment changesBase clinical decisions on the outcome results

“Medical Necessity” DocumentationProvider must document

Etiology of complaint(onset, severity, frequency , duration

Patient’s health historyCurrent subjective complaintsCurrent objective clinical findingsDiagnosisTreatment planMeasurements of patient improvement (outcome

assessment)

The Era of Outcomes AssessmentOutcomes in clinical practice provide the mechanism

by which the health care provider, the patient, the public, and the payer are able to assess the end results of care and its effect upon the health of the patient and society. (Anderson & Weinstein, 1994).

Provider AccountabilityHealth care providers must be accountable and be

prepared to maintain and provide appropriate documentation and patient records in a clinically efficient and economical manner. (Hansen, 1994).

Health PolicyWith the dawning, of the “ new era of

accountability,” there are new social mandates directed toward health care providers and health-related facilities. Measurements of quality, satisfaction, efficacy, and effectiveness now serve as essential elements for health care decisions and matters of health policy.(Hansen DT, Mior S, Mootz RD in Yeomans SG: The

Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)

Outcome MeaningsHealth Care Customer - Meaning of Outcomes

Payers-purchasers Cost containmentRegulators HCP complianceAdministrators Efficiency-low utilizationClinical Researchers Proof of a premiseOutcomes Experts Patient’s benefitHealth Care Providers Clinical-Health Status

(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical

Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)

Outcomes CriteriaUtility Is it useful?Reliability Is it dependable?Validity Does it do what it is supposed to?Sensitivity Can it identify patients with a

condition?Specificity Can it identify those that do not

have the condition?Responsiveness Can it measure differences

over time?

Outcome Measures Appropriate for Clinical Use

QuestionnairesGeneral health statusPainFunctional statusPatient satisfaction

Physiological outcomesUtilization measuresCost measures

Outcomes Measures Appropriately UsedWhen outcome measures are appropriately used

and integrated into an evidence-based, patient-centered model of practice, there is accountability and quality assurance.

(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)

Subjective QuestionnairesSubjective outcomes assessment information is

gathered by the patient in self-administered questionnaires and scored by either the:health care providerstaff members by a computer

Subjective QuestionnairesIn spite of the definition associated with the term

“subjective,” these “pen-and-paper tools” have been described as very valid and reliable – in many cases more so than many of the “objective’ tests that health care providers have relied upon for years.

(Chapman-Smith, 1992; Hansen, 1994; Mootz, 1994).

Subjective vs ObjectiveIt must be emphasized that although the term

“subjective” carries negative connotations, the reliability/validity data published regarding these methods of collecting outcomes is exceptional, typically out-performing the test-retest reliability and validity of most “objective” physical performance tests. (Chapman-Smith, 1992).

Classification of Outcome Assessment ToolsSubjective

(Patient Driven)General HealthPain PerceptionCondition or Disease

SpecificPsychometricDisability PredictionPatient Satisfaction

Objective (HCP Driven)

Range of MotionStrength - EnduranceNonorganicProprioceptionCardiopulmonaryDevelopmental

Outcomes Assessment Tools

It is important to remember to utilize the same outcome assessment tool through the course of case management with each patient.

General Health Questionnaires (GHQ)One can benefit from the use of a GHQ because it is

not condition-specific and, therefore, can be applied to virtually any complaint.Yeomans SG: The Clinical Application of Outcomes

Assessment, Stamford Connecticut, Appleton & Lange, 2000

Application of General Health Questionnaires (GHQ)The application of a GHQ should, at minimum,

be used at the following intervals:At the time of the initial presentation for baseline

establishment of outcomes assessmentTo identify problems for prompt managementAt a plateau in care or discharge for outcomes

assessment of the treatment benefits or lack thereof

Six months after discharge in order to evaluate the long-term benefits of treatment

Outcome-Based PracticeCorrelating this information to the patient’s

specific clinical data and then making a clinical decision based on the results, represents a difficult but important step in making the “paradigm shift” into becoming an “outcome-based” practice.Yeomans SG: The Clinical Application of Outcomes

Assessment, Stamford Connecticut, Appleton & Lange, 2000

Condition-Specific OutcomesOver 40 low back functional questionnaires exist

with five identified by researchers as “gold standards” (Kopec and Esdaile, 1995).Sickness Impact Profile (Bergner et al, 1981)Roland-Morris Disability Questionnaire (Roland

and Morris, 1983)Oswestry Low Back Pain Disability Questionnaire

(Fairbank et al, 1980).Million Visual Analogue Scale (Million et al, 1982).Waddell Disability Index (Waddell, 1984).

Pain Perception Visual Analogue Scales

Reliable and valid (Jensen and Karoly, 1993).Advantages over other measurement methods (Scott

and Huskisson 1976, Price et al 1994).

Quadruple Visual Analogue Scale (QVAS) Four specific factors - Von Korff et al, 1992

CURRENT Pain LevelAVERAGE or TYPICAL Pain LevelPain level at its BESTPain level at its WORST

Final ScoreRatings are averaged x 10 = TOTAL SCORE

(Range 0 – 100)

QVAS

QVAS – GuidelinesChronic Patient

Average Pain = Last 6 monthsAcute --- Frequency Use

Every 2 weeks since a patient’s failure to progress over a 2-week period may indicate a need for a change in management approaches (Haldeman et al, 1993).

Revised Oswestry

The Oswestry Disability Index (aka: Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient's permanent functional disability. It has become one of the principal condition-specific outcome measures used in the management of spinal disorders.

The test has been around for 25 years and is considered the "gold standard" of low back functional outcome tools.

Revised OswestryRetitled section 8, now identified as “Social Life,” This section was originally entitled “sex life” and

was left blank quite often by respondents.In the revised version, all ten sections are

completed more often than in the original version. Hudson-Cook N, Tomes-Nicholson K, Breen AC. A

Revised Oswestry Back Disability Questionnaire. Manchester Univ Press, 1989.

RevisedOswestry

Scoring the OswestryThere are ten sections and each section is scored 0-5 points.

Now, simply add up the points for each section and plug it into the formula to calculate the level of disability:

'point total' divided by '50' multiply by ' 100 = percent disability)

For example: If the total points were 14

14/50 X 100 = 28%

Oswestry - Score Interpretation

0-20% Minimal Disability20-40% Moderate Disability40-60% Severe Disability60-80% Crippled80-100% Bed Bound or

Exaggerating

Ref> Fairbank JC, Pynsent PB, “The Oswestry Disabilty Index” Spine 2000; 25(22):2940-2952

The Revised Oswestry

• Use as a baseline every two weeks

• A 5 point change is required to be minimally clinical different or meaningful

• The provider should avoid “treating to zero” as it not currently clinically supportable

Oswestry Questionnaire (Discharge Score)A score of 11% may be used as an appropriate cut-

off score for health care providers to consider for discharge and/or return to work in an uncomplicated Low Back Pain case. (Erhard et al 1994)

Neck Disability Index (NDI)“was designed by modifying the Oswestry Low

Back Pain Disability Questionnaire”“The instrument was utilized on an initial sample of

17 consecutive patients with whiplash injuries with good statistical significance reported”.

Neck Disability Index

 

Howard Vernon, DC, PhD

BACKGROUND:   Published in 1991, the Neck Disability Index (NDI) was the first instrument designed to assess self-rated disability in patients with neck pain. This article reviews the history of the NDI and the current state of the research into its psychometric properties--reliability, validity, and responsiveness--as well as its translations. Focused reviews are presented into its use in studies of the prognosis of whiplash-injured patients as well as its use in clinical trials of conservative therapies for neck pain.

SPECIAL FEATURES:   The NDI is a relatively short, paper-pencil instrument that is easy to apply in both clinical and research settings. It has strong psychometric characteristics and has proven to be highly responsive in clinical trials. As of late 2007, it has been used in approximately 300 publications; it has been translated into 22 languages, and it is endorsed for use by a number of clinical guidelines.

SUMMARY:   The NDI is the most widely used and most strongly validated instrument for assessing self-rated disability in patients with neck pain. It has been used effectively in both clinical and research settings in the treatment of this very common problem.

J Manipulative Physiol Ther 2008 (Sep); 31 (7): 491-502

The Neck Disability Index

• Use as a baseline every two weeks

• A 5 point change is required to be clinically meaningful

• The provider should avoid “treating to zero” as it not currently clinically supportable

Interpretation:0-4 = no disability5 - 14 = mild15 - 24 = moderate25 - 34 = severeabove 34 = complete

The Neck Disability Index

There are ten sections and each section is scored 0-5 points. Simply add up the points for each section and plug it in to the following formula to calculate the disability: point total / 50 X 100 = % disability For example: If the total points were 14

14/50 X 100 = 28%