Status surveys evolve as managed care tool

Practices use SF-36 for screening, monitoring

To find out whether their patients are getting better, physicians often begin with one sweeping, seemingly casual question: "So, how are you doing?"

Health plans ask the same question of patients — but increasingly they’re using a quantifiable tool, a health status survey such as the SF-36. To keep up with this trend, physicians should become familiar with the health status survey and consider adopting its use, outcomes experts say.

Rather than having a health status survey imposed by health plans, "it’s important for the clinician to be very involved in choosing how and where this particular technique would help them," says Dwana Bush, MD, an Atlanta family physician and president of the Integrative Health Institute, an organization that trains health care providers in use of the SF-36.

The SF-36 is a 36-question survey published by the Medical Outcomes Trust in Boston that measures eight categories, including physical, emotional, and social functioning. A version of that survey, called the Health of Seniors Survey, is a part of the Health Plan Employer Data and Information Set (HEDIS 3.0) of the National Committee for Quality Assurance (NCQA) in Washington, DC. It measures a sample of patients to determine if their health is deteriorating, improving, or staying the same.

Some managed care organizations also use the SF-36 to assess new enrollees or to monitor certain groups of patients with chronic illnesses.

Don’t underestimate patients’ emotions

Those surveys provide health plans with information that individual physicians don’t have. Without such tools, physicians often underestimate their patients’ physical and emotional problems, says John E. Ware Jr., PhD, senior scientist and director of the Health Assessment Lab at the New England Medical Center in Boston. "Doctors are missing the mark every day," he says.

Quick scoring of the SF-36 requires access to computer software, which can cost $3,000 to $5,000. (For more information on SF-36 resources, see box, at right.) Ware is testing a new, interactive version of the SF-36, in which questions are tailored to the patient’s previous responses. The patient might respond to fewer questions overall, but the "dynamic" tool would provide a more accurate health assessment, he says.

There are several approaches to introducing the health status survey into clinical practice:

- Use as a screening tool.

For example, imagine before entering the exam room, a doctor knew that a hip patient’s physical function had improved but emotionally the patient was depressed. Would that change the doctor’s approach to the patient’s problem?

Or what if a patient reported symptom improvement, but the physician noticed that the patient still limits daily activities.

"One of the most successful initial uses [of the SF-36] in clinical practice is in screening," says Ware. "You can ask, ‘Is this patient at, above, or below what I think they should be, given the age or medical condition?’"

With current technology, patients fill out the SF-36 in the reception area, either on a scannable card or a touch screen. Various vendors provide software that produce reports with bar charts showing the patient’s functioning and comparing it to previous surveys.

"It’s like a whole-person vital sign," says Bush. "How the whole person is functioning is very important."

Bush cautions, though, that the assessment can suddenly reveal higher numbers of patients with mental health disorders, such as clinical depression. Health plans that use the SF-36 or encourage physicians to use it also should help provide resources to adequately treat those newly identified patients, she says.

"There’s definitely a risk of overmeasuring and underresponding," she says.

- Use in patient subgroups.

Older patients are the first group targeted by NCQA for health status monitoring. But outcomes experts say it is likely that the diabetes measurement set currently under development will include a health status or quality of life element. (See related story, p. 114.)

The SF-36 allows physicians to gauge how well they and their patients are managing various chronic diseases. It can help reduce overutilization of health care resources. For example, if the survey determines that an asthmatic patient is depressed or anxious, that might clue the physician to work on the patient’s emotional needs as well as addressing management of the asthma, says Bush.

"These [distressed patients] are the people who are going to get their diseases out of control and end up in the [emergency department]." says Bush. "It makes it look like you’re managing their chronic disease poorly, but in truth, the patients have to manage themselves."

Surveying only certain subgroups of patients who have frequent doctors’ visits, such as diabetics or asthmatics, provides comparable data within a clinical practice. But it can also present some logistical issues, cautions Harry Wetzler, MD, senior vice president for clinical affairs and POSIT (Patient Outcomes and Satisfaction Via Interactive Telecommunications) for Health Process Management in Doylestown, PA, a health information firm.

"If you’re going to target groups for using the instrument, then somebody has to do that targeting," says Wetzler. "You have to have somebody (on staff) make the decision this person gets the SF-36 and this person doesn’t."

- Use to demonstrate health status improvement.

Bush has been using health status surveys on all her patients since 1995. The result: She now has functional health information on 700 patients within one HMO. "That gives me a better opportunity to talk about the appropriateness of utilization and capitation rates," she says.

SF-36 is a valid predictor of utilization rates, Bush says. Eventually, this tool could be used to adjust capitation rates, allowing higher payments to cover patients who are higher potential utilizers.

Also, with the SF-36, Bush can demonstrate successful treatment. For example, Bush has shown an improvement in her patients’ mental health scores over time.

Technology currently under development would allow patients to answer health status questionnaires through automated responses on the telephone, which would provide follow-up beyond scheduled office visits. "One to three months later you’d like to know how this person is doing," says Wetzler.

Health status surveys can prove to be a valuable resource in discussions with health care purchasers, as well. Two of the survey’s subscores reveal how physical or emotional problems are impacting the patient’s work or daily activities. Improvement in those scores means a more productive worker.

"You’re giving the purchaser, who is an employer, a chance to make a value-based buying decision as opposed to going for the lowest cost (of health care)," she says.