Are patients’ lives better after your procedures?

Tap into new outcomes tools to find out

Six months after your patients go home, are they better off because of the procedure performed at your facility? Thanks to a recent surge of research into functional outcomes monitoring, hospitals now have the tools to answer that question.

Special assessment tools measure whether specific procedures improved patient functioning. You can use this kind of functional outcomes information as a benchmark for quality improvement efforts and as ammunition in managed care negotiations.

Documenting the value of care

The National Association of Healthcare Quality has even included the SF-12 functional assessment survey as part of its formalized Health Employer Data and Information Set report, saysDennis Kaldenberg, PhD, manager of research and development with Press, Ganey Associates, a patient satisfaction measurement firm in South Bend, IN. It looks like managed care organizations will have to start doing functional assessments if they’re going to do HEDIS reporting, he says.

The most commonly used functional assessment tools are the short form with 12 questions — or SF-12 — and the short form with 36 questions — SF-36— both based on lengthy assessments and developed by a team of researchers over a number of years at The Health Institute of the New England Medical Center in Boston.

Functional assessment data allow hospitals and physicians to document the value of care, says Tom Statzenback, executive director of the Chicago-based American Association of Ambulatory Surgery Centers, formerly the American Society of Outpatient Surgeons. The society began an outcomes database to help members do just that. Prior to its development, there was nothing documented in outcomes research to substantiate the quality of outpatient surgery programs.

Price won’t be the only issue

"Ultimately, everybody’s going to squeeze all the price [difference] out, and prices are going to be just about the same" among competitors, saysMichael Pine, MD, MBA, president of Michael Pine and Associates, a Chicago-based consulting firm that specializes in measuring health care quality. "[Payers] are going to be looking at what they’re getting for their money. You have to establish that you not only do it cheaper, but you also do it better. Better is much harder to compete with than cheaper."

This trend toward measuring changes in patients’ quality of life creates a new paradigm for hospital managers, who must now follow up with patients beyond the 24-hour phone call, says Steven Strasser, PhD, president and chief executive officer of Healthcare Research Systems in Columbus, OH. This firm conducts outcomes measurement studies for providers, payers, and employers. Strasser also is an associate professor in the college of medicine at Ohio State University in Columbus.

Outpatient surgery department leaders should work together with physicians to track patient functioning until full recovery takes place, he advises. "This is going to be very powerful information. It helps you improve care. It helps you compete for managed care contracts. It improves morale among your staff by showing how their efforts improved patients’ lives. And it tells the customer you care."

The SF-12 and SF-36 are geared toward a general population and ask patients if and how much their health limits activities such as stair climbing, bending and stooping, walking half a mile, or bathing and dressing. "They’re trying to assess the extent to which the patient feels like their physical health is reducing what they’d like to do," Kaldenberg says.

Hospitals often use the tools with hip and knee replacement patients to assess the change in their health status from pre- to post-treatment. "You give the same questionnaire before the surgery, six months after, and 12 months after, and look for improvement in reported health status. One would expect that the scores would improve from pre-treatment to post- treatment. It’s in that way that some people have argued that it is a good outcomes measure," Kaldenberg says.

Other, more diagnosis- or procedure-specific functional assessment tools are becoming available as well, from the Health Outcomes Institute in Bloomington, MN, and various professional associations.

Ophthalmic surgery, for example, is on the forefront of outcomes measurement, particularly with cataract and refractive procedures. Physicians and outpatient surgery programs have had an impetus to prove their success: The Agency for Health Care Policy and Research in Rockville, MD, has created practice guide-lines that state the decision to perform cataract surgery should be based on whether the cataract is interfering with the patient’s daily functioning. And the Health Care Financing Administration in Washington, DC, has proposed a Medicare regulation requiring physicians to document medical necessity.

Providence Health System in Portland, OR, wants to prove its cataract surgeries are improving the quality of patients’ lives, says Laurie Skokan, PhD, senior research associate with the health system’s Center for Outcomes Research and Education. The health system, with participation from 20 physician’s offices, tracks visual functioning (VF) before surgery and at four and 12 months after surgery.

The VF-14, a survey developed by researchers at Johns Hopkins University in Baltimore, provides a reliable way to measure patients’ visual functioning, such as how easily they can read street signs or pursue hobbies such as knitting, Skokan explains. (See sample questions from the VF-14 survey, p. 51.)

"The survey demonstrates that the surgery is appropriate. The people who are getting it are the ones who needed it, and their lives have been improved," Skokan says.

Other specific questionnaires cover such areas of orthopedic surgery as sports-related knee injuries, foot and ankle pain, and arm, shoulder, and hand problems. For example, arthroscopy patients might be asked how much their knees swelled in the past week during light activity such as walking and during strenuous activity such as skiing.

Getting patients’ perspectives on their own recovery is critical, says Chad Munger, director of research and scientific affairs for the American Academy of Orthopedic Surgeons in Rosemont, IL. The academy has spent five years developing extensive tools for outcomes assessment.

The academy completed a pilot project involving 60 orthopedic practices and has opened its program to members nationally. "We’ll enroll as many orthopedic practices in the country as would like to participate," Munger says.

Munger anticipates collaboration between physicians and outpatient surgery programs in collecting outcomes data. That joint effort will be particularly important for surgery programs, which may have more difficulty following up with patients to obtain long-term outcomes information, he adds.

In its outcomes program, the academy is providing training as well as periodic reports comparing practices to a national or regional database. Functional health surveys are being developed in plastic surgery and other specialty areas as well. But if a procedure- specific form isn’t available through the organization representing the clinical specialty, you can use a general health questionnaire such as the SF-12 and add relevant questions related to the procedure, explains Strasser.

Functional outcomes assessment needs to answer one primary question, he says: Did we make the patient better?

To find that out, Strasser advises outpatient surgery program managers to target their high-volume procedures for functional outcomes evaluation. He envisions that in the future, managers will have scientifically validated assessment tools for frequently performed procedures, making their jobs easier.

Functional outcomes measurement goes hand in hand with more traditional patient satisfaction surveys, which ask such questions as whether patients thought the outpatient surgery staff was friendly. Statistically, there is a correlation between patients’ satisfaction and the improvement in their functional health, Strasser says. Happy patients also have had good clinical outcomes, he says.

Functional outcomes assessment is more difficult for hospitals than the simple patient satisfaction queries, of course. Typically, patient satisfaction surveys are done within days or a month after surgery. Functional outcomes assessment may last for months or a year, depending on the recovery time required for the procedure.

Yet that long-term outlook provides side benefits, Strasser says. Hospitals usually do not have ongoing contact with patients. But with functional outcomes assessment, "they get good data and maintain good relationships with patients," he says. Those relationships ultimately may produce other patients for referrals, he says.

Collecting data isn’t always a simple process for physician or surgery program staff, Munger says. Patients complete questionnaires at a physician’s office before surgery, then at follow-up visits that vary depending on the procedure, he says.

Physician office staff "need to have a little bit of training in how to handle reluctant patients," Munger says. "There are some patients who don’t want to spend the time [filling out a questionnaire], and they need some advice from managers who have worked out the clinical flow of gathering outcomes information."

For example, patients may receive their pre-op questionnaire before their pre-surgery visit to the physician’s office or before their day of surgery. "The more lead time you can give somebody, the better overall response you get," he explains.

Kaldenberg says hospitals should ask the patients involved if they will participate in a year-long study and warn them that they will receive functional assessment surveys in six and 12 months. Using this strategy, he says, he has seen a remarkable 50% return rate on functional assessment surveys mailed to patients’ homes.

[For more information, contact: Dennis Kaldenberg, manager of research and development, Press, Ganey Associates, 1657 Commerce Drive, South Bend, IN 46628. Telephone: (219) 232-3387. Steve Strasser, president and chief executive officer, Healthcare Research Systems, 1650 Lakeshore Drive, Suite 300, Columbus, OH 43204. Telephone: (614) 487-6300.]