Are patients better after a procedure? Tap into new tools to find out

Questionnaires measure outcomes in ophthalmology, orthopedics

Six months after your patients go home, have their conditions improved because of the procedures performed at your same-day surgery facility?

Thanks to a recent surge of research in outcomes monitoring, same-day surgery (SDS) managers can answer that question. For the first time, assessment tools are available to measure whether specific procedures improved patient functioning. National associations are creating databases of outcomes information that provide members with reports they can use as quality improvement benchmarks and ammunition in managed care negotiations. (See list, p. 64.)

If the value of ambulatory surgery programs lies in cost, patient satisfaction, and quality, then SDS managers and physicians must be prepared to document all three, says Tom Statzenbach, executive director of the Chicago-based American Society of Outpatient Surgeons. The society began an outcomes database to help members do just that.

"We all know the quality of ASCs, but there's been nothing documented in an outcomes research project to substantiate it," Statzenbach says.

Administrators of organizations such as the Society of Outpatient Surgeons also want to give their members a competitive edge when they negotiate with managed care organizations.

"Ultimately, everybody's going to squeeze all the price [difference] out, and prices are going to be just about the same" among competitors, says Michael 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.

Better and cheaper

"You have to establish in the public mind that you are specialists in [same-day surgery], and you not only do it cheaper, you also do it better," says Pine, who spoke at the recent annual meeting of the Alexandria, VA-based Federated Ambulatory Surgery Association meeting. "Better is much harder to compete with than cheaper."

This trend toward measuring changes in patients' quality of life creates a new paradigm for same-day surgery managers, who must now follow up with patients beyond the 24-hour phone call, says Steve Strasser, PhD, president and CEO of Healthcare Research Systems in Columbus, OH. This firm conducts outcomes measurement studies for providers, payers, and employers. Same-day surgery managers should work together with physicians to track patient functioning until full recovery takes place, Strasser says.

"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," he says. "And it tells the customer you care."

Can cataract patients knit?

Ophthalmic surgery is on the forefront of outcomes measurement, particularly with cataract and refractive procedures. Physicians and surgery centers have had an impetus to prove their success. Clinical practice guidelines created by the Rockville, MD-based Agency for Health Care Policy and Research state that the decision to perform cataract surgery should be based on whether the cataract is interfering with the patient's daily functioning. In the Oct. 6, 1995, Federal Register, the Health Care Financing Administration proposed a Medicare regulation requiring physicians to document that medical necessity.1

At Hunkeler Eye Centers in Kansas City, MO, cataract patients fill out vision-related questionnaires before surgery on their first eye and again if they have surgery on their second eye. They also complete the questionnaire at a follow-up visit at the physician's office one year after their surgery.

"The intent is to find out if the surgery is giving the patients the vision they expect or perceive that they want," says Debby Milliken, LPN, clinic leader for John Hunkeler, MD. "It also helps the doctors track their own outcomes."

Providence Health System in Portland, OR, wants to prove that its cataract surgeries are improving patients' quality of life, says Laurie Skokan, PhD, senior research associate with the health system's Center for Outcomes Research and Education.

The health system has recruited the participation of 20 physician offices and will track patient functioning before surgery and at four and 12 months after surgery, Skokan says. The VF-14, an 18-question 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, she says. (A copy of the questionnaire is enclosed in this issue.)

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

Orthopods ask: Does your knee still swell?

Orthopedic surgeons also are prepared to demonstrate their ability to improve patients' lives with specific questionnaires in such areas 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. (See sample questionnaire, enclosed in this issue.)

Getting the patients' perspective 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.

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

In its outcomes program, the academy is providing training as well as periodic reports comparing practices to a national or regional database. Collecting the data isn't always a simple process for physician or surgery center staff, Munger says. Patients complete questionnaires at a physician's office visit 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, he says.

For example, patients may receive their preop questionnaire before their pre-surgery visit to the physician's office or before their day of surgery, Munger says.

"The more lead time you can give somebody, the better overall response you get," he says.

You can develop your own survey

Functional health surveys are being developed in plastic surgery and other specialty areas. But if a procedure-specific form isn't available through the organization representing the related clinical specialty, you can use a general health questionnaire such as the SF-12, which was developed by the Health Institute of the New England Medical Center in Boston. Add relevant questions related to the procedure, suggests Strasser, who is an associate professor in the college of medicine at The Ohio State University in Columbus. (For a copy of the SF-12, see Same-Day Surgery, December 1995, p.141.)

Outcomes assessment needs to answer one primary question, says Strasser: Did we make the patient better?

To find that out, Strasser advises same-day surgery managers to target their center's high-volume procedures for outcomes evaluation. Strasser envisions that in the future, same-day surgery managers will have scientifically validated assessment tools for frequently performed procedures, which will make the same-day surgery manager's job easier.

For now, Strasser designs customized questionnaires and conducts outcomes studies for health care providers. The firm charges $10 to $20 per patient interviewed, with a sample size of several hundred. The price varies depending on the depth of the study, he says.

Satisfaction relates to outcomes

Functional outcomes measurement goes hand in hand with more traditional patient satisfaction surveys, such as whether patients thought the surgery center was accessible and whether the staff were friendly. (For a list of top 10 patient satisfaction concerns, see p. 69.)

Statistically, there is a correlation between patients' satisfaction and the improvement of their functional health, he says. Happy patients also have had good clinical outcomes, he says.

Outcomes assessment is more difficult for surgery centers and hospitals than the simple patient satisfaction queries, Strasser concedes. Typically, patient satisfaction surveys occur within days or a month after outpatient surgery. 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. Same-day surgery managers usually do not have ongoing contact with patients. But with outcomes assessment, "they get good data -- and maintain good relationships with patients," he says. Those relationships may ultimately produce other patient referrals, he notes. *

For more information on developing outcomes questionnaires, contact:

* Steve Strasser, President and CEO, Healthcare Research Systems, 1650 Lakeshore Drive, Suite 300, Columbus, OH 43204. Telephone: (614) 487-6300. Fax: (614) 487-6301.