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What Total Joint Arthroplasty Outcome Measures are Used by Physiotherapists in British Columbia? Balik, Danielle; Naing, Veronica; Voros, Drey; Wagner, Belinda; Welch, Lauren Aug 31, 2011

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What Total Joint Arthroplasty Outcome Measures are Used by Physiotherapists in British Columbia? Danielle Balik, Veronica Naing, Drey Voros,        Belinda Wagner, Lauren Welch Group 2 ?Overview of osteoarthritis (OA) and total joint arthroplasty (TJA) ?Rationale for the total joint arthroplasty outcome measure (TJAOM) survey study ?Methods ?Results ?Discussion ? Implications     Outline ? Is a painful and disabling disease that involves the progressive development of joint pain, stiffness and decreased range of motion1  ? Is a major factor in morbidity, disability and health care utilization  ? The risk factors for osteoarthritis include: ?Heredity (joint alignment) ? Excess weight ? Injury ? Joint damage from another type of arthritis       Osteoarthritis  ?Affects more than three million (1 in 10)      Canadians, mostly over the age of 452   ? Between 1991 and 2031: ? its prevalence in Canada will increase by 46% ? the number of Canadians with OA                     will increase 124%2    The progress of the disease can be slowed by exercise, weight loss and medications, but there is no cure Osteoarthritis ? In BC over 10,000 TJAs are performed yearly2 to treat painful and severely degenerated joints ? Most often total knee arthroplasty (TKA) and total hip arthroplasty (THA)  ? TJA is a viable treatment option for end-stage OA when conservative, pharmacological and lifestyle treatments are no longer effective   ? Publicly funded physiotherapy-based rehabilitation is available pre- or post-surgery    Total Joint Arthroplasty ? The lack of standardized outcome measures (OMs) across practice settings and phases (inpatients, outpatients, home/community) may be preventing clinicians from using them to inform clinical decision-making and program evaluation  ? Standardized OM use may facilitate physiotherapists? (PTs?) rehabilitation and discharge planning on a broader scope, encompassing patients? activities and participatory roles  Rationale ? A set of consistent outcome measures benefits: ? Patients ? Clinicians ? Researchers ? Health insurance companies  ? A first step in facilitating OM use in clinical practice in BC is to evaluate the current variability in OM use by PTs treating patients with TJA throughout the province    Rationale Program Evaluation Barriers Survey T   J AOM ?Ethics WHAT  ?Clinicians  WHY ?Administrator ?Mary Pack Arthritis Centre ?LGH ?PHC, VCH ?Private Practice ?Chart Audit HOW Project Overview ? Primary Investigator ? DR. MARIE WESTBY, BSC(PT), PHD - Rehabilitation Sciences, UBC ? Co-investigators o DR. DARLENE REID (SUPERVISOR) ? BMR(PT), PHD ?            Professor, UBC Department of Physical Therapy   o CATHERINE MCAULEY, BSC(PT), MSC (REHAB) ?              Physical Therapy Practice Coordinator, Vancouver Coastal Health   o ALISON HOENS, BSC(PT), MSC ? Physical Therapy Knowledge Broker, Clinical Associate Professor and Physiotherapy Research, Education and Practice Coordinator, Providence Health Care   o DANIELLE BALIK, VERONICA NAING, DREY VOROS,                 BELINDA WAGNER, LAUREN WELCH ? UBC MPT Grad Students  Team Members ? TJAOM Survey Study  ? The purpose of this study is to identify through a survey the types and International Classification of Function (ICF) categories of outcome measures currently or likely to be used by PTs in British Columbia for treating patients with TJA: ? Pre- and post-operative ? Pre- and post-rehabilitation   Purpose Methods ? 100% of PTs working in areas with <100 registrants: administration, sports medicine, rheumatology, consulting and client service management  ? 60% of PTs working in gerontology                             (164 total registrants)  ? 30% of PTs working in orthopaedics and general practice areas (870 total registrants)  694 selected participants; 28.6% of the total eligible number of 2425 PTs registered with CPTBC Methods - Participants ? Demographic information   ? The OMs were divided into three sections:  1. Patient-reported OMs (PROM) 2. Performance-based OMs 3. Prognostic factors/indicators   ? A fourth section referred to outcomes considered but not recommended by PRAG   Methods ? Survey Questionnaire Patient-Reported Outcome Measures  ?Arthritis Self-Efficacy Scale ?Self-Management Behaviours Exercise ?Numeric Pain Rating Scale ?Pain Visual Numeric Scale ?Lower Extremity Function Scale (LEFS) ?Oxford Hip Score (OHS) ?Oxford Knee Score (OKS) ?EuroQOL (EQ-5D) ?Knee Injury & Osteoarthritis Outcome Score (KOOS) ?Hip Injury & Osteoarthritis Outcome Score (HOOS)  Performance-Based Measures Indicators for Prognosis   ?Sit To Stand Test     ?Walking Speed ?Timed Up and Go (TUG) ?6 Minute Walk Test ?Tinetti Mobility Test ?Timed Stair Climb ?Single Leg Stance  ?BMI ?Waist Circumference      Outcome Measures in Survey Measures Considered  But Not Included  ?Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) ?Global Impact Item (GI) ? of the Arthritis Impact Measurement Scale (AIMS) ?Client Satisfaction Questionnaire  ?Harris Hip Score ?Submaximal VO2     Outcome Measures Not in Survey ? 4-point ordinal scale:   ? Not familiar ? Familiar with measure but no clinical           experience with it or do not use it ? Some experience ? Considerable experience using it in TJA            population  ? Data collapsed into two categories for ease of analysis:  1. Not experienced with the OM (options1 and 2 combined)  2. Experienced with the OM (options 3 and 4 combined)    Methods ? Survey Questionnaire Methods ? Timeline Dates Activity   June 8, 2010 Electronic  ?e-blasts? sent out to raise awareness June 15, 2010 Questionnaires mailed to a sample of 694 PTs June 22, 2010 Reminder postcards sent out September - November 2010 Data entry November 10, 2010 Data collection discontinued December 2010 - January 2011 Data Analysis ? Survey participants were grouped into three categories:   1. Complete responders ? completed all or most of the survey 2. Partial responders ? responded but completed only the first page (demographic info) 3. Non-responders ? did not in any way respond  Methods ? Data Entry  Data Collection Methods & Analysis  ? SURVEYS RECEIVED AT THE MUSCLE BIOPHYSICS LABORATORY Data Collection ? CODING LEGEND CREATED ? DATA INPUT INTO AN EXCEL DATA SHEET BY UBC MPT STUDENTS  Data Input   ? STATISTICAL ANALYSIS QUESTIONS DEVELOPED ? STATISTICAL ANALYSIS PERFORMED BY STATISTICIAN ? DESCRIPTIVE STATISTICS WERE USED TO DESCRIBE DEMOGRAPHIC CHARACTERISTICS ? OM?S WERE GROUPED ACCORDING TO TYPE AND ICF CATEGORIES   Data Analysis Methods ? Procedures Results RESULTS  Of the 694 survey  packets mailed:   298: Returned (42.9%)    172: Completed (57.7%)   126: Partially Completed (42.3%)  ?  74% of PTs did not work with TJA patients  ? 25% did work with TJA patients but were not interested in filling out   the questionnaire  ? 1% did not give a reason for not completing  Table 3 - Demographics  Characteristic Respondents (n = 298) Completers  (n = 172) P-values (respondents vs. completers) Health Authorities Vancouver Coastal Health 110 (36.9%) 62 (36.0%) 0.45 Vancouver Island Health 59 (19.8%) 32 (18.6%) 0.39 Fraser Health 56 (18.8%) 35 (20.3%) 0.57 Interior Health 58 (19.5%) 39 (22.7%) 0.16 Northern Health 9 (3.0%) 5 (2.9%) 0.82 Other 2 (0.7%) 1 (0.6%) 0.79 Sector ? Public 137 (46.0%) 92 (53.5%) 0.18 ? Private 122 (41.0%) 72 (41.9%) Area of Practice ? In Patient 52 (17.4%) 27 (15.7%) 0.16 ? Home/ Community Care 34 (11.4%) 22 (12.8%) ? Outpatient 173 (58.1%) 115 (66.9%) Years since graduation ? <10 years ago 56 (18.8%) 43 (25.0%) 0.008 ? 10-19 years ago 75 (25.2%) 52 (30.2%) ? 20+ years ago 135 (45.3%) 74 (43.0%) Practice Setting ? Urban 181 (60.7%) 96 (55.8%) 0.036 ? Rural 77 (25.8%) 53 (30.8%) ? Mixed urban/rural 28 (9.4%) 19 (11.0%)  Results - Demographics ? Respondents worked in the expected clinical areas of physiotherapy ? rheumatology ? sports medicine ? gerontology ? orthopaedics ? general practice  ? % Respondents working in each care phase:  ? pre-operative (54.4%) ? post-operative (74.9%)  ? rehab (66.1%) ? post-rehab (40.9%)  Results - Demographics Results ? Average use of OMs in each survey category 36% 53% 38% 0%10%20%30%40%50%60%Patient Reported OutcomeMeasuresPerformance Measures Prognostic IndicatorsAverage use of OM's in each category Survey Category Types Patient Reported Measures Performance Based Measures Prognostic Measures Arthritis Self Efficacy Scale Self-Management Behaviours Exercise Numeric Pain Rating Scale Pain Visual Numeric Scale Lower Extremity Functional Scale (LEFS) Oxford Hip Score (OHS) Oxford Knee Score (OKS) EuroQOL (EQ-5D) Knee Injury & Osteoarthritis Outcome Score (KOOS) Hip Injury & Osteoarthritis Outcome Score (HOOS) Sit To Stand (STS) Walking Speed 6 (or 2, 3, 12) Minute Walk Test Timed Up and Go (TUG) Timed Stair Climb Tinetti Mobility Test Single Leg Balance (SLB) Waist Circumference Body Mass Index (BMI) Results ? Percentage of PTs reporting some/good experience with the current use of OMs for clinical decision making within the general survey categories   98% 84% 59% 75% 49% 4% 5% 27% Results ? Average use of OMs in each ICF category  International Classification of Function (ICF) Survey Categories Body Structure/Function Activity/Participation Personal Contextual Factors Numeric Pain Rating Scale Pain Visual Numeric Scale Lower Extremity Functional Scale (LEFS) Oxford Hip Score (OHS) Oxford Knee Score (OKS) EuroQOL (EQ-5D) Knee Injury & Osteoarthritis Outcome Score (KOOS) Hip Injury & Osteoarthritis Outcome Score (HOOS) Sit To Stand (STS) Walking Speed 6 (or 2, 3, 12) Minute Walk Test Timed Up and Go (TUG) Timed Stair Climb Tinetti Mobility Test Single Leg Balance Arthritis Self Efficacy Scale Self-Management Behaviours Exercise Waist Circumference Body Mass Index (BMI) Results ? Percentage of PTs reporting some/good experience with the current use of OMs for clinical decision making within the ICF categories   98% 84% 5% 4% 75% 49% 27% Discussion ? Two most highly used OMs ? Numeric Pain Rating Scale (NPRS) 97.7%  ? Pain Visual Numeric Scale (PVNS) 83.7%  ? Patient-reported OMs (PROMs)  ? ICF category of body structure/function  ? Considered to be measurements of impairment   Discussion ? Primary Findings ? Why are pain scales frequently used?  ? Main symptom/complaint of arthritis ? Highly related to function ? Considered a major outcome for fitness ? Primary OM in arthritic care33     Pain scales are also free and considered to be reliable, valid, and easy to administer33 Discussion ? NRPS & PVNS ? Third highest used patient-reported OM ? Lower Extremity Function Scale (LEFS) 59.1%  ? Why is the LEFS frequently used? ? Single page, quick (less than 5 min) ? Often cited in scientific journals32 ? Widely used in many areas of physiotherapy  ? High test-retest reliability37    Discussion ? LEFS   Considered to be reliable, valid and responsive when used with THA  and TKA patients33   ? Almost half the responders used Body Mass Index (BMI) as an OM at 48.8%  ? Prognostic Measure  ? ICF category of personal contextual factors   Discussion ? Body Mass Index ? Why is BMI used?  ? High correlation between body weight and its effect on arthritic joints ? Obesity is a risk factor for OA7  ? Just a one pound weight increase can add four pounds of force through the joints40 ?Weight loss is a key general recommendation for OA management35  Discussion ? Body Mass Index ? Two least used OMs ? Hip Injury & Osteoarthritis Outcome Score (HOOS) 3.5% ? Knee Injury & Osteoarthritis Outcome Score (KOOS) 4.7%  ? Patient-reported OMs (PROMs)   ? ICF category of activity & participation ? Body structure/function (pain, symptoms) ? Activity (activities of daily living) ? Participation (function, sports and recreational activities)  Discussion ? HOOS & KOOS ? Why are HOOS & KOOS NOT frequently used?  ? Both contain 42 items to score which may seem overwhelming to complete14 ? Traditionally used to evaluate younger population and may be perceived as not relevant for older population36     Greater than 50% of complete responders reported no familiarity with either the HOOS or KOOS    Discussion ? HOOS & KOOS ?Why SHOULD we use HOOS & KOOS?  ? Designed for easy evaluation of knee and hip         OA or in TJA ? Easy to score within each section and as a total ? Take less than 10 minutes to complete     Are reliable and responsive in TJA and have good content and criterion validity14, 36     Discussion ? HOOS & KOOS ?Why SHOULD we use HOOS & KOOS?  ? Roos et al. 2003 study found KOOS was applicable to a more senior population  ? Expectations of younger subjects with OA are the same as those of more elderly subjects with OA     KOOS is valid and responsive for both the aged and younger populations14    Discussion ? HOOS & KOOS ? Sit To Stand (STS) ? Walking Speed ? Timed Stair Climb ? 6 (or 2, 3, 12) Minute Walk Test (6MWT)  ? Timed Up and Go (TUG) ? Tinetti Mobility Test  ? Single Leg Balance (SLB)  ? >50% responders indicated using performance-based OMs        ? ICF category of activity & participation   Discussion ? Generality Performance-based OMs may be superior to PROMs when testing for change in physical functioning33  ? General health OMs used and recognized by more PTs than those more specific to            OA and/or TJA   ? Pain scales & TUG ? Most used and are considered general  ? HOOS & KOOS ? Least used and are considered specific    Discussion ? Generality ?Why use more general measures? ? Measurement of co-morbidities/other complications not directly related to disease38 ? May be more cost-effective38 ? Fewer tools/more widely usable over many areas of physiotherapy38 ? Familiarity could allow for a shorter time for completion and ease of use    Discussion ? Generality Not as sensitive and specific to TJA rehabilitation, but allow for a single tool to cover multiple areas  Conclusion ? Findings suggest that PTs in BC are most experienced with measures of performance and impairment  ? Not always the most sensitive and specific to TJA rehabilitation     Conclusion Lack of consistent OMs for  use in TJA rehabilitation19, 30, 32  ? Implementing standardized OMs for TJA in clinical settings could: ? Encourage use of more appropriate OMs for TJA rehabilitation ? Facilitate clinical decision-making, planning, evaluation ? Allow for better cross-over of information for PTs and patients across care ? Achieve consistency of use among practitioners       Conclusion  ? Part of an integrated knowledge transfer  ?Ministry of Health-funded initiative for orthopaedic surgeons in the Vancouver Island Health Authority (VIHA)    Implications References 1 - Davies, A. (2002). Rating systems for total knee replacement. Knee, 19(4), 261-6.  2 - Provincial Health Services Authority. (2009, August 30). For Health Professional - Surgical Services: Decision Support Tools. Retrieved April 7, 2010, from Vancouver Coastal Health: Collaborative/Tools/Decision-Support-Tools.htm 3 - Minns Lowe, C., Barker, K., Dewey, M., & Sackley, C. (2009, August 4). Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskeletal Disorders , 10-98.  4 ? Vancouver Coastal Health Website (2009,  April 28). Hip & Knee Surgery ? Frequent Questions ? OASIS. 5 - Drake, B., Callahan, C., Dittus, R., & Wright, J. (1994). Global rating systems used in assessing knee arthroplasty outcomes. Journal of Arthroplasty , 9 (4), 409-17.  6 - Marx, R., Jones, E., Atwan, N., Closkey, R., Salvati, E., & Sculco, T. (2005). Measuring improvement following total hip and knee arthroplasty using patient-based measures of outcome. Journal of Bone & Joint Surgery - American Volume , 87 (9), 1999-2005.  7 - Riddle, D., Stratford, P., & Bowman, D. (2008). Findings of Extensive Variation in the Types of Outcome Measures Used in Hip and Knee Replacement Clinical Trials: A Systematic Review. Arthritis & Rheumatism (Arthritis Care & Research) , 59 (6), 876-883.   References 8 - Abrams D, Davidson M, Harrick J, Harcourt P, Zylinski M, Clancy J. (2005).   Monitoring the change: Current trends in outcome measure usage in physiotherapy. 11: 46-53. 9 - Van Peppen R, Maissan F, Van Genderen F, Van Dolder R, Van Meeteren N. (2008). Outcome measures in physiotherapy management of patients with stroke: a survey into self-reported use, and barriers to and facilitators for use. 13(4): 255-270. 10 - Portney L.G., Watkins, M.P.  (2009).  Foundations of Clinical Research: Applications to Practice. 3rd ed. New Jersey: Prentice Hall, Inc.  THANK YOU! Questions? ? Survey results specific to BC and may have limited external validity for PTs in the rest of Canada or internationally  ? Respondents may misinterpret the questions or have varying levels of motivation or bias about the study and subsequently over- or under-report OMs use leading to inaccurate data  ? There is also a chance of non-response bias ? those who do not reply to the survey are likely to be those who do not use OMs29 Discussion - Limitations ? There is also a tendency in those self-reporting to report a better picture in response to a questionnaire than what actually occurs.  If this is the case, their reported use of OMs could be higher than their actual use  ? This limitation will be considered and evaluated against the chart review portion of the overall study that will describe what is common practice for the use of OMs Discussion - Limitations 


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