Nearly two-thirds of prosthetists reported infrequent use of outcome measures and a low-to-moderate level of confidence in administering such measures, according to study results published in Prosthetics and Orthotics International.
The cross-sectional, single-group study sought to assess whether prosthetists used outcome measures in their clinical practice, which outcome measures were used the most and for what purpose the measures were used (e.g., to justify an intervention or to document patient status). In addition, the study examined whether a focused training program could improve prosthetists’ confidence in administering two commonly used performance-based outcome measures, the Amputee Mobility Predictor (AMP) and the Timed Up and Go (TUG), according to Ignacio Gaunaurd, PhD, PT, research physical therapist at the Miami Veterans Affairs Healthcare System, assistant professor of physical therapy at the University of Miami Miller School of Medicine and lead author of the study.
A total of 79 certified prosthetists from 12 states composed the study population. The mean clinical experience of participants was 16 years. All participants agreed to take part in a hands-on training program to administer the AMP and TUG, and to complete pre- and post-training surveys.
The pre-training survey assessed participants’ experience with 20 standardized outcome measures suited for use with prosthetic patients. The list was compiled by the authors from various sources and included both performance-based and self-report measures. The survey also examined prosthetists’ perceptions of potential outcome measure applications, as well as their confidence in administering the AMP and TUG.
Training sessions began with a presentation providing a review on the value, use and principles of outcome measures as well as a summary on the use of the AMP and TUG. The investigators demonstrated setup, administration and scoring for the two measures on volunteer patients. Participants then practiced administering and scoring the AMP and TUG under the guidance of the investigators.
Training improves confidence
“We found that many of the prosthetists in our study (62%) did not regularly use any outcome measures in their clinical practice,” Gaunaurd said. “These results were consistent with previous published literature findings from other allied health professionals, such as psychologists, physical therapists and occupational therapists, all of whom have reported similar challenges routinely using outcome measures in their practices.”
The two most frequently used outcome measures were the AMP (22%) and the Patient Assessment Validation Evaluation Test (PAVET) (17%). Participants indicated that they used outcome measures to justify selection of an intervention, document patient status and inform clinical decisions.
The study found the training program significantly improved prosthetists’ confidence in the administration of both the AMP and TUG. The majority (64%) of participants improved two or more (of five) confidence categories after receiving TUG training, and slightly more than half (52%) of participants improved two or more categories after receiving AMP training.
“We did not expect prosthetists to report such a low confidence level in the administration of the AMP and TUG. Prosthetists often noted being only ‘a little bit’ or ‘somewhat’ confident administering these measures prior to training,” Gaunaurd said. “But we were pleasantly surprised that the developed training program significantly improved prosthetists’ confidence to the degree that it did. Most prosthetists reported being ‘very much’ confident after training, which was significantly improved, relative to their pre-training confidence.”
Familiarity connected to value
The authors also were surprised by the stark contrast in opinions regarding the value of outcome measures between prosthetists who routinely used measures and those who did not, according to Brian J. Hafner, PhD, associate professor in the Department of Rehabilitative Medicine at the University of Washington and principal investigator of the study.
“As a percentage of prosthetists in each group, about five[-times] to six-times more clinicians who were routine outcome measure users acknowledged their value for justifying interventions, monitoring and documenting patients’ status, informing clinical decisions, communicating with other stakeholders and predicting outcomes,” Hafner said.
Hafner said while results of the study seem to show prosthetists who value outcome measures use them more often, it also could mean that prosthetists might learn to value and benefit from using outcome measures if they were made easier to use, through training programs such as the one developed for the study.
“I believe the latter to be true and hope that as a profession, we can create more opportunities for prosthetists and orthotists to become familiar with outcome measures and use them to improve patient care,” Hafner said.
As the demand for enhanced documentation continues to increase in the current health care climate, clinicians can expect to be required to use outcome measures in their clinical practice to justify their interventions and associated requests for reimbursement. Gaunaurd noted that the findings “emphasize the need to educate current and future prosthetists in the use of standardized outcome measures to evaluate their patients’ current function and mobility, and to assist with their clinical decision making.”
A key challenge for prosthetists is to gain familiarity and experience with measures suited to the settings and patients they serve. For practitioners, particularly those with limited experience in outcomes measurement, Hafner recommended seeking or creating opportunities to use different outcomes measures to determine which ones provide useful information. He suggested practitioners attend courses on outcomes measurement at meetings or conferences, or reach out to colleagues to ask about their experiences with outcomes measures.
“I believe strongly that measurement of patient outcomes is an important professional responsibility,” Hafner said. “Further, I am convinced that if we, as a profession, do not take the opportunity to select, use and advocate for measures suited to prosthetics patients, those external to our profession (e.g., reimbursement agencies) will do so for us. I suspect the latter would not be in the best interests of our patients or our profession.”
The authors recently completed a follow-up study to examine long-term retention of the training program and to evaluate any changes in confidence in outcome measures use over a period of 1 year to 2 years. The follow-up study also examined barriers to outcome measure use that remained after the training to inform development of new strategies and techniques.
“Our future efforts will focus on improving prosthetists’ and orthotists’ ability to select outcome measures appropriate for each patient, developing measures that can be quickly and easily administered in clinics, and informing how outcome measures can be best used to direct patient care,” Hafner said. “This research is critical so that we can help all stakeholders (e.g., patients, clinicians, researchers, and policy makers) identify measures best suited to their needs.”– by Mary L. Jerrell
- Gaunaurd I, et al. Prosthet Orthot Int. 2015;doi:10.1177/0309364614532865.
Disclosure: Gaunaurd and Hafner report no relevant financial disclosures.