Clinical outcomes research from the occupational therapist's perspective

Hand therapist use of patient-reported outcomes

BACKGROUND

The use of standardized outcome measures is essential for best clinical practice by hand therapists to determine patient status, progress, and the outcome of interventions. A better understanding of current patient-reported outcome (PRO) use in hand and upper extremity practice is warranted.

PURPOSE

This study sought to understand what outcome measures are being used in clinical practice, how they are being used, and the perceived usefulness of PROs by active members of the American Society of Hand Therapists (ASHT).

STUDY DESIGN

This study employed a cross-sectional design.

METHODS

The web-based survey was distributed through Qualtrics (Qualtrics, Salt Lake City, Utah) to active members of ASHT with an email address on file. The survey consisted of multiple choice and open-ended questions.

RESULTS

A total of 348 members responded to the survey. Seven hundred thirty-two different outcome measures were reported to be used by the hand therapist respondents. The most used outcome measure was QuickDASH by 38% of the respondents. Two hundred seventy-five (88%) indicated that their workplace advocated the use of PROs. Most respondents indicated that there were not constraints preventing the use of a PRO. Few therapists respondents use a psychosocial PRO in clinical practice.

CONCLUSIONS

Most of the hand therapist respondents to our survey use a PRO and discuss the results with their clients. The QuickDASH was the PRO used most often by hand therapists. Only a few hand therapists use a psychosocial tool to measure patient status in clinical practice.

Quantitative measures with WREX usage

This paper presents the results of two surveys conducted with users of a functional upper extremity orthosis called the Wilmington Robotic EXoskeleton (WREX). The WREX is a passive anti-gravity arm orthosis that allows people with neuromuscular disabilities to move their arms in three dimensions. An online user survey with 55 patients was conducted to determine the benefits of the WREX. The survey asked 10 questions related to upper extremity function with and without the WREX as well as subjective impressions of the device. A second survey used a phone interview based on the Canadian Occupational Performance Measure (COPM). Parents rated their child's performance and satisfaction while partaking in important activities both with and without the exoskeleton device. Scores were assessed for change between the two conditions. Twenty-five families responded to this survey. Twenty-four out of 25 subjects reported greater levels of performance and satisfaction when they were wearing the WREX. The mean change in performance score was 3.61 points, and the mean change in satisfaction score was 4.44 points. Results show a statistically significant improvement in arm function for everyday tasks with the WREX.

Challenges to Measuring Outcomes in Occupational Therapy: A Qualitative Focus Group Study

The aim of this study was to explore the process used by occupational therapists to measure the effect of their interventions. A second aim was to explore the challenges associated with this process. Stroke rehabilitation was chosen as the focus for the study.

This qualitative study was conducted in Sydney, Australia. Ten occupational therapists from both hospital and community-based services participated in one of three focus groups. The data were analysed using constant comparison techniques.

The participants struggled when describing the process used to measure outcomes. They focused more on the challenges to measuring outcomes, which were described as focusing on occupation, deconstructing occupation and lacking knowledge, skills and assistance.

The participants in this study had difficulty in articulating and setting measurable goals linked to interventions. As a result, they could not easily select appropriate outcome measures. Education is needed to help such occupational therapists to develop the required skills and to begin to measure clinical outcomes. Further research should determine if similar experiences and challenges are faced in other areas of practice and by occupational therapists in other countries.

Personal Care Participation Assessment and Resource Tool: Clinical utility for inpatient rehabilitation

Background.

Evidence supports validity of the Personal Care Participation Assessment and Resource Tool (PC-PART), but clinical utility remains unverified.

Purpose.

This study aimed to investigate occupational therapists’ perceptions about the PC-PART’s clinical utility for inpatient rehabilitation.

Method.

Using mixed methods, occupational therapists who had used the PC-PART as part of a research study in an inpatient rehabilitation setting completed a questionnaire ( n = 9) and participated in a focus group ( n = 6) to explore their perspectives about its clinical utility. Quantitative data were summarized and qualitative data analyzed using inductive thematic analysis.

Findings.

Quantitative data highlighted both positive and negative aspects of the PC-PART’s clinical utility. Five themes emerged from the qualitative data: nature of information gathered; familiarity with the instrument; perceived time and effort; item phrasing, interpretation, and presentation; and external influences on clinical use.

Implications.

The PC-PART was perceived to support gathering of clinically useful information, helpful to intervention and discharge planning. Recommendations for improving some item phrasing, operational definitions, and instructions were identified. Although standardized assessments were valued, use in routine practice was challenging, requiring a knowledge translation strategy.

Hand therapist use of patient report outcome (PRO) in practice: a survey study

PURPOSE

The purpose of this survey was to gain greater insight into hand therapists' use of Patient Report Outcome (PRO) measures.

METHODS

An 11-question survey that evaluated therapists' perceptions, preferences, and patterns of use of patient report outcome measures was sent to members of ASHT.

RESULTS

A total of 633 ASHT members participated in the survey study. A large majority of participants (92%) responded affirmatively to using a PRO measure in practice. The DASH was reported as the most frequently used measure (90%). The majority of therapists (84%) discuss the results of the outcome measurement score with their patients. Of the participants who use more than one outcome measure, 44% report that this allows them to better establish their patient's functional and physical limitations.

CONCLUSION

The findings in this study suggest that a large percentage of hand therapists are currently including a PRO measure in their hand therapy practice.

Attitudes of mental health occupational therapists toward evidence-based practice

Background.

Evidence-based practice is an important driver in modern health care and has become a priority in mental health occupational therapy in recent years.

Purpose.

The aim of this study was to measure the attitudes of a cohort of mental health occupational therapists toward evidence-based practice.

Method.

Forty-one mental health occupational therapists were surveyed using the Evidence-Based Practice Attitude Scale (EBPAS). Mann-Whitney U tests and Spearman’s rho were used to analyze the data.

Findings.

The occupational therapy respondents had generally positive attitudes toward evidence-based practices comparable to established norms. Respondents with further qualifications beyond their professional degree were significantly more likely to try new interventions ( p = .31). Significant negative correlations were found also for the subscales of Appeal and Openness in relation to years of occupational therapy practice (rho = –.354, p = .023; rho = –.344, p = 0.28) and mental health experience (rho = –.390, p = 0.12; rho = –.386, p = .013).

Implications.

Therapist factors can significantly impact attitudes toward evidence-based practice.

Evaluating the Impact of Audits and Feedback as Methods for Implementation of Evidence in Stroke Rehabilitation

Introduction:

This paper evaluates audits and feedback as methods to increase implementation of evidence in stroke rehabilitation.

Method:

The study used an action research approach and theories of knowledge translation. A sample of 22 occupational therapists participated from two Danish hospitals that admitted stroke patients. Data collection methods included audits of occupational therapy medical records, documentations of daily practice, and collaborative discussions. Active feedback and discussions of the findings took place, at a group level in four local clinical audits. Data analysis of daily self-reported recordings and audits was descriptive. Audit data were analysed using descriptive statistics. A phenomenological hermeneutical interpretive methodology was used for analysing qualitative data.

Findings:

Audits and feedback were based on clear standards and contextual developing action plans. Daily practice in both settings adapted to the clinical guidelines. Implementations of the standardized assessment tools seemed to be the most successful.

Conclusion:

The effects of audit and feedback profited from the active participation of the therapists, as well as local gatekeepers having formal responsibilities for implementing change. The process was strengthened by providing the audits and feedback more than once. The effect of audits and feedback was positively influenced by being in line with current conceptual frameworks, local policies, and values.

Interrater Reliability and Clinical Utility of the Personal Care Participation Assessment and Resource Tool (PC–PART) in an Inpatient Rehabilitation Setting

OBJECTIVE. We examined the interrater reliability and clinical utility of the Personal Care Participation Assessment and Resource Tool (PC–PART) in a rehabilitation setting.

METHOD. Ninety-six patients were recruited from the caseload of four occupational therapists. Patients were assessed on admission. Clinical utility was based on time to complete assessments.

RESULTS. Interrater reliability for the total score was very high (intraclass correlation coefficient = .91). Limits of agreement for the program indicated aggregate data from individual scores were within 1.3 units (range = −1.3 to 0.5) but individual scores would be within 10 units (range = −9.3 to 0.2). The PC–PART took 27 min to complete.

CONCLUSION. The PC–PART may have sufficient interrater reliability and clinical utility to evaluate program outcomes. The limits of agreement for rating individuals were relatively large, suggesting that it may be difficult to use the PC–PART to make clinical inferences about an individual patient.

Functional assessments used by occupational therapists with older adults at risk of activity and participation limitations: a systematic review and evaluation of measurement properties

BACKGROUND

Older adults experience activity and participation limitations that are associated with ageing. Activity and participation limitations affect an older adult's ability to engage in meaningful daily activities and valued life roles. Occupational therapists provide interventions to reduce such limitations and monitor client change to ensure that interventions are effective. Client change should be measured through the use of valid and reliable assessments. Yet occupational therapists can favour the use of non-standardised assessments leading to inaccurate reflections of client change and difficulties in comparing the effectiveness of interventions. A number of reasons have been suggested as to why therapists may favour non-standardised assessments, including a lack of knowledge (of assessments and their properties) and lack of skill.

METHODS/DESIGN

This paper describes the systematic review protocol that will be used to identify functional assessments used in randomised trials of occupational therapy interventions for older adults (≥70 years of age). Interventions will focus on enhancing functional independence for either older adults transitioning from hospital to home, or community dwelling older adults. We will search Medline, EBSCO and OTseeker using a pre-determined search strategy to identify Functional assessments. These assessments will be recorded and, in phase two, their measurement properties analysed.

DISCUSSION

This protocol provides a comprehensive guideline for conducting the proposed systematic review. The results of this systematic review will provide a thorough and unbiased identification and evaluation of measurement properties of functional assessment tools used in randomised trials to evaluate occupational therapy intervention. This information can be used to determine which assessment has superior measurement properties and will inform occupational therapy practice.

Facilitation of Research-Based Evidence within Occupational Therapy in Stroke Rehabilitation

Purpose:

This study investigated the facilitation of evidence-based practice with the use of everyday life occupations and client-centred practice within occupational therapy in three settings of stroke rehabilitation.

Method:

The study was based on a phenomenological hermeneutical research approach, and inspired by participatory action research methods. Participant observations, focus group discussions and individual interviews took place over a period of 20 months. Text interpretation, developed by Ricoeur, was used in data analysis.

Findings:

The key role of the facilitator in the implementation of evidence-based practice as a change process was stressed. During the implementation, it was crucial that the therapists as a group had the opportunity to discuss local practice knowledge, and to appraise the knowledge use critically, in order to develop their practice knowledge and new skills adapted to local contexts. The implementation resulted in various new working routines. Learning processes became part of developing the occupational therapists' professional identities, expressed in more professional confidence. Collaboration in the organisation of the implementation process was significant.

Conclusion:

The main findings indicated that the use of participatory action research methods and theory of situated learning interacting with the Promoting Action on Research Implementation in Health Services framework provided useful perspectives and structures for the investigation of the implementation of evidence-based occupational therapy.

An interactive education session and follow-up support as a strategy to improve clinicians' goal-writing skills: a randomized controlled trial

BACKGROUND

Recent research indicates that allied health clinicians have difficulty articulating client needs and priorities into specific and measurable goals. As a result, a number of strategies to facilitate improvement in allied health clinicians' goal-setting skills have been recommended in the literature. In order to assist clinicians develop the skills required to set SMART goals, it is necessary that the strategies are rigorously tested.

AIM

To determine if a 50-minute education session and 3-month email and telephone support programme improves clinicians' SMART goal-writing skill and accurately predicts improved goal-writing behaviour.

METHODS

Concealed random allocation of participants (n = 120) into two parallel groups: (1) intervention group received education on writing goals using the SMART Goal Evaluation Method as part of a workshop on outcome measurement and received 3 months of follow-up support (n = 60); and (2) control group attended a workshop on evidence-based practice (n = 60).

RESULTS

Education and follow-up support improved clinicians' SMART goal-writing skills at both the 3- and 6-month review (Yates chi(2) = 4.324, d.f. = 1, P = 0.0375). Structural equation modelling revealed education and follow-up support is an accurate predictor of SMART goal-setting behaviour change at both 3 months (standardized regression weights = 0.21; P = 0.014) and 6 months (standardized regression weights = 0.19; P = 0.02) post intervention. Changes were modest and developed over a 6-month period.

CONCLUSION

This study provides empirical evidence that a programme of educating clinicians in a standardized method of goal setting and providing follow-up support improves allied health clinicians' SMART goal-writing skills.

Development and psychometric testing of the Clinician Readiness for Measuring Outcomes Scale

BACKGROUND

If allied health professionals are to begin measuring outcomes routinely, a change in attitudes and behaviour is necessary. However, individuals need to be ready to change and often move through several stages before practice change is observed.

AIM

To develop and test the psychometric properties of a questionnaire that determines clinicians' readiness to measure outcomes.

METHODS

A study of instrument development, validation and reliability. Ten expert allied health professionals were involved in content validity testing. A further 396 allied health professionals completed the questionnaire to establish content and construct validity, internal consistency and temporal reliability (or stability). Of these 396 allied health professionals, 70 participated in the temporal reliability assessment. Content validity was established using the Content Validity Index (CVI). Construct validity was determined using confirmatory factor analysis (CFA) and internal consistency was ascertained using Cronbach's alpha. Temporal reliability was confirmed using intraclass correlation coefficients (ICC 3,1).

RESULTS

A 30-item questionnaire was developed, reflecting the five stages of change from the Transtheoretical Model of Change, and commonly cited barriers to outcome measurement. Content validity was excellent (CVI = 0.96). Using CFA, a two-factor model provided best fit. Based on CFA results, four items were dropped resulting in a 26-item questionnaire (range 26-156). Internal consistency reliability was excellent (alpha = 0.94). Temporal (stability) reliability ICC (3,1) was very good (r = 0.86, P = 0.0001).

CONCLUSIONS

The final 26-item questionnaire takes 10 minutes to complete and 5 minutes to score. The Clinician Readiness for Measuring Outcomes Scale provides educators with useful information about clinician readiness and helps identify strategies for affecting behaviour change.

A collaborative scholarly project: constraint-induced movement therapy

SUMMARY This paper describes the phases of a scholarly project process within one occupational therapy (OT) professional program. Using the example of a scholarly project on constraint-induced movement therapy, the collective endeavor among two OT graduate students, a faculty advisor, and two occupational therapists is demonstrated. The process leading toward a clinically-relevant outcome provided benefits to all collaborators. The students experienced evidence-based scholarship firsthand, while the advisor and practitioners experienced the rewards of shaping a clinically useful product and received outcomes research assistance. The description of this scholarly project process serves as a model for future scholarly collaboration among graduate students, practitioners, and faculty members.