Establishing clinician reliability using the therapy outcome measure for the purpose of benchmarking services

Methodological issues in the design and evaluation of supported communication for aphasia training: a cluster-controlled feasibility study

OBJECTIVE

To assess the feasibility and acceptability of training stroke service staff to provide supported communication for people with moderate-severe aphasia in the acute phase; assess the suitability of outcome measures; collect data to inform sample size and Health Economic evaluation in a definitive trial.

DESIGN

Phase II cluster-controlled, observer-blinded feasibility study.

SETTINGS

In-patient stroke rehabilitation units in the UK matched for bed numbers and staffing were assigned to control and intervention conditions.

PARTICIPANTS

70 stroke rehabilitation staff from all professional groups, excluding doctors, were recruited. 20 patients with moderate-severe aphasia were recruited.

INTERVENTION

Supported communication for aphasia training, adapted to the stroke unit context versus usual care. Training was supplemented by a staff learning log, refresher sessions and provision of communication resources.

MAIN OUTCOME MEASURES

Feasibility of recruitment and acceptability of the intervention and of measures required to assess outcomes and Health Economic evaluation in a definitive trial. Staff outcomes: Measure of Support in Conversation; patient outcomes: Stroke and Aphasia Quality of Life Scale; Communicative Access Measure for Stroke; Therapy Outcome Measures for aphasia; EQ-5D-3L was used to assess health outcomes.

RESULTS

Feasibility of staff recruitment was demonstrated. Training in the intervention was carried out with 28 staff and was found to be acceptable in qualitative reports. 20 patients consented to take part, 6 withdrew. 18 underwent all measures at baseline; 16 at discharge; and 14 at 6-month follow-up. Of 175 patients screened 71% were deemed to be ineligible, either lacking capacity or too unwell to participate. Poor completion rates impacted on assessment of patient outcomes. We were able to collect sufficient data at baseline, discharge and follow-up for economic evaluation.

CONCLUSIONS

The feasibility study informed components of the intervention and implementation in day-to-day practice. Modifications to the design are needed before a definitive cluster-randomised trial can be undertaken.

TRIAL REGISTRATION NUMBER

ISRCTN37002304; Results.

Use of the extended therapy outcome measure for children with dysarthria

Increasing demand on healthcare resources has led to a greater emphasis on the examination of the impact of service delivery on outcomes. Clinical assessments frequently do not cover all aspects of change associated with interventions for those with complex conditions. This paper reviews the need for more comprehensive outcome measurement suitable for clinical practice and benchmarking. It describes an extension of the Therapy Outcome Measure for specific use in reflecting the impact of the broad range of interventions commonly required when managing children with dysarthria. Three case histories are used to illustrate the approach, and data from four speech-language pathology services are used to illustrate the value of benchmarking.

Introducing the therapy outcome measure for AAC services in the context of a review of other measures

PURPOSE

This article discusses the importance of outcome measures in improving Augmentative and Alternative Communication (AAC) services, reviews existing methods and introduces a new approach.

METHOD

Three methods were used in this study. 1. A literature review identifying outcome measures used in AAC research. 2. A questionnaire to AAC services in the UK which aimed to identify the objectives of their services and the outcome measures commonly used. 3. A working group of AAC experts provided additional information and interpretation. Central properties and conceptual framework were considered.

RESULTS

The literature review and questionnaire identified 23 outcome measures none of which cover the conceptual frameworks associated with all of the overall objectives of AAC provision. The review has informed the further development of a particular outcome measure the AAC Therapy Outcome Measure (AAC TOM) ensuring that basic principles of the International Classification of Functioning (ICF-WHO) are retained and the measure can be used in benchmarking.

CONCLUSION

An outcome measure needs to reflect change associated with service delivery. AAC services endeavour to impact on all of the domains of the ICF. A new measure is required in order to reflect the nature of these services. This article introduces an outcome measure which is in the process of being trialled by some services in the UK.

Therapy outcome measures: where are we now?

Outcomes information contributes to the provision of quality services: sharing that information requires speech-language pathologists (SLPs) to use terminology readily understood by professions ranging from health and education to social and voluntary services. The Therapy Outcome Measure (TOM) provides a way of presenting outcome data in a digestible form, comprising part of a range of multiple measures used to collect information on the structures, processes, and outcomes of care. TOM was developed to provide a practical method of measuring outcomes in routine clinical practice. Furthermore, it has been used in a number of research studies as an outcome indicator. As an example of its utility in research, the article cites a benchmarking study, together with examples of internal and external benchmarking of outcomes intended to illustrate how the benchmarking of TOM data can inform practice. The TOM can therefore inform SLPs on their own outcomes, the outcomes for specific client groups, and, by benchmarking TOM data, can contribute to the delivery of better, more efficient services.

Does the number of system paramedics affect clinical benchmark thresholds?

OBJECTIVE

Competency is affected by skill exposure, skill complexity, and training program quality. The purpose of this study was to reevaluate the biennial (24-month) critical care skill and experience benchmark thresholds established by the Milwaukee County Emergency Medical Services (MCEMS) system in 1997.

METHODS

This was a retrospective review of annual experience profiles for paramedics working during 2001-2005 using the MCEMS patient care record (PCR) database. The number of patient contacts, role as team leader/report writer, adult and pediatric endotracheal intubations, adult and pediatric intravenous (IV) access initiations, medication administration, and 12-lead electrocardiogram (ECG) acquisitions were analyzed. t-tests and descriptive statistics were performed for comparison with the 1997 study.

RESULTS

Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts. Annual means+/-standard deviations [ranges] were as follows: patient contacts 245+/-133 [12-788]; team leader: 106+/-119 [0-739]; intubations: adult 2.57+/-2.54 [0-20], pediatric 0.1+/-0.3 [0-3]; IV starts: adult 44+/-37 [0-267], pediatric 0.34+/-0.77 [0-5]; treated cardiac arrests: adult 8+/-6 [0-34], pediatric 0.26+/-0.61 [0-4]; treated hypotensive trauma: 5+/-6 [0-42]; and ECGs acquired: 31+/-19 [0-144]. The 1997 analysis (1987-1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts generated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysis and the current study, except medication administration, which increased 25%.

CONCLUSION

These data show a decreased opportunity and a wide variability in the frequency of successfully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are performed infrequently. A multifaceted approach should be considered for maintaining provider competency.

Towards an international framework for communication disorders: use of the ICF

There has been an interest in the World Health Organization's framework of functioning and disability by those in communication disorders since the original 1980 International Classification of Impairments, Disabilities, and Handicaps (ICIDH). In 2001, WHO published the substantially revised International Classification of Functioning, Disability, and Health (ICF). This framework is gaining in acceptance as a system that would be beneficial for the field and for our clients. This article describes the basics of the ICF and how it differs from the ICIDH; the possible applications of the ICF to communication disorders; some of the work done with the ICF in communication disorders internationally; and the benefits to the field from increased interdisciplinary and international collaboration using the ICF as a common framework.

LEARNING OUTCOMES

As a result of this activity the reader will be able to: (1) describe the basics of the ICF, (2) describe the applications of the ICF to communication disorders, and (3) describe the possible impact upon the field internationally.