we don’t do outcomes—give me a starter approach glen h. porter, phd cardiac rehabilitation john...

We Don’t Do Outcomes—Give Me A Starter Approach

Glen H. Porter, PhDCardiac Rehabilitation

John Muir Medical CenterWalnut Creek, CA

The Primary Focus of This Presentation• Why Outcome Evaluation?

• What Outcome Measurements Might You Use In A Starter Program?

• How Can I Store And Retrieve My Data Without Costly Hardware And Software?

• How Can I Analyze My Data?

• How Can I Present My Data In A Meaningful And Professional Fashion?

Why Outcome Evaluation

The primary reasons for including outcome evaluation within cardiac and pulmonary rehabilitation programs are to improve patient care and to use the information to improve program effectiveness.

AACVPR Consensus StatementOutcomes Evaluation in Cardiac Rehabilitation/Secondary Prevention

Programs

JCR 2004; 24:68-79

Use Your Outcomes

• VP & Director of Cardiac Rehab• Medical Director• Cardiology Committee• Quality Management/Utilization Review• Hospital Board of Directors• Medical Director of IPA• JCAHO/Centers for Medicare Services• AACVPR Certification• Anyone Who Asks

Outcome Tools Resources

• www.aacvpr.org/publications

• Outcome Tools Resource Guide

• Outcome Domains

• Outcome Evaluation in Cardiac Rehabilitation/Secondary Prevention: Improving Patient Care and Program Effectiveness, JCR 2004; 24:68-79

Specific Domains of Outcome Evaluation

• Clinical Domain• Functional Capacity/Exercise Training Level• Blood Pressure Management• Lipid Management• Diabetic Management• Weight• Other

Specific Domains of Outcome Evaluation

• Behavioral Domain• Education/Patient Teaching• Smoking Cessation• Stress Management• Diet Planning• Exercise Habits• Other

Specific Domains of Outcome Evaluation

• Health Domain• Health-Related Quality of Life (QOL)• Health Status

• Service Domain• Patient Satisfaction• Financial/Economic• Access/Utilization Rates

Specific Outcomes From Each Domain In A Starter Approach• Clinical

• Exercise Training Responses• Blood Pressure Management• LDL-C Management

• Behavioral• Smoking Cessation

• Health/QOL• SF-36 Health Survey or• Ferrans & Powers Cardiac Version IV

• Patient Satisfaction Questionnaire

Specific Measurement In Each Core Component• Exercise Training

• Training Met Level GOAL- Increase• Rate Pressure Product (RPP)/Training Met Level

GOAL- Decrease

• Blood Pressure Management GOAL- <130/90

• Lipid Management• LDL-C GOAL <100mg/dl

• Smoking Cessation GOAL- Abstinence

• Health/QOL• SF-36 or Ferrans & Powers Cardiac Version IV

GOAL- Increase in Category Score

Compare Each Measurement to Benchmark Values

Patient Satisfaction Outcomes

• The staff was knowledgeable and provided me with the information I needed to understand the disease process and my cardiac rehabilitation goals.

Disagree 1 2 3 4 5 Agree• The staff provided me with adequate individual

attention and modified the exercise routine as necessary to meet my abilities and/or limitations.

Disagree 1 2 3 4 5 Agree

Patient Satisfaction Outcomes

• The length of the program was sufficient for me to gain the knowledge and confidence to continue my exercise and lifestyle modifications at home or in a club setting, and I can follow an exercise program and risk factor modification strategy developed for me by the staff.

Disagree 1 2 3 4 5 Agree• I did not have any significant difficulty with insurance or

billing issues. Disagree 1 2 3 4 5 Agree• Please give us any suggestions to help us attain our goal

of providing the best possible patient care. Thank You.

Outcome Data StorageExcel Spreadsheet

ID# Age Gender Diag. Wt,

lbs

Wt,

Kg

HR SBP DBP

007 52 Male MI/PCI 146 66.4 52 100 62

10 64 Female CABG 170 77.3 82 110 60

12 75 Male MI/PCI 216 98.2 82 140 70

Outcome Data StorageExcel Spreadsheet

ID# TM

Sp

%

Gr

METs Min Kcal Ex

HR

Ex

SBP

Ex

DBP

RPPX10-2

007 64.3 0 2.8 10 33 66 130 56 85.8

10 72.3 0 3.1 14 56 80 168 70 134.4

12 34.8 0 2.0 5 17 94 120 60 112.8

Outcome Data StorageExcel Spreadsheet

ID# RPP/MET

HR SBP DBP TM

Sp

%

Gr

METs Min Kcal

007 30.2 70 108 62 91.1 3.5 5.2 25 152

10 43.8 92 112 70 80.4 2.5 4.3 25 146

12 56.6 80 130 80 45.6 0 2.3 8 32

Outcome Data StorageExcel Spreadsheet

ID# Ex

HR

Ex

SBP

Ex

DBP

RPP X10-2

RPP/MET

LDL Goal

Y/N

SBP

007 86 120 68 103.2 19.7 88 Y 108

10 138 142 58 196.0 45.2 81 Y 112

12 106 160 80 169.6 73.6 57 Y 130

Outcome Data StorageExcel Spreadsheet

ID# Goal

Y/N

Smoking

007 Y None

10 Y Current

12 N Previous

Outcome Data StorageExcel Spreadsheet- SF-36

ID# PF PF

Post

RF RF

Post

BP BP

Post

GH GH

Post

VIT

017 43.8 44.4 29.2 29.9 33.9 37.2 48.6 48.8 42.7

018 43.8 52.8 31.6 54.5 30.2 51.1 50.9 48.2 51.8

019 31.8 44.4 27.5 44.6 33.0 55.4 50.6 52.0 36.5

Outcome Data StorageExcel Spreadsheet- F&P QOL

ID# Tot Tot

Post

He He

Post

Soc Soc

Post

Psych

Psych

Post

Fam

020 27.8 29.2 28.2 29.6 30.0 28.1 24.9 30.0 30.0

021 20.8 18.9 22.4 20.1 26.1

022 24.2 24.9 23.4 25.8 22.9 22.6 24.4 24.0 28.3

Statistical Analysis

• Using your EXCEL Spreadsheet Recorded Data• From Tools Menu Drop Down to Data Analysis

Select Descriptive StatisticsInput Range of DataOutput Range of DataSelect Summary Statistics

Gives you Mean, Median, Stnd. Dev., SE, Etc

Select t-testt-test for paired/two-sample means

• Calculate percent change of pre/post values% Change = [(post – pre)/pre] x 100

Summary Data

Weeks Before Entry 6.6 + 5.9

Age, yrs 66.2 + 10.4

Body weight, kg 81.4 + 17.9

HR, rest bpm, third visit 74 + 13

BP, systolic mmHg, third visit 123 + 10

BP, diastolic mmHg, third visit 67 + 7

Values are means + SD

Summary Data

Exercise Values At Third Visit

Exercise Met level 2.8 + 0.7min walked 14 + 4 kcal 60 + 35

Exercise HR, bpm 96 + 16

Exercise SBP 146 + 10

Exercise RPP 141 + 24

Exercise RPP/MET 52 + 13

Values are means + SD

Group Summary Report

• Patient PopulationMean Age 67.7 yrsGender

Female% 23%

Male % 77%Diagnosis

CABG% 38%MI% 32%PCI% 15%Other% 15%

• Outcomes• Training METs

Pre 2.7

Post4.3* (P<.01)

• RPP/METPre

53.6Post

39.6* (P<.01)

• Blood Pressure Management% <130 79 %

• Lipid Management

% <100 85%

• Smoking Cessation % Abstinence 86%

• Health Status SF-36 Scales *All Sign.>

Use PowerPoint To Develop A Presentation of the Outcomes• Open PowerPoint

And Do Title Slide• Insert New Slide with

Content Layout Blank • Click on Insert Chart

• Gives you a Template-Data Sheet

• Set The Data Sheet To Fit Your Selected Datai.e., for

• Select Chart Type

A B

1 Female Male

2 25 75

3

PowerPoint- data sheet

Patient Population- Gender

23%

77%

Male

Female

Patient Population- Diagnosis

38%

32%

15%

15%

CABG

MI

PCI

Other

Exercise Training Outcomes

2.7 4.4

53.6

39.6

0

10

20

30

40

50

Training METs RPP/MET

Initial

Final

*

*

* Significant Difference at P < .01

63% Increase

26% Reduction

LDL-C OutcomesGoal < 100 mg/dl

85%

15%

Goal Not Met

Goal Met

Mean= 80, Median=79 mg/dl

Use Previous Figure to Change ResultsDouble click on figure

Double click on figure again and the data sheet will appear

Change the data entries

Click, New figure appears

A B

1 Goal Not Met

Goal met

2 88 42

3

PowerPoint- data sheet

LDL-C OutcomesGoal < 70 mg/dl

32%

68%

Goal Not Met

Goal Met

Blood Pressure OutcomesGoal < 140

110

20

125

5

0

20

40

60

80

100

120

140

Nu

mb

er i

n C

ateg

ory

Initial Final

Goal Met

> 140

Mean= 123/69 mmHg Mean= 122/67 mmHg

Blood Pressure OutcomesGoal < 130

99

1120

103

20

7

0

20

40

60

80

100

120

Nu

mb

er i

n C

ateg

ory

Initial Final

Goal Met

130-139

>140

Blood Pressure OutcomesGoal < 120

51

59

20

51

74

5

0

10

20

30

40

50

60

70

80

Nu

mb

er i

n C

ateg

ory

Initial Final

Goal Met

120 - 139

> 140

Blood Pressure OutcomesGoal < 120 mmHg

39%57%

4%

SBP > 140 mmHg

SBP 120-139 mmHg

Goal Met

Smoking Cessation OutcomesInitial Status

57, 44%

51, 39%

22, 17%

Never Smoked

Previous Smoker

Current Smoker

Smoking CessationFollowing Acute Event

Goal, Quit

3, 14%

19, 86%

Quit After AcuteEvent

Continue to Smoke

SF-36 Scores for Total Group

0

10

20

30

40

50

60

PhyFunc

RolePhy

BodyPain

GenHealth

Vitality SocFun

RoleEm

MenHealth

PhySum

MenSum

Pre (N=224)

Post (N=163)

All significantly increased (P < .01)

Norm Score

SF-36 Scores 1-year Follow-up

0

10

20

30

40

50

60

PhyFunc

RolePhy

BodyPain

GenHealth

Vitality Soc Fun RoleEm

MenHealth

PhySum

MenSum

1 yr FU (N=98)72% Return

Norm Score

Ferrans & Powers Scores

0

5

10

15

20

25

30

Total Health Social Psych Family

Pre (N=96)

Post (N=42)

In Summary

• In a “starter approach,” select at least one outcome measure to follow from each domain. Keep it simple.

• Develop a storage system that is user friendly and one that fits your computer skills. The statistical analysis should flow smoothly from the stored data.

• Develop an approach to present your summary data.

In Summary – Continued

• Stay current with the data. Store the data on a regular basis.

• Compare your data to published results (benchmarks), and also compare your own data on a yearly basis.

• Select one person who is interested and dedicated to outcome evaluation.

Selected References

1. AACVPR Consensus Statement—Outcomes Evaluation in Cardiac Rehabilitation/Secondary Prevention Programs: Improving Patient Care and Program Effectiveness. JCR 2004;24:68-79.

2. Verrill D, Barton C, Beasley W, Brennan M, Lippard M, King C. Quality of life measures and gender comparisons in North Carolina cardiac rehabilitation programs. JCR 2001;21:37-48.

3. Gulanick M, Gavic AM, Kramer V, Rey J. Outcome in cardiac rehabilitation across Illinois. JCR 2002;22:329-333.

References

4. Vitcenda M. The Wisconsin outcome experience: Baseline Outcomes of the WISCVPR web-based outcomes project. JCR 2003;23:290-298.