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