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Objectifying the Subjective Through the Use of Outcome Assessment Instruments for Managed Care Documentation
By James Lehman DC, FACO
Integration of chiropractic services into the current healthcare system dominated by
managed care organizations is essential for the growth and development of the
profession. Scientific documentation of the specific benefits of chiropractic intervention
enables managed care organizations to expedite treatment guidelines that include
chiropractic services. Chiropractic research is certainly more obvious than any f the other
complementary medicine services. Further scientific studies that demonstrate the value
of chiropractic care relative to outcomes that measure patient satisfaction and cost
effectiveness would benefit chiropractic intervention.
Field practitioners should provide financial support for our research organizations. In
addition, chiropractic physicians must implement use of appropriate and necessary
assessment instruments that document their own clinical outcomes. Their studies may be
biased due to the selection process. A private practitioner outcome study could be more
scientific with less possibility for error if 100% of patients were selected. A protocol that
utilized both a verbal and visual analogue scale may be preferred. This could be
complemented by pain drawings, headache questionnaire, Oswestry (low back pain) and
Vernon Mior (neck pain) specific functional disability questionnaires. Perhaps a brief
discussion of each is in order at this time.
Verbal Analogue Scale
Verbal rating scales have been used effectively in hospital clinics to measure pain
intensity and analgesia (Beecher 1959.) The verbal numeric rating scale is efficient and
minimizes both patient and staff burden when collecting data.1 This is also the simplest
and most frequently used approach to assessing subjective pain states with numeric rating
scales.
During the history taking process, request patients to indicate how severe their pain is on
a scale of 0-10. 0 represents “no pain at all” and 10 “the worst pain imaginable.”1 My
preference is to describe the scales a 0 = no pain at all, 1 = very mild discomfort, 5 =
moderate pain interfering with some of your activities of daily living and 10 = suicidal.
Some pain authorities advise against this last descriptor, but I find it beneficial. Patients
reconsider their pain status and, in my opinion, offer a more realist response. Also, it is
clearly significant to reveal suicidal proclivities during the initial assessment.
Visual Analogue Scales (V.A.S.’s)
According to two authors (Huskisson, 1974; Joyce, 1975), visual analogue scales (VAS)
have been effectively utilized to provide simple, efficient, and minimally intrusive
measures of pain intensity which have been used widely in clinical and research settings
where a quick numerical value can be assigned.1 The most commonly used V.A.S.
consists of a 10 cm. Horizontal line (Huskisson, 1983) with two end points labeled “no
pain” and “worst pain ever” or similar descriptors. The patient is required to place a
mark on the 10 cm. Line at a point, which corresponds to the level of pain intensity he or
she presently feels. The distance in cm. from the low end of the V.A.S. to the patient’s
mark is used as a numerical index of the severity of pain.1
This instrument with the pain drawing is a suggested by the clinical practice guideline
#14 to augment patient history for acute lower back problems in adults.2 My personal
preference is the use of a revised combination of a numeric and visual analogue scale.
This instrument complements my approach to history data collection. Listed below are
some examples that you may find beneficial for your own clinical use to evaluate pain
and document response to care.
Revised Oswestry Disability Questionnaire (O.D.Q.)
This instrument was designed to evaluate the effects of lower back pain on functional
disability and soon became established as a valuable outcome measure as reported in
1987.3 This instrument is considered reliable, internally consistent and valid.4 The
O.D.Q. consists of ten sections addressing important normal activities of daily living
(ADL) that are highly relevant to patent functional status: pain intensity, personal care,
lifting, walking, sitting, standing, sleeping, social life, traveling, and changing degree of
pain. Each has a six-point scale, suggesting a greater potential responsiveness than
instruments using a yes or no format.
My clinical use of this instrument includes the revised V.A.S. (numerical) and Oswestry
(O.D.Q.) combined to create one form with two instruments. Patients complete this form
prior to their initial evaluation and prior to their initial re-evaluation. Our clinical
protocol involves re-evaluations following three to six treatments. It has been decided to
remit additional forms to discharge patients during 1997. An interval of six, twelve, and
twenty-four months following discharge has been selected. Interesting data should be
generated that might reveal long-term effects of care. Another specific assessment
instrument for neck pain is the Vernon Mior Disability Questionnaire. It should be
utilized in the same manner as the O.D.Q.
Pain Drawing Assessment (P.D.A.)
An excellent critique of the P.D.A. was presented by Bryner this year in Topics of
Clinical Chiropractic.5
My purpose is to briefly state that it has clinical value in the chiropractor’s clinic for
neuromusculoskeletal disease evaluation. Bryner states “despite current limitations, pain
drawing remains a valuable tool to document an individual’s perception of status or
change of status.” It is my perception that any objective documentation of subjective
complaints benefits the chiropractic record keeping process, reduces professional
liability, and improves opportunity for integration and proper reimbursement. Outcomes
assessment instrumentation may guide the clinician and support the rationale for
conservative chiropractic medicine interventions with neuromusculoskeletal disease.
Conclusions:
Growing use of managed care terminolo gy has created numerous buzzwords including
quality improvement, benchmarking, risk, capitation, and outcomes assessment, to name
only few. Allopathic assessments have been expensive, invasive, and almost always
“high-tech.” Managed care demands improved quality and valid assessment instruments
with reduced costs. A “low-tech” outcome assessment must be time efficient,
economical, reliable, and valid.6 Chiropractic physicians will be expected to objectify
patient status and document patient progress dur ing the course of treatment.
Every chiropractic physician should solidify his contract position with managed care
organizations by collecting data. The ability to demonstrate your clinical results and
patient satisfaction may enable you to renegotiate mo re favorable capitation schedule or
receive bonuses. High production capability is important to managed care but only with
accompanying high quality care and patient satisfaction.
In order to avoid biased data accumulation, may I suggest utilization of outcome
assessment instruments during and following the course of treatment? This data should
enable practitioners to improve quality of care and illustrate results of care. In addition,
telephone surveys of patients one month post initial work-up could complement patient
satisfaction date retrieval. An excellent model was developed by Dr. Kelli Pearson.
Publish or perish, put up or shut up, document or isolate are three expressions that might
guide our profession on the realities of its journey to attain managed care integration.
1 Wall, P., Melzack, R., “Pain Measurement in Persons with Pain,” Textbook of Pain; Edinburgh, London,
Madrid, Melbourne, New York and Tokyo; Churchill Livingstone 1994; 338
2 “Acute Low Back Problems in Adults,” Clinical Practice Guideline, Number 14; U.S. Department of
Health and Human Services, Public Health Service, Agency for Healthy Care Policy and Research, 1994;
19
3 Haas, M., Jacobs., G., et.al. “Low Back Pain Outcome Measurement Assessment in Chiropractic
Teaching Techniques: Responsiveness and Applicability of Two Functional Disability Questionnaires,:
JMPT, 1995 18”19-87
4 Hudson-Cook, N., “The Revised Oswestry Low Back Pain Disability Questionnaire,” Bournemouth,
England; Anglo-European College of Chiropractic, 1988
5 Bryner, P., “Analysis of Low Back Pain Drawings,” Aspen Publishers; Top Clin Chiro 1996; 3 (3) 26-31
6 Yeomans, S., Lievensen, C., “Quantitative Functional Capacity Evaluation; The Missing Link to
Outcomes Assessment,” Aspen Publishers, Top Clin Chiro 1996;3 (1):32-43