Good afternoon everyone. Welcome participants to the 2020 AAPM&R virtual annual assembly. This session is research spotlight quality improvements. This is the best of research session. Each presenter has pre-recorded their presentation that has made time to be available for Q&A today. Please save questions until the end of the session. To pose your questions to the faculty please hit the little button for the question side and please type your questions in the Q&A or chat field on the left side of your screen. To start off we'll go with the video of cost analysis comparison of dysphagia evaluations for a freestanding inpatient rehabilitation hospital presented by Dr. Kevin Thomas from the University of Missouri-Columbia. Hi my name is Kevin Thomas. I'm currently a PGY-4 at the University of Missouri Hospital PM&R program. So my presentation is a quality improvement project that was a cost analysis comparison of dysphagia or dysphagia as some may say evaluations at our inpatient rehabilitation hospital or IPR as I'll be referring to it. As I'm sure most of us are already aware dysphagia or difficulty in swallowing is a very common impairments that we manage in patients at an IPR. It can result from a whole variety of disease processes including but not limited to strokes, brain injuries, spinal cord injuries, head and neck cancers, neuromuscular diseases, and many more pathologies. The current gold standard for diagnosis of dysphagia and to characterize the degree of dysphagia is modified barium swallow or MBS for short. However another accepted modality of diagnosis is fiber-optic endoscopic evaluation of swallowing or FEES for short. Now I think it's important that I give some background information about our IPR given that our specific situation may or may not apply to other IPRs. So my inpatient rehab hospital is Rusk, Rusk Rehabilitation Hospital in Columbia Missouri. We are in a bit of a unique situation in that previously at our hospital we did complete all of our MBS studies in-house with a speech therapist and radiology tech. However in May of 2018 we had an equipment failure that occurred with our fluoroscopy machine and the replacement cost at that time would have been more than $80,000. Thus the decision was made at that time by corporates and Rusk administration to not replace the equipment. Instead the way in which we would have MBS done for our patients was to transport patients to an outside facility with fluoroscopy capability. So there's two facilities that we're able to transport our patients to and both of these are approximately three miles away from our IPR or approximately a 10-minute drive. And of course this requires coordination of radiology, speech therapy, transportation, and the patient's therapy schedule. On June 11th of 2019 we began performing fees in-house at our facility. So this allowed for a nice side-by-side comparison of the two modalities given that at that point we were able to do both, albeit with transportation for MBS. As far as design it was fairly straightforward. So basic cost analysis of the two diagnostic modalities. So yeah as far as participants and settings that would be inpatients at Rusk Rehabilitation Hospital. The primary outcome measure that we were interested in was the total cost for each diagnostic test per patient and that did slightly vary based on certain factors which I will discuss in the results section. With these numbers in mind we also had available the number of patients who were sent for each study over that one year period of 2019. One of the secondary measures of interest that we looked into was time efficiency of each test. So in other words how long would a patient typically be occupied in order to complete each of these two diagnostic tests. The other secondary measure that we looked at was swallowing functional outcomes for all patients at Rusk in 2019 prior to the time that FEAS was implemented compared to 2019 after FEAS was implemented. So looking at our results it's important to note that transportation costs do vary if the patient goes by wheelchair versus stretcher. Specifically the total cost for MBS would be $1,446 when it was wheelchair transportation versus $1,726 when it was stretcher transportation. And of course those are factoring in transport costs going both to and from the hospital. Next we looked at the cost for performing FEAS at our hospital. As you can see that figure is $1,185. However there is an additional $395 charge when a FEAS vendor is present. This is standard protocol to have the FEAS vendor present early on as speech therapists are training to perform the test independently. Eventually once the speech therapists have completed the privileging process to perform FEAS independently then a vendor will no longer have to be present and so thus this extra charge will not be present. At the time that I had completed my project our speech therapists had not quite completed this yet but they were close to doing so. Unfortunately the whole COVID situation kind of threw a wrench into things and so there was actually a period of time where we were not able to do FEAS. We are again able to do it albeit with extra precautions that I can certainly discuss afterwards if people are interested. And so as of now one of our speech therapists is able to do FEAS independently and I spoke to her some more to learn about what the privileging process actually is. And so it's worth noting that there actually isn't really a specific criteria that must be met in Missouri at this time. However apparently this is a hot topic in the speech therapy field right now so that could potentially change at some points. So anyways going back to our results in 2019 we had 117 patients who underwent outside MBS studies and 69 patients who had FEAS performed at Rusk. We unfortunately did not have an exact figure as far as how many patients required wheelchair versus stretcher transportation but with the data I did have available I calculated an average cost of $185,591 for the year and our total cost for FEAS in 2019 was $109,020. As far as secondary outcomes the average amount of time that patients were occupied for MBS was three hours per study and that of course includes the time of transport as well as the actual test. The average amount of time that patients were occupied for FEAS was 30 minutes per study. So clearly at our hospital there is a lot less time involved for the patient with FEAS as opposed to MBS. Then lastly we looked at the eating functional independence scores for all patients at our hospital prior to implementation of FEAS in 2019 versus after. I tried to do some more digging to see if we could narrow it down to only patients with dysphagia but unfortunately that data was not available. As you can see the average eating FIM change score essentially stayed the same from before to after implementation of FEAS. So in conclusion implementing in-house FEAS at Rusk Rehabilitation Hospital has reduced costs and missed therapy hours and functional outcomes for swallowing status were not compromised in the process. And so that's basically the end of my presentation but... Thank you Dr. Thomas. Loud round of virtual applause Dr. Kevin Thomas from the University of Missouri-Columbia. Our next presentation is Dr. Joseph Horniak from the University of Michigan EQPC Quality Scan. Dr. Horniak. Hi I'm Joe Horniak. I'm chair of the Evidence Quality and Performance Committee presenting our work on quality scans for low back pain and ischemic stroke. First I would like to thank Beth Radtke, Kavitha Narikonda and Sarah Samsel. They are staff from AAPMNR. They keep the EQPC in line and keep us moving forward. They've also done a ton of work for the committee including much of the work for this. The committee members are listed as the authors but Beth, Kavitha and Sarah have done the lion's share of the work. Throughout 2019 and 2020 the work of the EQPC has been focused on expanding ways to promote the value of physiatry for specific conditions and care partners. This work is intended to be aligned with the PMNR BOLD initiative and other work of the Academy and its members. This poster describes our process findings and recommended path forward for the quality scans we've completed in 2019 and which are guiding our 2020 and beyond portfolio of work around the following objectives. First, document evidence-based value of physiatry within and beyond the specialty. Two, evaluate existing comparative and cost-effectiveness research. And three, promote collaboration within the Academy and specialty. Moving across the top of the poster, the EQPC collaborated with AAPMNR quality staff to build and initiate a comprehensive quality strategy. Our goal has been to thread together multiple strategies, tactical plans and resources to better strengthen the specialty. To get to our goal, our first step was to understand the evidence base and barriers to improving quality for a specified population. This was one, excuse me, this was done by prioritizing the conditions for our quality strategy, strategy foci. Early in 2019, we identified back pain and ischemic stroke as prime opportunities to explore where and how physiatry contributes to improve quality of care. These conditions represent a large portion of physiatry practice and are also focus areas of the BOLD initiative. We then completed an evidence scan, which means we reviewed existing and current clinical guidelines for our focus areas. We also reviewed other meta-analyses and evidence reviews to help us better understand which aspects of care have what level of evidence and creative recommendations behind them. We conducted a scan of existing measures and the types of data being collected on these conditions and specifically ensure alignment with the AAPMNR registry pilots that are kicking off now. This is important so we could learn what type of data is currently being collected and that could contribute to the evidence base. These steps all led to a gap analysis and helped us answer the questions of where do we need more evidence to support our value as a specialty, what data can we contribute especially to advance evidence, and what types of quality strategy tactics can we develop and lead to fill these gaps identified. Once we identified gaps in both low back pain and ischemic stroke care, we moved through a series of discussions to determine what to recommend to AAPMNR as the best routes to fill these gaps. This included gaining an understanding of efforts from other committees and members to be sure we aren't duplicating their efforts. The results of those discussions and our recommendations on quality tactics AAPMNR could pursue to close gaps in care for ischemic stroke and low back pain are shown the two tables on the bottom left of the poster. As a committee, we feel strongly that the evidence for physiatry and rehabilitative care could be strengthened through improved and coordinated data collection and use for research and note the Academy's effort to do this through the registry pilots. We also identified the need for definition of physiatry episodes of care for back pain and ischemic stroke. Understanding how physiatry contributes across the care continuum for patients and where outcomes and costs are attributed are important to improving value for our specialty. The far right top of the poster lists the EQPC initiatives for 2020. These emerge from the quality scans and start to build the infrastructure and add conditions and populations for additional scans and ultimately recommendations for quality tactics. In closing, AAPMNR is pursuing the development and implementation of a comprehensive and integrated quality strategy for broader membership in order to promote high quality care and deliver value to patients across physiatry practices. By identifying areas where more research is needed to promote high quality care and deliver value to patients across physiatry practices, we can foster improvements in practice that align at multiple levels of the healthcare system. Thank you. Thank you, Dr. Horniak. Large round of virtual applause. Dr. Joseph Horniak from the University of Michigan. Our next speaker is Dr. Sterling Herring from Vanderbilt University. He'll discuss the impact of patient satisfaction score utilization on physician burnout and career change. Dr. Herring. Good morning. My name is Sterling Herring. I'm a PGY-4 at Vanderbilt University Medical Center in physical medicine rehabilitation. The talk today is on the impact of patient satisfaction score utilization on burnout on physician burnout and career change. So a little bit of background on this. Patient satisfaction scores are a growing part of the healthcare environment in general and we anticipate that will probably continue into the future. Moving back to 1999 was the first kind of landmark IOM report on healthcare quality or one of the first to err as human, followed by crossing the quality chasm in 2001. Both of these kind of put the onus on healthcare systems and healthcare providers for improving healthcare quality and kind of helped to underscore the problems in healthcare quality and patient safety that exists in the United States healthcare system. Around 2006 a gentleman named Elliot Fisher started talking about accountable care organizations and in 2011-2013 those really started to come onto the scene and those really implemented patient satisfaction scores as a key component of reimbursement and of the healthcare system model in general. So we see that as CAP scores, HCAP scores, Press-Ganey scores, depending on where you're where you're practicing that is how you will most likely encounter those patient satisfaction scores. The purpose of these scores is to identify opportunities for improvement in healthcare specifically to say you know if we're scoring very poorly in one area perhaps we need more training or more emphasis on that area. Unfortunately they have not always been used as they were intended and some might say they've been weaponized to the extent that they have been used as a stick or a carrot as opposed to a more formative feedback measure. So our objective for this study was to evaluate the associations between collection of patient satisfaction scores or utilization of patient satisfaction scores and physicians perceptions of job satisfaction and burnout. So we sent a 23 question survey on utilization of patient satisfaction scores. We sent it to members of the Spine Intervention Society. We sent it via email. We posted on the website. We also had a couple of QR codes and talks given at that society. Responses were collected via RedCap and they were analyzed using standard descriptive statistics. Our results were interesting. We had 108 physicians respond. 77% reported that their institutions tracked patient satisfaction scores and 22% reported that these scores were used for informing the conversation around compensation. So more than that said that they were used for performance review but 22% said that they were specifically used for compensation. 59% said that patient satisfaction scores had a negative effect on their job satisfaction overall. Nearly a third said that they have considered leaving their job or leaving their career because of the utilization of patient satisfaction scores or the perceived misutilization of patient satisfaction scores. And nearly 80% felt that the collection and utilization of patient satisfaction scores is contributing to physician burnout on the whole. Some of these results were surprising to us but in general patient satisfaction scores, as I mentioned, they play an important role in determining areas for improvement but misutilization of these scores can be detrimental to physician well-being. It may be detrimental to the healthcare system as a whole and then kind of have a paradoxical negative effect on, we anticipate, on patient satisfaction. That I think is the next step of research here. And then just kind of underscore some of these major points in our study that nearly 80% felt like this the misutilization of these scores were contributing to physician burnout and that nearly one in third had actually considered leaving their job or career due specifically to the misuse of patient satisfaction scores. I think there's a lot of research showing that there are a number of factors contributing to burnout and physicians decisions to leave practice or leave their careers in general. But if there is one piece that one in three respondents identify as a major contributor to that decision that I think bears watching and bears further scrutiny. So in summary I feel that healthcare systems and healthcare practices may benefit from careful consideration of how patient satisfaction scores are utilized and may want to rethink how they collect them and how they utilize them in terms of implementing the data that are collected. That is our study. You will see it hopefully in publication soon. And if you have any questions, feel free to reach out to me directly at the information provided along with this presentation. Thank you. Thank you, Dr. Herring. Another virtual round of applause. Dr. Sterling Herring from Vanderbilt University. Our final speaker today is Dr. Benjamin Carpenter from the University of Washington, Seattle. He's gonna discuss reducing early falls on an acute rehabilitation unit. Dr. Carpenter. Hello, my name is Benjamin Carpenter. I'm a fourth year resident and chief resident in rehabilitation medicine at the University of Washington. This study improvement project on the acute rehabilitation unit at the VA Puget Sound was started after a bed chair alarm protocol to reduce falls was successfully rolled out at the University of Washington. We wanted to create a similar protocol for the acute rehabilitation unit at our affiliated VA hospital. We used the Plan, Do, Study, Act model as a method to perform and document implementing this new protocol. During the planning phase, we reviewed data from falls over the previous year and noticed that a significant proportion of falls were occurring within the first 72 hours after admission. We decided to target our intervention to these early falls. Our aim was to reduce the number of falls during the first 72 hours by 25%. There were a total of 10 early falls on this unit in the year prior. So we anticipated needing to continue this protocol for up to a year to determine if there had been any significant change. We encountered a significant amount of early resistance from staff to rolling out a new protocol and nursing staff in particular were concerned that this would add additional nursing burden and take away some nursing autonomy around bed and chair alarms placement and discontinuation. Our protocol consisted of initiating bed and chair alarms on all veterans upon admission to the unit. These could be removed once the veteran demonstrated that they could use a call light appropriately three times in a row. The veteran also had to be alert, oriented, not demonstrate impulsivity and could not have otherwise impaired cognitive function. We discussed the protocol extensively with rehab staff and got both in-person and anonymous survey feedback. As a result, we added a stipulation for pre-admission clearance, which could be performed during a discussion of the veteran at a pre-admission meeting. After the alarms were placed, the alarms were then discussed at our interdisciplinary meetings three times weekly and alarms on veterans were either removed or continued as a result of this discussion. If they were continued, they were discussed again at the next interdisciplinary meeting a few days later. This protocol was first discussed in the fall of 2018 and was finally rolled out fully in April of 2019. We monitored the falls data monthly and sent out surveys to staff at around the three-month mark to get feedback on the protocol. We formally analyzed our data and compiled feedback at the six-month mark. At that time, there had been no falls on the unit within the first 72 hours of admission. As a result of survey feedback and informal review with staff, we changed the protocol at the six-month mark. We added an additional option for early clearance for veterans who were coming from in-house and had already been cleared for in-room mobility. The survey responses we received demonstrated that overall, the perceived burden from staff to implementing the protocol was low. 85% of our staff reported minimal difficulty initiating the protocol, and 80% spent less than 15 minutes per patient over the course of the admission, implementing and reinforcing that protocol with veterans. We ended our year trial period on April 2020. At that point, there had been only one veteran in 12 months who had fallen within 72 hours of admission, which represents a 90% decrease in the number of early falls from the pre-intervention period. We also found a 36% decrease in total falls on the unit, so the early falls plus those occurring during the rest of the veteran's stay. Overall, we found that implementing a standard bed and chair alarm protocol on an inpatient unit can reduce the number of early falls after admission and may also help to reduce the overall fall rate. Based on our experience in rolling out this protocol, early staff buy-in is extremely important to achieve a smooth rollout, and in our case, getting frequent feedback from staff helped to achieve more buy-in. We feel that this protocol could be rolled out as is or with minor adaptations on other acute inpatient rehab units, and it may be particularly useful if patients are found to be falling within 72 hours of admission. Thank you for your time and attention. I'm happy to answer questions or discuss this work and can also be reached at carpenve at udub.edu, C-A-R-P-E-N-V-E at udub.edu. Thank you. Thank you, Dr. Benjamin Carpenter from the University of Washington, Seattle, and that concludes the pre-recorded part of our session today, and now we're live with all the presenters to take questions, and our first question comes for Dr. Carpenter. What was your patient's satisfaction or dissatisfaction from the alarms? Hey, overall, I would say part of the protocol was explaining the importance of the alarms, and so we designed a script so that the nurses could explain it to the veterans. Most of the veterans were okay using a call light three times. There was always a little pushback from a few people about wanting more independence, but I don't think it was any more than the pre-intervention period, but it was patient or veteran satisfaction was not one of the direct measures. So overall, just to have more of a feel that it was about the same, and we did take it into account, but it wasn't something that we measured directly, but great question. Thank you. So you're saying that the veterans could be a little salty at times? I know, it's hard to believe, but yeah, occasionally, but no more salty than before. Hard to believe. Did you find that the alarms triggered the veterans to wait for help from getting up from a seated position, or was that more for the staff? So I think it was probably a combination of both things. I think putting the alarm protocol kind of front and center made the staff more aware of the importance of keeping alarms on and reinforcing, waiting for staff before mobilizing for the veterans. And I also think it helps make the veterans more cognizant that even if they're used to being more mobile, that while they're here on the unit, they need to use the call alarm appropriately and wait for staff to come help them. So I think it was helpful for both the veterans to kind of recognize that, and then also keeping it in the forefront of the staff members. I've got another question, but it seems similar. Oh, Dr. Herring, what are your thoughts on making patient satisfaction available to the public? Was that a factor in your study? Excellent question, Dr. Essel. Thank you. That is a great question. That was not a factor in our study. I personally feel that that would be another form of potential misuse of patient satisfaction scores. And in my opinion, patient satisfaction scores are kind of, pardon me, hold on just a second. In my opinion, patient satisfaction scores are most effectively used as a recipe, as an ingredient in a recipe for a larger kind of guidance on how we're doing as an institution, how we're doing as a health, as a society, but kind of on the health system level, particularly. On the individual doctor level, certainly if you're seeing a trend, there may be opportunities for further training there, but I don't think making patient satisfaction scores open to the public is always effective. I think it ends up, I personally have seen a few different times, very Yelp-like pleas in physician offices saying, hey, leave us a five-star review. And I don't think that's necessarily a healthy part of medicine. But no, we did not study that specifically. So to follow up on that, I think you're basically preaching to the choir here, Dr. Herring. Those of us who have been followed by Press Ganey scores since the early 90s, at a huge expense to our institution, but it's basically for, in my experience, it's been utilized by the administration to quantify how we as an institution were performing. In 1999, it allegedly got us a Baldrige Award for the institution. And then suddenly it was dropped after the award was given to us. So it's interesting how you can get into trouble with these things as well. And I agree with you that it is very Yelp-like. Dr. Krause asks, are there recommendations for physicians to respond to the reviews online? You know, I'm unaware of these, and I imagine there's gonna be a lot of variation. Can you hear me? Yes. Can you hear me okay? Okay, all right. I imagine there's gonna be a lot of variation from institution to institution on that. I think some institutions are going to be, take more hands-off approach, and others I think are going to be very, I certainly have been, personally have been affiliated with institutions that took a hands-off approach or even encouraged interaction, either with patient groups or the media or whatnot, and then other institutions that have tried to keep a tight grip on those sorts of things. So I imagine there's gonna be a lot of variation in institution to institution, and if you are part of your own personal practice, you know, I think you can take it, take whatever approach you choose. I think responding to reviews is difficult. It's one of those things that some people tend to see as engaging with negative reviews as kind of playing the game, whereas I think some of us are, I think ignoring them would be at our own detriment, but I really don't have an answer. I don't really know how to best navigate this kind of new system that we're living in. Well, do you know if in these reviews, in these scoresheets, if they encapsulated other things besides the physician portion? I don't, because we didn't ask, we didn't go into too many details with regard to what each institution was asking, and really, I think that the patient satisfaction piece, as you mentioned, there's a physician piece, there's a systemic piece, there's everything from when you walk in, in some cases, outside the door, to in the room itself and then afterward. So I mean, if you look at ACO score, like the quality scoring metrics, there are something like 32, 33. I think it's been increased to 38 now over the past few years, and HCAHPS are just one component. So I think that is how it should be used. I think systems should be judged in terms of quality on a variety of metrics. And I think the helpfulness of your staff and the music that was playing in the waiting room should just be a tiny, tiny component of that and shouldn't necessarily, I worry that we're becoming too reactionary to these sorts of things. Well, it's been going on for 30 years, and it starts out from their ability when they call in to make an appointment easy to directions, the parking, to the first direction when they go through the door. We have another question now regarding falls. One problem I have seen at different institutions is response to the alarms could be due to staffing issues, apathy, et cetera. Did you look at the response time to answering alarms before initiating the protocol? That's a great question. That's something that we did not look at specifically. The unit, actually, the unit layout is such that the main nursing station is within about 20, 25 feet of all the rooms. So there are, I think, there's a fairly quick response time. One of the other things that actually came to light was the availability of different alarms in different patient rooms. And so that was another thing that could have also helped reduce the number was just there were a few beds that had non-working alarms, for example. And so needing to get those replaced or being creative about finding different alarm systems was something that I think was brought to light as a part of this study that maybe was another thing that wasn't being addressed before. So I think one of the big benefits of doing this study was really just increasing overall awareness of these other kind of systems issues, which is what QI is all about. And we actually have continued this protocol. And so we've only had actually five total falls since the results I mentioned. So over the past 18 months or so, we've just had that one early fall still. So it's continuing to be a pretty successful new protocol to keep those alarms on and make people prove that they're able to have them off or to be safe with them off. Thank you. So Dr. Thomas, in your cost comparison analysis between utilizing the scope as well as the swallowing study, do we know if there's a difference in quality of the assessment of what you're getting besides the cost? So for the purposes of my study, I didn't have like a great measure for that. The closest thing that I did after that was that eating functional independence measure score. But again, that was kind of for all patients. Just talking to our speech therapists, I know that she does, there's a lot of benefits that she does appreciate about these, particularly like at our institution because one of the advantages, for example, is the fact that they're able to do the tests on their own patients as opposed to with MBS, we're sending it off to a different hospital and then they'll have a different speech therapist performing the test. And then also some other things is the fact that when they're doing fees, they're able to assess for fatigue being a factor, for example, because there aren't the time constraints that you have with MBS, given like radiation exposure and whatnot. And then also, I know she mentioned that it's easier to incorporate things like biofeedback while doing fees. But ultimately to answer your question, I don't have any specific data regarding the quality between each of the two measures, but I think that would be a great subsequent thing to look into for the future. Well, it's important. There's been a whole industry behind this since the 80s now of modified barium swallows and Jerry Login has been giving courses for this for 35, 40 years now. And so it's interesting to see that there's another alternative that may actually save your institution or yourself money on the front end. And it'll be interesting to see how to compare quality-wise. And I think we'll have one question for Dr. Horniak. Where do you think the Academy goes from here now with these early quality initiatives? So at this point, we're starting to move forward with the registries, the spine low back pain registry is in the preliminary stages for being sent out and actually starting to get data. We're starting to implement the stroke registry and getting that a little bit more together. And then we've also recently completed, well, we're completing a survey for pediatrics. That's kind of the next group that we're gonna be looking at. So getting these registries together so we can start collecting data from across the country in bigger groups and use both for research and then for clinical outcomes. So we can use this for CMS and insurance companies as well. Well, I think that all administrators would wanna see something objective. And now we finally have the means to show something truly objective where PM&R is a good thing to have and it saves them money in the long run. And it produces quality results. That's what we hope to show. That's part of the PM&R bold initiative. All right, any other questions to our fine talented pool today? Three of our four presenters were current residents, which is fantastic. Wanna thank you for your time and efforts. And if there are no more questions, we'll conclude our session. Thank you everyone.

dysphagia evaluations

fiber-optic endoscopic evaluation of swallowing

cost analysis

patient satisfaction score utilization

physician burnout

early falls

bed and chair alarm protocol