Choosing Outcome Assessments for Back Pain

By Kara Shannon, DC, and Zacariah Shannon, DC, MS

What is health and how do you measure it?

In chiropractic practice, improving our patients’ health is the primary treatment goal. “Health,” however, has a broad definition. The World Health Organization defines health as “a state of physical, mental, and social well-being not merely the absence of disease or infirmity.”¹ Because health represents a wide range of factors, and patients are individuals with unique views and perspectives, they likely seek treatment to improve different aspects of health.

Understanding a patient’s treatment and health goals is a core component of shared decision-making, a process where provider and patient come together to make informed decisions about treatment and/or management.

Once treatment goals are set, a way to track progress toward them is needed. Sometimes outcomes involving laboratory tests, imaging, and other findings, such as range of motion and muscle strength are used. While these outcomes may be useful, they are not typically patient-centered. Patient-reported outcome measures quantify patients’ subjective symptoms and are often more in line with accomplishing patient-centered goals. Patient-reported outcomes can give valuable information to evaluate the success of a treatment plan and aid in determining a prognosis based on past response. They are also used by insurance companies for re-imbursement purposes, such as determining medical necessity.

How to Pick the Right Outcome Measure

Some important factors to consider when choosing outcome assessments (not all can be covered in this article):

• Cost/Accessibility (including language)
• Number of questions/Burden to fill out
• Reliability, validity and responsiveness (research evidence)
• Applicability to patient presentation and treatment goals
• Resistance to floor and ceiling effects (able to measure change in patients with high or low scores)

Chiarotto et al.² developed a core outcome set (COS) for use in clinical practice with accompanying suggested measures for patients with low back pain. The COS was developed based on the results of a Delphi process, in addition to recommendations of other outcome initiatives. COS domains include three domains that reached consensus: physical functioning, pain intensity, and health-related quality of life (HRQoL); and three domains that were close to consensus: work, psychological functioning, and pain interference. This COS is suggested to be measured in all patients with low back pain to better capture an overall picture of the patient’s health progress.

Table 1. Core outcome set for low back pain suggested by Chiarotto et al.²

Domain	Suggested Outcome Measures
Physical function	RMDQ-24, ODI 2.1a, or QBPDS
Pain intensity	0-10 NRS scale Consider: average in last “24 hours” for acute pain average in last “week” for subacute pain average in last “2 weeks” or “1 month” for chronic pain
Health-related quality of life	EQ-5D-3L or SF-12
Work Work ability      Work productivity	Single Question: “Are you working at a physically less demanding job now     because of your back and/or neck pain?”      Two questions: “What is your current work status?” “How long after you received treatment for low back pain did you return to work?”
Psychological Depression     Anxiety	HADS HADS
Pain Interference	BPI-PI or MPI-PI

 

For more information on these measures including definitions, scoring, cost, etc., see Chiarotto et al. ²

RMDQ: Roland Morris Disability Questionnaire; ODI: Oswestry Disability Index; QBPS: Quebec Back Pain Disability Scale; NRS: Numerical Rating Scale; EQ: EuroQol; SF: Short Form health survey; HADS: Hospital Anxiety and Depression Scale; BPI: Brief Pain Inventory; MPI: Multidimensional Pain Inventory; -PI: Pain Interference subscale

PROMIS for the Future?

The National Institutes of Health funded the development of the Patient Reported Outcomes Measurement Information System (PROMIS), which includes measures covering more than 300 health domains.³ Clinicians can choose the appropriate PROMIS domains for their patient(s), including recommended domains listed in the COS. Much research evidence has already been published on the validity of many PROMIS domains. More evidence may be necessary to establish validity and clinically meaningful improvement scores of some domains for patients with low back pain.

Though more research on PROMIS measures is still needed, there are appealing aspects for clinical application. PROMIS measures can act as one instrument that can be tailored to patient presentation/condition while still measuring physical, mental, and social aspects of health. For instance, instead of having to put together five or more different outcome assessments to assess low back pain patients, you can choose the appropriate domains and have them all as part of the PROMIS assessment. Additionally, you can track progress in other aspects of health, which are not assessed in outcome measures commonly used in chiropractic practice, such as change in sleep disturbance, fatigue or self-efficacy, among many others.

PROMIS also offers computerized adaptive testing (CAT). CAT asks the most important question (the one that gives the most information) first and chooses the following questions, from the bank of questions, based on the patient’s responses. This means that even the questions asked for the outcome assessment are tailored to the patient.

PROMIS computer adaptive testing allows clinicians to extend patient-centered care into outcome assessments by tailoring which questions are asked to each patient.

PROMIS can be incorporated into the electronic health record and/or be collected electronically, such as with the use of a tablet.³

Clinical Application

Have you ever had a patient report feeling much better, but their outcome assessment showed little improvement?

One possible cause is that the outcome assessment is not sensitive to the health change some patients experience. By incorporating the COS measures and tailoring additional outcomes to patient goals, you are better positioned to detect these changes.

• Consider PROMIS to streamline your outcome assessments
• Use the COS measures for patients with low back pain
• Use patient goals and presentation to determine additional relevant outcomes
• Track patient progress

Clinicians have the choice to collect patient outcome assessments solely to satisfy documentation requirements or to inform patient-centered care.

Kara Shannon, DC, is a part-time faculty member of the Palmer College of Chiropractic, Davenport, Iowa. She also runs a private chiropractic practice in Buffalo, Iowa.
Zacariah Shannon, DC, MS, is a post-doctoral research scholar at the Palmer Center for Chiropractic Research, Davenport, Iowa.

 

References

1. Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June – 22 July 1946; Official Records of WHO, no. 2, p. 100
2. Chiarotto A, Terwee CB, Ostelo RW. Choosing the right outcome measurement instruments for patients with low back pain. Best Pract Res Clin Rheumatol. 2016 Dec 1;30(6):1003–20.
3. Intro to PROMIS [Internet]. Available from: http://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis