Benchmarking Outpatient
Rehabilitation Clinics
Pedro Gozalo, PhD
Dennis L. Hart , PT, PhD
Linda Resnik , PT, PhD, OCS
Background
• Large number of Outpatient Therapy
users:
– Medicare CY 2006:
• 4.4 m. beneficiaries (9.7% of all beneficiaries)
• $4.1 billion (75% for PT)
– Medicare CY 2000: 3.6 m benefic., $2.1 b.
– CY 2002: 22 m. (25%) of all MD visits resulted
in referral to PT.
Gozalo--Academy Health 2009, Chicago
2
Main Goals
• What to measure as performance?
• Is it the clinic or the therapist that
influences performance the most?
• Should benchmarking be done by
condition type (knee, lumbar,…)?
Gozalo--Academy Health 2009, Chicago
3
Methods
• Prospective , longitudinal, cohort study.
• July 2006—June 2008 Data from Focus On
Therapeutic Outcomes, Inc. (FOTO)
database.
• N=90,392.
• Therapists=2,040.
• Clinics=538 (excluded clinics with N < 30).
Gozalo--Academy Health 2009, Chicago
4
Key Variables
• Outcome = Self-Reported patient
functional status (FS) at discharge.
– Measured on a 0-100 scale (100=highest
functioning).
– Measured with Computerized Adaptive
Testing (CAT) assessment methods specific to
the patient’s impairment using items
calibrated into FS scales using IRT methods.
– FS CAT Scales validated and found reliable,
valid, sensitive and responsive.
Gozalo--Academy Health 2009, Chicago
5
Covariates
Patient case-mix
– age
– gender
– functional status at
intake
– number of days since
onset of condition
– number of surgeries
– functional
comorbidities index
– payer type
– #conditions treated in clinic
Type of Condition
–
–
–
–
–
–
–
–
–
–
lumbar
shoulder
knee
cervical
foot/ankle
hip
wrist/hand
elbow
ribs
craniofacial
Gozalo--Academy Health 2009, Chicago
6
Analytic Strategy
• Hierarchical 3-level model
– Patients
– Therapists
– Clinics
• Corrected for potential informative
censoring using Inverse Probability of
Censoring weights
Gozalo--Academy Health 2009, Chicago
7
Results (1)
Discharge FS (0-100)
Intake FS (0-100)
Age
Female (%)
Surgery (1 or more) (%)
Onset (Days)
>6 MONTHS (%)
22-90 DAYS (%)
91 DAYS - 6 MON
Payer (%)
PPO
Medicare Part B
HMO
Gozalo--Academy Health 2009, Chicago
Mean (SD) or %
64.4 (16.4)
48.8 (14.2)
54.0 (16.2)
61
31
36
30
15
37
19
10
8
Results (2)
Intake and Discharge FS by Impairment Group
Min Avg Diff=11.5 Cranofacial Max Avg Diff=18.5 Knee
CERVICAL
CRANIOFACIAL
ELBOW
FOOT/ANKLE
HIP
KNEE
LUMBAR
RIBS
SHOULDER
WRIST/HAND
0
20
40
60
Discharge FS
Gozalo--Academy Health 2009, Chicago
80
100
Intake FS
9
-20
12009
157805
36687
77092
49187
82122
16344
39455
34838
213404
82264
60374
81496
86058
25813
1919
84044
215504
77822
69026
58277
125886
192089
75307
23847
8931
35174
181816
3718
27130
107741
40775
26409
108186
152094
210164
119009
62127
37015
60656
21612
111270
214898
29362
17190
210720
38920
45255
20974
89946
211995
24089
45067
41808
Clinic random intercept with 95% CI
-10
0
10
20
86799
30
Results (3)
0
400
200
Rank of predicted clinic random intercept
Gozalo--Academy Health 2009, Chicago
600
10
Results(4)
• Clinic Effects were Larger than Therapists
(9% of total variation vs. 2.4%)
• Estimated discharge FS due to clinic range
from 0.4 to 24 units (in 0-100 scale).
• Censoring of discharge FS was 36% but
correcting for it had little effect in ranking
of most clinics (a few had larger changes).
Gozalo--Academy Health 2009, Chicago
11
Results(5)
• Clinic rankings can be non-uniform across
conditions (based on condition-specific
rankings)
Gozalo--Academy Health 2009, Chicago
12
Results (6)
Overall Ranking vs Lumbar Impairment Ranking
0
100
200
300
400
500
N=469 clinics with 8+ patients in Lumbar impairment
0
100
300
400
200
Rank based on all Impairment outcomes
Rank based on lumbar impairment outcomes
Gozalo--Academy Health 2009, Chicago
500
Fitted values
13
Results(7)
Lumbar vs Shoulder Impairment Rankings
0
100
200
300
400
N=423 clinics with 8+ patients in each impairment
0
300
100
200
Rank based on shoulder impairment outcomes
Rank based on lumbar impairment outcomes
Gozalo--Academy Health 2009, Chicago
400
Fitted values
14
Significance
• Profiling methods can be used for
benchmarking outpatient rehab clinics
• Clinic benchmarking can be used (with
care) for P4P or similar economic incentive
policy
• Benchmarking performance can be used to
help identify good/bad practice processes
Gozalo--Academy Health 2009, Chicago
15