July 2019

Survey Identifies Quality of Care Indicators for AFO Users

By Laura Fonda Hochnadel

Lower limb orthoses are worn by nearly 2 million Americans of all ages. Certified orthotists have reported spending 59% of their time providing lower limb orthoses, of which 18% is spent providing ankle foot orthoses (AFOs). Despite such a substantial time commitment spent providing patients with lower-limb orthoses, and specifically AFOs, patient satisfaction reporting and quality of care assessment have not been fully documented.

“As in all aspects of healthcare practice, patients, providers, payers, and insurers recognize that quality measurement is vital to monitor services, improve systems, and obtain reimbursement,” explains Allen Heinemann, PhD, ABPP, FACRM, director, Center for Rehabilitation Outcomes Research and professor, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University. “We must identify what aspects of quality stakeholders value and how to measure those aspects.”

Heinemann and a multidisciplinary team of researchers surveyed 461 orthotists and 153 physical therapists (PTs) to rate the importance of 10 broad themes related to quality of care, and to determine which of 16 standard performance measures they thought feasible and good to use in AFO users. Themes were rated as extremely, somewhat, slightly, and not at all important. If a theme was rated extremely or somewhat important, the respondent was then asked to rate subtopics; in total, 35 subtopics were available for responses. The 10 broad themes were previously determined and were relevant to patients who use AFOs.

The results indicate the two professional groups are largely in agreement regarding quality themes. Over 60% of orthotists and PTs rated these 9 quality themes as extremely important: organizational characteristics, clinician competency, good clinician-patient communication, care coordination, device characteristics, device usage, device fit and comfort, body function, activity and participation. The 10th theme, importance of the care environment, was rated extremely important by 52.4% of orthotists and 37.6% of PTs.

Again using a >60% threshold, of the 35 subtopics, orthotists rated 26 as extremely important and PTs rated 28 as such, also indicating a high degree of consensus. Topics that did not meet this threshold for either group were facility ambiance, device adjustability by patients, patients’ evaluation of device aesthetics, joint range of motion (ROM), gait speed, and endurance. Topics that did not meet this threshold for orthotists were collection of meaningful data, device weight, and social confidence wearing the device, while facility layout was the only topic that did not meet this threshold for PTs.

Survey respondents were also asked to identify who or what would be the best source for quality care markers. They could choose from patient self-report, clinician report, performance measures and tests, facility/patient records, or a combination thereof. A threshold of >50% consensus was applied. The responses are presented in the table.

The subtopics of device durability and balance met the >50% threshold, but without consensus. Over 50% of orthotists indicated device durability is best assessed via clinician report, while >50% of PTs said patient self-report is a better care indicator. Over 50% of orthotists said balance is best assessed using patient performance measures combined with patient self-report, while >50% of PTs indicated that patient performance measures should be combined with clinician report.

While the study shows patient self-report and clinician report could be used to assess a majority of the care indicators, the respondents clearly indicated that patient performance measures should be used to assess how well the AFO helps the patient ambulate. In the context of this study, to measure gait speed and pattern, walking endurance, and balance in AFO users, a >60% consensus of the two groups rated 12 of the 16 measures presented below as feasible and/or excellent/good to use. Those measures were:

  • Ankle passive ROM using a goniometer
  • Timed Up and Go test
  • 5m walk test
  • 10m walk test
  • 6-minute walk test
  • Berg Balance Scale
  • Timed Up and Down Stairs test
  • Functional Ambulation Categories
  • Borg Rating of Perceived Exhaustion
  • Physiological Cost Index
  • Modified Emory Functional Ambulation Profile, and
  • Rivermead Mobility Index.

The authors’ stated purpose was to provide insight into quality care indicators and how to collect and measure that data. The results can provide focus for additional studies.

Source: Heinemann AW, Fatone S, LaVela SL, Slater BCS, Deutsch A, Peterson M, Soltys NT, McPherson V CPO. Orthotists’ and physical therapists’ perspectives on quality of care indicators for persons with custom ankle-foot orthoses. Assist Technol. 2019; 15:1-11.

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