Rehabilitation providers have focused on outcomes for more than twenty years and are still asking the same questions. What outcomes should we measure? What are the two or three indicators we should be reporting? What are the quality measures for rehabilitation hospitals? The industry is divided by varied interests and the diversity of rehabilitation providers. When it comes to measuring effectiveness or quality the one-size-fits-all approach continues to frustrate an industry struggling to justify and demonstrate its value. The learning derived from these efforts have minimal effects upon altering the practices of inpatient rehabilitation.
Traditional random controlled trials (RCT) in rehabilitation conflict with existing clinical practices and just don’t fit today’s rehabilitation hospital delivery models. They are not timely, too costly and do not address the variation associated with problem-oriented patient centric care. Alternatively, knowledge is derived empirically through trial and error approaches to managing patient impairment. At best, communicating best practice through the industry has been through a process of recommending expert opinion as guidelines with little enforcement or monitoring capabilities to evaluate its effect. What is needed is to build a system in which clinical effectiveness is a more natural by-product of the care process.
Comparative Effectiveness Research (CER) is figuring out what treatments, tests and procedures work and which ones don’t work by synthesizing evidence comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor patient conditions in “real world” settings. Intuitively, it makes perfect sense to find the best approach to a clinical problem and share that with all providers who treat that problem, assuming others will have the same success. This has been the underlying motivation for our quality improvement initiatives. It hasn’t been very successful in changing practice because clinicians strongly resist any attempts to restrict their choice or judgment, even if the evidence is compelling. A stronger incentive is needed to change how we practice. Pay for performance is heading down that road as payors restrict payment to only treatments with acceptable benefit. However, when payors aggregate sufficient evidence and limit payment to providers who achieve only a positive outcome, the system will collapse and only payors will be available to provide care. It will save money, but it will not advance clinical practice.
Clinicians, however, need to know how, for whom, when (in the course of illness or in the course of treatment) and in what settings specific treatments are best used. Every clinician performing a therapeutic procedure must self assess the limitations, expectations and effectiveness of those procedures. Concurrent and retrospective review of the circumstances will lead to learning. Unless, armed with this knowledge, expecting change in clinical behavior will remain the frustrating push to forced compliance.