1. AROC Clinical Benchmarking Workshop Review Craig Evans and Tony Fitzsimons 19 th March 2010

2. What is AROC? “Australasian Rehabilitation Outcomes Centre” – University of Wollongong Provide a national benchmarking system to improve clinical outcomes Collect outcome information - rehab centres across Australia (155) and NZ (12); ~ 1200 amputee rehab episodes Annual Reports (The AROC Annual Report: the state of rehabilitation in Australia in 2008 – http://chsd.uow.edu.au/Publications/2009_pubs/son_2008.pdf)

3. So what happened at the workshop? Greg Bowring – Practice guidelines for amputee management – VA/DoD Clinical Practice guideline for Rehabilitation of Lower Limb Amputation (http://www.healthquality.va.gov/amputation/amp_sum_5 08.pdf)http://www.healthquality.va.gov/amputation/amp_sum_5 08.pdf

4. VA – Amputation Rehabilitation Health- Related Outcomes and confounders Pain Service Availability Post-operative Pain Allied Health availability Physical Health Deconditioning / frailty Cognition Function Social isolation, psyche service availability and Past Hx Psychological support and Well-being Adjustment issues Patient Satisfaction Alone Accommodation suitability, Home mods Reintegration Wound Healing Co-morbidities Healthcare Utilisation

5. Current Guideline Outcome Measures Post-operative PainPhysical Health FIM / Discharge FIM Function (ADLs and QOL)Psychological support and Well-beingPatient Satisfaction Discharge Destination Reintegration LOS and FIM efficiency Healthcare Utilisation

6. Models of Care Pre Op / High Risk Foot Clinics Acute inpatient Inpatient Rehab Parking / Transitional Care Prosthetic Management – inpatient and outpatient Discharge Highly variable between centres making benchmarking a difficult task!

7. Model Variation Factors Availability of staff /teams Inpatient rehabilitation admission criteria Geographic location (metro/regional/remote) Ability to slot clients into community services Lack of local specialty expertise Ability to access funding for home mods “Parking” patients Timing of prosthetic clinics and visits Timing and type of prosthetic intervention. Ability/funding to access technology to assist in healing, pain management, & prosthetic phases Prosthetic funding models Patient Type changing

8. AROC Data Inclusions – full data sets Exclusions – Ambulatory, outpatients, mortality

9. AROC Impairment Codes Amputation of limb o 5.1 – Single Upper Extremity Above Elbow o 5.2 - Single Upper Extremity Below Elbow o 5.3 - Single Lower Extremity Above Knee o 5.4 - Single Lower Extremity Below Knee o 5.5 - Double Lower Extremity Above Knee o 5.6 - Double Lower Extremity Above/Below Knee o 5.7 - Double Lower Extremity Below Knee o 5.8 – Partial Foot Amputation o 5.9 – Other Amputation

10. AN-SNAP Version 2 Classes Amputation of Limb – 2-224 Motor 72-91 – 2-225 Motor 14-71* *Cohort groups too broad. Smaller Cohort groups = smaller samples Functional vs “adequate sample” groups

11. SYNATIX Data Collection Form Examples of Data Presentation

12. Hurdles to achieving outcome benchmarks Consequences of prolonged immobility Presence of medical co-morbidities Cognitive function Adjustment issues Learning capacity Inappropriate accommodation Intransigent attitudes

13. Agreed Stages of Amputee Management Pre-op Immediate Post Operative Pre Prosthetic ProstheticFollow up

14. New AN-SNAP Codes? FIM admission Motor Count (n)Avg FIM changeAvg LOS 14-409123.6647.96 41-6024221.0141.17 61-7120612.6334.54 72+1115.7423.74 Ceiling effect in higher FIM scores

15. New Data Collection Date of Surgery Date ready for casting Date of first prosthetic fitting – reason for delay Clinically ready for discharge Discharge Delay Reason Home mods Equipment Community support ACAT / Residential Care availability

16. New Outcome Measures Ambulatory Data – FIM not sensitive enough 6 min walk test TUG ?? 10mWT, Amppro, 4SST, K-classification, LCI, mobility aide and assistance Other Clinical Frailty index MMSE ? – as a screening tool

17. What does it mean for us? Data collection What else should we be collecting that could make a difference or improve our practice?