Outcome Measures in the Hospital Setting: How reliable are they? Which are most used? How often are they utilized?

Have you ever wondered how outcome measures we learn about in school are utilized in the acute care setting? Have you wondered how reliable they are if you have quick patient turnover or inconsistent therapist testing due to rotating therapists between floors? Have you wondered how useful these measures are toward goals and functional outcomes? If so, you’re like me, so in this edition of the acute care crash course newsletter I’ll do my best to take a deep dive into functional outcome measures and try to find some answers!

1. In a survey sent out in 2022 by the Journal of Acute Care PT, 159 of the 227 respondents, about 70%, reported using outcome measures. Top facilitators that aided in the use of outcome measures included a clinical specialty in the use of outcome measures as well as support from administration in use of outcome measures. The biggest barrier as you may expect was time.

2. Some of the most common Functional Outcome Measures used in acute care setting are:

• AM-PAC "6 Clicks"
• Acute Care Index of Function (ACIF)
• Functional Independence Measure (FIM)
• Barthel index
• Katz Index of Independence in Activities of Daily Living
• Timed Up and Go (TUG)
• 2 & 6 minute walk test
• 4 stage balance test
• Community Balance and Mobility Scale

3. Katz Activity of Daily Living Instrument, the Nottingham Health Profile, Barthel Index, and Duke Activity Status Index measure outcome retrospectively by phone call to the patient after the patient had returned home, and did not specifically measure functional status at time of discharge.

The Katz Index of Independence in Activities of Daily Living is often used by nursing professionals to evaluate functional status in hospitalized patients, but has not consistently been used by physical therapists.

The Katz instrument measures of function include bathing, dressing, toileting, eating, transferring, and remaining continent, but does not address other functions such as mental status and the ability to move in bed, which are important functional activities for patients in the acute setting.

Neither the Katz nor other instruments of function were developed to predict discharge status of hospitalized patients.

Part of the issue with outcome measures is that they are difficult to set up and perform, especially if your patient population is either confused, unresponsive, an unreliable historian, in poor health with contraindications or safety impairments which would make the tests difficult or unsafe to perform. Then as stated before, time is a large factor where productivity expectations may make the performance of outcome measures difficult to manage. Therefore, I will highlight what I believe to be the most realistic and useful outcome measure at our disposal as acute care PTs and include information about the test on the next page if you were also unfamiliar with the test as I was.

The Acute Care Index of Function:

• Developed to address mental status, low level activities such as bed mobility, and other aspects of mobility.
• On average can be completed in 12 minutes
• Predicts
  • functional status at levels of function required in acute care
  • prediction of discharge placement
• Inter-rater reliability for the ACIF in a 5-week study using 6 physical therapist raters trained in usage of the ACIF instrument
  • The weighted Kappa values* ranged from 0.88 to 0.98 on the scores for physical function items
  • 0.60 to 0.98 on the scores for the mental function items.
• Test-retest reliability of the ACIF was not measured
• The weighted Kappa for agreement among physical therapist judgment when looking at validity was 0.75

4. *values ≤ 0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement.