Determining AM-PAC “6-Clicks” Functional Assessment Cutoff Scores to Predict Discharge Destination in Patients

Following Total Joint Replacement

Dana R. Maida, PT, DPT, GCS, University of Scranton, Scranton, PA

Barbara R. Wagner, PT, DPT, MHA, University of Scranton, Scranton, PA

Heidi Bockelkamp, PT, DPT, Regional Hospital of Scranton, Scranton, PA

APTA CSM 2018

Background

• Great emphasis on PT evaluations in acute care due to changing healthcare environment and push for shorter length of stay

• Few non-condition specific outcome measures exist that are specific to the acute care environment and discharge destination

• i.e. Acute Care Index of Function, The RAPT for Hip or Knee Arthroscopy

• The AM-PAC “6 Clicks” Inpatient Daily Activity and Basic Mobility Short Forms are not condition specific and can provide therapists with objective information in a quick and easy to interpret manner1

Background

• Boston University AM-PAC Short Forms1

• Activity limitations instrument developed by researchers at Boston University

• International Classification of Functioning, Disability, and Health (ICF) conceptual framework

• Designed for use across patient diagnoses, conditions, and settings

• 3 domains – Basic Mobility, Daily Activity, Applied Cognitive

• Basic Mobility “6 Clicks”

• How much difficulty does patient currently have… turning over in bed, sitting on and standing up from a chair with arms, moving from lying on back to sitting on side of bed

• How much help from another person does the patient currently need…moving from a bed to a chair, to walk in hospital room, climbing 3-5 steps with railing

• Scoring – Unable (1), A Lot (2), A Little (3), None (4)

• Based on raw score, therapist can figure out degree of functional impairment and ultimately assign G-code

Background

• Prior research established validity, and inter-rater reliability of the AM-PAC “6 Clicks” Basic Mobility and Daily Activity Short Forms2,3

• AM-PAC “6 Clicks” scores obtained during initial assessment demonstrated fair to good accuracy predicting discharge destination4

• Cut-off scores Basic Mobility Short Form - 42.9 (Raw score 17/24)

• Cut-off score Daily Activity Short Form - 39.4 (Raw score 18/24)

• Limitations: discharge destination impacted by many factors, rater reliability not established

Background

• Previous findings presented at CSM 2016 (sample size 323 status post total joint replacement (TJR) )5

• Low to moderate correlations between initial PT (r=.318, p<.001) and OT (r=.195, p<.001) “6 Clicks” scores and discharge destination (Home/Home Health; Rehab/SNF), where PT was somewhat more predictive

• Robust correlations between discharge PT (r=.688, p<.001) and OT (r=.712, p<.001) “6 Clicks” scores and discharge destination (Home/Home Health; Rehab/SNF)

• Statistically significant factors impacting discharge: age, type of insurance coverage, support at home, and use of an assistive device prior to surgery

• 2016 study by Menendez et al, determined that “6 Clicks” Mobility score predicting discharge disposition better than base model (age, sex, medical comorbidity, and procedure type) following TJR6

Purpose

• Determine the specific cutoff “6 Clicks” scores that predict discharge destination for patients undergoing elective TJR.

Hypotheses

• Cutoff score would be equal to or slightly lower than previous research on patients with general medical conditions (given that patients were fairly healthy individuals who were significantly impacted by surgery related directly to functional mobility)

• Patients could be discharged to home in spite of lower IE scores due to compensatory strategies taught during hospital stay

• Predictability of “6 Clicks” would be somewhat limited due to the tool being strictly functional which does not account for other factors that impact discharge, such as house set up, social support, etc.

Methods

• Approval from University of Scranton Physical Therapy and Occupational Therapy Department Review Board

• Approval from hospital administration at Regional Hospital of Scranton, Scranton, Pennsylvania

• Joint Commission Accredited Total Shoulder Replacement facility

• Joint Commission Advanced Certification Total Hip and Knee Replacement facility

• Retrospective review of 839 charts of patients having elective TJR between June 2013 and February 2015

• Data collected and analyzed using SPSS and MedCalc with help from statistician on campus

• Initial Evaluation “6 Clicks” and Discharge “6 Clicks” scores for PT and OT

Results

Pearson Correlation

IE “6 Clicks” PT 0.390*

D/C “6 Clicks” PT 0.727*

IE “6 Clicks” OT 0.241*

D/C “6 Clicks” OT 0.705*

Table 1. Correlation Between “6 Clicks” Scores and Discharge Destination

*Correlations significant at the 0.01 level

Results

Cutscore 13-5 IE for

PT

IE 6-Click PT * DischargeRECODED

Crosstabulation

Count

DischargeRECOD

ED Total

ToRehab ToHome Cut-score at 13.5

IE 6-Click

PT 7 1 0 1

8 1 1 2

9 5 3 8

10 22 3 25

11 138 34 172

12 70 34 104 From this table

13 61 52 113 true Neg false Neg 298 127

14 69 81 150 false Pos true Pos 145 263

15 29 49 78

16 39 110 149

17 6 12 18 For medcalc

18 2 7 9 true Pos false Pos 263 145

19 0 3 3 false Neg true Neg 127 298

24 0 1 1

Total 443 390 833

Table 2. Distribution of IE

“6 Clicks” Scores PT

Results

Table 3. Data Analysis at Determined Cut-off Scores

* IE OT correlation too weak to determine accurate IE cutoff score

Results

Score Sensitivity Specificity

12.5 81% 53%

13.5 68% 67%

14.5 47% 83%

Figure 1. ROC Curve IE “6 Clicks” PT

Table 4. Coordinates of the Curve IE “6 Clicks” PT

AUC= 0.727

Results

Score Sensitivity Specificity

19.5 88% 83%

20.5 82% 90%

21.5 74% 95%

Figure 2. ROC Curve D/C “6 Clicks” PT

Table 5. Coordinates of the Curve D/C “6 Clicks” PTAUC= 0.925

Results

Score Sensitivity Specificity

13.5 99% 3%

14.5 97% 9%

15.5 94% 14%

16.5 87% 30%

17.5 66% 53%

18.5 33% 84%

Figure 3. ROC Curve IE “6 Clicks” OT

Table 6. Coordinates of the Curve IE “6 Clicks” OT

AUC = 0.637

Results

Score Sensitivity Specificity

21.5 88% 84%

22.5 76% 94%

23.5 65% 98%

Figure 4. ROC Curve D/C “6 Clicks” OT

Table 7. Coordinates of the Curve D/C “6 Clicks” OT

AUC = 0.915

Discussion• There are limited, evidence-based standardized measures available to assist therapists in the

acute care setting for objective assessment of patient performance to guide decision making regarding discharge

• In recent years, Jette, et al2,3,4 have published several studies establishing the reliability and validity of the “6 Clicks” and the utility of using it to determine discharge destination

• Our previous research demonstrated value of using this tool to help predict discharge destination as well as identifying those variables that contribute to determining discharge destination.5

• Recent published research specific to TJR population further validates the 6-Clicks as a valid tool to predict non-routine discharge (rehab/SNF) in immediate post-op period6

• Findings from this research provide more detailed information regarding IE and D/C cutoff scores to support clinical decision making

• From a clinical standpoint, utilizing specific cutoff scores at the time of IE can assist therapists in confidently make discharge recommendations early in the patient care episode

Limitations

• Patients included were undergoing elective TJR and were otherwise healthy and independent prior to surgery

• Limited generalizability for the general acute care population who have a more complex medical history or lower mobility level prior to hospital admission

• All patients underwent surgery at the same hospital by a group of four surgeons

• Recent research by Dewhirst et al7 found that more research needs to be done to gain support for use of the AM-PAC “6 Clicks”, including more education for therapists when implementing it in the acute care setting

Future Research

• Further investigation of why IE OT scores are not predictive and whether type of TJR impacts cutoff score.

• Comparison of the findings of this study with findings involving patients who undergo surgical repair following hip fracture

• Comparison of the findings of this study with findings involving patients having general medical diagnoses

• Potential development of a tool that combines functional assessment with demographics and psychosocial factors to assist therapists in determining discharge destination early in the acute care stay

Conclusions

• When evaluating patients who have TJR, PT can confidently consider recommending D/C to home for IE PT scores > 13.5 and confirm recommendation with D/C scores >20.5.

• OT can feel confident considering recommending D/C to home for D/C OT scores >22.5. Based on the findings of this study, IE OT scores are not predictive of D/C destination greater than chance.

References1. Jette A, Haley SM, Coster W, Ni PS. AM-PAC Short FormsTM for Inpatient and Outpatient Settings Instruction Manual v.3. Boston University School of Public Health Health and Disability Research Institute. Revised August 2, 2013. Available at: http://www.bu.edu/bostonroc/files/2013/10/AM-PAC-Short-Form-Manual_10.24.2013-SAMPLE.pdf. Accessed February 12, 2015.

2. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Validity of the AM-PAC "6-clicks" inpatient daily activity and basic mobility short forms. Phys Ther. 2014;94(3):379-91.

3. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. AM-PAC "6-clicks" functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014;94(9):1252-61.

4. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Interrater reliability of AM-PAC “6-Clicks” basic mobility and daily activity short forms. Phys Ther. 2015;95(5):758-766.

5. Maida DR, Wagner BR, Bockelkamp H. Investigating the predictive value of the AM-PAC “6 Clicks” on discharge destination following elective joint replacement. Department of Physical Therapy at the University of Scranton and Regional Hospital of Scranton, Scranton, Pennsylvania. Presented at APTA CSM 2016 Anaheim, CA.

6.Menendez ME, Schumacher CS, Ring D, et al. Does “6-Clicks” day 1 postoperative mobility score predict discharge disposition after total hip and knee arthroplasties? J Arthroplasty. 2016;31(9):1916-1920. doi: 10.1016/j.arth.2016.02.017.

7. Dewhirst RC, Ellis DP, Mandara EA, Jette DU. Therapists’ perceptions of application and implementation of AM-PAC “6-Clicks” functional measures in acute care: qualitative study. Phys Ther. 016;96(7):1085-1092.

Acknowledgements

• Thomas P. Hogan, PhD, Statistician

• Tammi Cherra, Administrative Assistant, Allied Health Field Office

• Alexander Arrow, PT, DPT, Former Graduate Assistant

• Kerry Callahan, PT, DPT, Former Graduate Assistant

• Alyssa Studwell, PT, DPT, Former Graduate Assistant