Skube SJ Lindemann EA Arsoniadis EG Akre M Wick EC Melton GB Background Functional health status is an individuals ability to perform daily activities required to meet basic needs fulfill usual roles and maintain their health and wellbeing ID: 786498
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Slide1
Characterizing Functional Health Status of Surgical Patients in Clinical Notes
Skube SJ,
Lindemann
EA
,
Arsoniadis
EG,
Akre
M, Wick EC, Melton GB
Slide2BackgroundFunctional health status
is an individual’s ability to perform daily activities required to meet basic needs, fulfill usual roles, and maintain their health and well-being
Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA. 1995;273(1):59-65.
Slide3BackgroundFunctional status is important in:
Determination of overall general health
Assists in estimating perioperative risk
Factors in occurrence of adverse events
More broadly, functional status can be correlated with one’s overall health and quality of life
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CJ, Conrad MF, Lancaster RT, Watkins MT, et al. Preoperative functional status predicts perioperative outcomes after
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Albright EL, Davenport DL, Roth JS. Preoperative functional health status impacts outcomes after ventral hernia repair. Am Surg. 2012;78(2):230-4.
Slide4Background
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Bjorner
JB,
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DA, Spritzer KL,
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D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.
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A,
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EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC
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M, Sidney K,
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G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity.
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. 1990;13(8):555-65.
Organization WH. How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. Geneva: WHO; October 2013.
Slide5Use Case
Outcomes databases such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) offer high quality data for quality improvement and research efforts
Complex data is currently collected manually by trained surgical clinical reviewers
Assess functional status in the use case of the NSQIP database
Ingraham AM, Richards KE, Hall BL,
Ko
CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach.
Adv
Surg. 2010;44:251.
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CS,
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MM, Wang L,
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G, Zhu J, et al. Cost-effectiveness of the National Surgical Quality Improvement Program. Ann Surg. 2011;254(4):619-24.
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Slide6Hypothesis
It may be possible to improve automated abstraction efforts for complex, poorly defined elements such as functional health status
Significant data related to functional health status is found in free-text documentation in clinical notes
Objective
To understand the value of clinical notes in determining functional health status
To develop a library of terms associated with functional health status
Slide7Methods
Slide8Methods
Karnofsky
Performance Score
100
No complaints, no evidence of disease
90
Able to complete major activities; minor signs and symptoms of disease
80
Normal activity with effort; some signs and symptoms of disease
70
Care of self; unable to carry on normal activities or do active work
60
Requires occasional assistance; able to care for most of personal needs
50
Requires considerable assistance and frequent medical care
40
Disabled; requires special care and assistance
30
Severely disabled; hospital admission is indicated; death not imminent
20
Very sick; hospital admission necessary and active treatment necessary
10Moribund; fatal processes progressing0Death
Following chart review, NSQIP functional health status score and Karnofsky score were calculated based only on functional health status associated terms
NSQIP functional status scale
Independent
Does not require assistance from another person for any activities of daily living, including one who functions independently with the use of prosthetics, equipment, and/or devices.
Partially Dependent
Requires some assistance from another person for activities of daily living regardless of use of prosthetics, equipment, and/or devices.
Totally Dependent
Requires total assistance for all activities of daily living.
Slide9Results1,353 clinical notes were reviewed
1,328 phrases were associated with functional health status
Of the 75 charts reviewed:
39 patients (52%) were male
Median age was 51.5 (range 21-91)
Slide10Results
The most common specialties for chart encounters were urology (17.3%), orthopedic surgery (14.7%), gynecologic surgery (13.3%) and neurosurgery (13.3%)
Most phrases were recorded by a staff physician (59.9%) or an advanced practice provider (13.7%)
Clinical Note Type
Phrases n (%)
History & Physical
440 (33.1%)
Anesthesia Pre-Op Assessment
338 (25.5%)
Office Visit
237 (17.8%)
Progress Note
160 (12.0%)
Consultation Note
69 (5.2%)
Emergency Department Visit
51 (3.8%)
Telephone Note
23 (1.7%)
Operative Note
8 (0.6%)
Discharge Summary2 (0.2%)Clinical Note Section History of Present Illness327 (24.6%)
Not Applicable215 (16.2%) Assessment/Plan199 (15.0%) Review of Systems185 (13.9%) Physical Exam156 (11.7%)
Past Medical History
141 (10.6%)
Social History
38 (2.9%)
Past Surgical History
26(2.0%)
Chief Complaint
18 (1.4%)
Form Elements
14 (1.1%)
Operative Indications
9 (0.7%)
Slide11Results
Phrases
related to functional health status were categorized into 7 major categories:
Diagnoses
Activity/Care needs
Physical exam elements
Functional
scores
10% of functional status associated phrases assessed for inter-rater agreement (90.7%,
κ
=
0.737)
Assistive equipment
Symptoms
Surgical history
Slide12Results
Phrases Grouped by NSQIP Functional Category
Slide13Results
scoliosis
kyphosis
lumbar stenosis
subdural hemorrhage
chronic pain
neurogenic bladder
spinal cord injury
multiple sclerosis
meningioma
CNS lymphoma
hemiplegia
monoplegia
autism
learning disability
Mobius Syndrome
paraplegia
ulcer
neurogenic bowel
hip fracture
dementia
malnutritionSpina Bifidahydrocephalusdecubitus ulcerparalysisPoliopost-Polio syndromes
hyperreflexiaspasticityLyme DiseaseChiari Malformationweaknessspasmodic dysphonialimb hypogenesiscongenital deformity
radiculitis
Cauda Equina
stroke
critical limb ischemia
seizure
Alzheimer Disease
Parkinson Disease
mental retardation
Cerebral Palsy
cognitive defects
dysreflexia
developmental delay
Diagnoses (472 phrases, 47 unique)
“The patient has two, clean sacral pressure ulcers.”
“She has progressive multiple sclerosis.”
Slide14Results
spinal cord stimulator
indwelling Foley
wheelchair
motorized wheelchair
Baclofen pump
urinary catheters
home oxygen
lift chair
walker
bath bench
leg brace
foot brace
knee brace
torso brace
neck brace
crutches
scooter
intrathecal pump
home ramp
prosthesis
ostomy pouchJay cushionRoho cushionHoyer liftshower chaircaneBiPAP
hospital bedstretchergrab barsventilator Assistive Equipment (110 phrases, 31 unique) “The patient requires a hospital bed at home with transportation via stretcher from the hospital.”
Slide15Results
pain
weakness
shortness of breath
tingling
numbness
spasticity
fatigue
secretion problems
multiple falls
hematuria with cath
urinary incontinence
fecal incontinence
altered sensation
paresis
paresthesias
radiculopathy
worsening gait
swelling
urinary retention
neuropathy
worsening motor functionworsening neurologic statusseizuresunresponsivecombative behaviorconstant movementmemory deficit
slurred speech Symptoms (95 phrases, 28 unique)“She has experienced fecal incontinence since the onset of her disease”
Slide16Results
epidural injection
below knee amputation
thoracic spine surgery
artificial urinary sphincter
suprapubic catheter placement
Mitrofanoff
ventriculo-peritoneal shunt
ventriculo-pleural shunt
neck fusion
above knee amputation
tracheostomy
colostomy
craniotomy
urinary diversion
nephrostomy tubes
percutaneous gastrostomy
ileal conduit
Monti
bladder augmentation
urostomy
disarticula-tiongastro-jejunostomy Surgical Terms (80 phrases, 22 unique)“A urostomy
was performed for persistent incontinence”
Slide17Results
Activity/Care Needs (297 phrases)
Many phrases with varying levels of dependence/assistance
“He requires full assistance with transfers”
Physical Exam Elements (154 phrases, 87 unique)
General/Appearance-Cognitive-Motor/Strength/Sensation
“No motor or sensation of the lower extremities”
Functional Scores (120 phrases)
Useful, but infrequent
“
Karnofsky
Score, 70”
Slide18Results
Slide19Results
Slide20DiscussionFunctional status is a complex topic that can vary by provider and has not been well integrated into electronic medical records and clinical workflows
As functional status complexity increases, there was wider variability in categorical designation (NSQIP and
Karnofsky
Score)
Slide21Limitations
Retrospective review
Undocumented factors
Single institution
Underrepresentation of physical and occupational therapists
Slide22Future Plans
Publish a database of functional status terms
Improve automated detection techniques for functional health status determinations
Slide23ConclusionFunctional status can be found in clinical notes through diagnoses, activity and home care descriptions, physical exam elements, functional scores, assistive equipment, symptoms, and surgical procedures
There is a lack of standardized functional health status documentation
Phrases found in this study could be used to assist in the automation of detection of functional health status
Slide24Acknowledgements
Project Mentor: Genevieve Melton-
Meaux
, MD, PhD
This research was supported by the University of Minnesota Academic Health Center Faculty Development Award, Agency for Healthcare Research and Quality (R01HS24532), National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) program (UL1TR000114), NIH/National Institute of General Medical Sciences (NIGMS) (R01GM120079), Fairview Health Services, and University of Minnesota Physicians.
Slide25Thank You