Acute Care Physical Therapy Practice Analysis Identifies the Need for a Core Outcome Measurement Set : Journal of Acute Care Physical Therapy

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Acute Care Physical Therapy Practice Analysis Identifies the Need for a Core Outcome Measurement Set

Mayer, Kirby P.; Norris, Traci L.; Kumble, Sowmya; Morelli, Nathan; Gorman, Sharon L.; Ohtake, Patricia J.

Author Information
Journal of Acute Care Physical Therapy: October 2021 - Volume 12 - Issue 4 - p 150-157
doi: 10.1097/JAT.0000000000000161
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Outcome measures (OMs) are a vital component of practice that provides opportunities for assessing the individual response to physical therapy and allowing for comparison across groups.1 The APTA Guide to Physical Therapist Practice states that “obtaining measurements is an essential and integral part of physical therapy practice.”2Formal or standardized OMs are defined as measurement tools used to establish a baseline and document change in one or more constructs over time.3,4 A patient outcome is the actual result from implementing the plan of care and is related to the physical therapy goals in collaboration with the patient or client.2 Therefore, the use of OMs is vital for all phases of physical therapy practice, including assessing baseline functioning, setting goals, tracking responses to interventions over time, and they are particularly important in the acute care setting to support clinical decision-making such as deciding appropriate discharge disposition. OMs are used to collect outcome data and may be used across the continuum of care to provide insight into the patient's recovery. The importance of OMs is demonstrated by their frequent use in evidence-based practices, quality improvement initiatives, and cost-benefit analyses.5 Recent initiatives, including the Physical Therapy Outcomes Registry, use outcome data to assess the quality and value of physical therapy systematically. OMs are powerful tools because they quantify the effect or effectiveness of physical therapist interventions on patient outcomes.

In acute care physical therapy practice, many relevant OMs are available, and significant heterogeneity exists in selecting OMs. In a recent systematic review of OMs used by physical therapists with patients with critical illness in the intensive care unit, the authors identified 33 measures focused only on the activity impairment and limitations domain of the International Classification of Functioning, Disability, and Health (ICF) framework.6 Given the wide range of health conditions and specialized areas managed in acute care physical therapy practice, estimating the number of OMs available for all patient management components is difficult. Moreover, databases do not allow searching OMs based on setting, thus creating another barrier to finding and evaluating OMs for use in acute care physical therapy practice.

A 2009 practice analysis of all physical therapy practice settings revealed that physical therapists primarily used OMs to improve communication with patients and develop plans of care.7 However, 50% of physical therapists reported not consistently using OMs7 due to the length of time for completion, the difficulty for patients to perform the tasks, patient confusion about task performance, and patient anxiety.7 Even more surprisingly, physical therapists practicing in the acute care setting were reported to be less likely to use an OM than therapists practicing in any other setting. Therapists practicing in the outpatient setting were 7 times more likely than therapists practicing in the acute care setting to use an OM.7 Physical therapists' use of OMs in acute care settings may vary based on the patient's medical condition. For example, physical therapists treating patients with acute stroke in hospital and rehabilitation settings frequently use OMs to assess balance and gait, with 78% of respondents reporting that levels of comfort, evidence, resources, and time influenced the selection and use of a specific OM.8 These findings are significant but are more than 10 years old. Recent practice changes, including the increased focus on evidence-based practice,9–11 standards for safe patient handling and mobility,12,13 and recommendations from The Joint Commission14 and the Centers for Medicare & Medicaid Services15 support the use of valid and reliable OMs in rehabilitation and active mobilization practices in the hospital. Moreover, the Interprofessional National Standards for Safe Patient Handling and Mobility specifically include “Integrating patient-centered assessment” as 1 of the 8 national standards.12 These changes may have impacted the practice patterns and use of OMs by physical therapists in acute care settings. Limited evidence exists describing the rationale for either how acute care physical therapists select an OM or the frequency with which it is used.


This study's primary goal was to determine the current use of OMs by physical therapists practicing in acute care settings. Secondly, this study aimed to establish whether physical therapists support the development of a core set of OMs for use in acute care settings.


Survey Instrument

The survey was developed by the Acute Care Outcome Measures Clinical Practice Development (CPD) Committee of APTA Acute Care. A mixed-model survey was created with multiple-choice responses, priority ranking, and open-ended text. The survey contained 4 sections with 28 total questions:

  • Section I. Ten questions were asked about current acute care physical therapist practice patterns, including current role and experience in acute care (n = 4), type of setting (n = 2), delineation of duties (n = 1), common patient caseloads (n = 2), and average impairments encountered by a physical therapist (n = 1).
  • Section II. Six questions were asked about the use of formal OMs in practice, including frequency (n = 2), the rationale for utilization (n = 2), and selection criteria (n = 2).
  • Section III. Four questions were asked about the development of a core OM set, including perceived need, benefits, preferred organization of the core OM set, and an open-ended question for comments about the core OM set.
  • Section IV. Eight questions were asked about respondents' demographics, education, and experience in the physical therapy profession.

Pilot Survey

A convenience sample of 7 acute physical therapy stakeholders including 5 acute care physical therapists (1 with a master's degree and cardiovascular and pulmonary clinical specialist, 1 with a doctor of physical therapy (DPT) degree and geriatric certified clinical specialist, 1 with a DPT degree, and 2 with transitional DPT degrees), 1 academician/educator with a teaching focus in acute care physical therapist practice (DPT, PhD), and 1 APTA staff member (masters in administration) pilot tested the survey. Each respondent had the opportunity to provide written feedback to improve the survey tool. Feedback, in general, was positive and provided editorial suggestions to optimize the readability of the tool.

Survey Distribution

The survey was distributed to acute care physical therapy stakeholders, including practicing physical therapists, physical therapy educators, and acute care physical therapy administrators through the APTA AcutePT listserv. At the time of dissemination, the listserv had 1713 members. In addition, acute care physical therapists were solicited to participate via Twitter and email. The survey was not restricted to members of the APTA. The survey was administered through an online format (Qualtrics XM, Provo, Utah), with participation presumed to indicate informed consent. The survey received exempt status from the Institutional Review Board of the University of Kentucky. Prior to engaging in the survey, physical therapists were informed that the survey was voluntary, with the results being anonymous. The survey was active for 3 months in the summer of 2019, and bi-weekly email reminders were sent to the listserv. Twenty-two incomplete surveys were excluded, as respondents answered fewer than 50% of the questions. Respondents were provided CPD Committee contact information for correspondences.

Data Analysis

Data were analyzed using SigmaPlot 14.0 (Systat Software Inc, San Jose, California). Quantitative data were analyzed for descriptive purposes, including response frequencies and percentages. Two independent reviewers reviewed qualitative data to determine themes emerging from the open-ended comments. Theme assignments were compared, and discrepancies were resolved through discussion.


A minimum of 1713 physical therapists received the link to complete the survey. Due to snowball sampling with the link open to be forwarded to additional physical therapists, an estimate of completion rate cannot be calculated. Of the 192 surveys received, 22 were excluded due to less than 50% completion, leaving a sample of 170 respondents. The previously completed pilot surveys were not used in the final data analysis. A convenience sample of 170 acute physical therapy stakeholders with a mean (SD) age of 45 (11) years, 71% female, and 38% with DPT degrees completed the survey (see Table 1). American Board of Physical Therapy Specialties (ABPTS) certification was held by 26% of respondents. The majority of respondents reported working in academic medical centers (n = 77; 45%) with varying experience levels (see Table 1). Respondents represented 38 states (see the Figure), and a variety of acute care practice settings were reported. The majority of respondents (n = 153; 90%) reported practicing in one or more acute care specialty areas (see Table 2).

Map of Respondents (N = 170). Blue dot represents response from 1 physical therapist. In addition, 1 respondent from Hawaii and 1 from Alaska not represented in this image. This figure is available in color online (www.JACPT.COM).
TABLE 1. - Demographic, Education, and Physical Therapist Experience of the Respondents to the Survey (N = 170)
Parameter Mean ± SD or n (%)
Age 44.8 ± 11.1
Gender, female 121 (71)
Current positiona
Practicing physical therapist

143 (84)
35 (21)
30 (18)
14 (8)
Professional membership
APTA Acute Care

139 (82)
126 (74)
Entry-level physical therapist degree
No response recorded

64 (38)
59 (35)
33 (19)
7 (4)
7 (4)
Advanced degree
No advanced degree
Transitional DPT
Other master's
PhD, EdD
Advanced PT master's
No response recorded

75 (44)
35 (21)
18 (11)
15 (9)
14 (8)
13 (8)
ABPTS specialty
No response recorded

122 (72)
13 (8)
13 (8)
13 (8)
1 (0.6)
1 (0.6)
1 (0.6)
6 (4)
Experience in acute care (direct patient care)
<3 y
3-5 y
6-10 y
11-20 y
>20 y
13 (8)
19 (11)
33 (19)
43 (25)
62 (36)
Hospital type
Academic medical center
Private hospital
Community hospital
Tertiary care center
Government hospital
Acute rehabilitation facility

77 (45)
60 (35)
14 (8)
6 (4)
5 (3)
4 (2)
4 (2)
ABPTS, American Board of Physical Therapy Specialties; CVP, cardiovascular and pulmonary; DPT, doctor of physical therapy; EdD, doctor of education; PhD, doctor of philosophy; SD, standard deviation.
aRespondents were able to select multiple answers.

TABLE 2. - Practice Setting of the Respondents (N = 170) to this Survey
Specialty Area/Settinga n (%)
General/mixed/float 153 (90)
Critical care 91 (54)
Neurology 88 (52)
Cardiovascular or thoracic 81 (48)
Surgical 90 (47)
Orthopedic 79 (46)
Medicine/pulmonary 74 (43)
Trauma 62 (36)
Oncology 65 (34)
Emergency department 34 (20)
Administration 27 (16)
Burn/wound 24 (14)
Other 8 (4)
Retired 3 (2)
No specialty area reported 2 (1)
aRespondents were able to select multiple answers.

The majority of respondents (n =143; 84%) reported using OMs very often (50%-74%), frequently (75%-99%), and consistently (100% of the time) in their acute physical therapist practice (see Table 3). Only 5% (n = 5) of respondents reported using an OM infrequently (<25% of time) or never (0% of time). Assessing physical function (n = 163; 96%) was the primary reason respondents used OMs (see Table 3), and the 2 most commonly reported uses of the outcomes from OMs were to track responses to interventions (n = 134; 79%) and to develop a plan of care (n = 91; 54%; see Table 3). The rationale for selecting an OM included the length of time to complete (n = 150; 88%), clinical utility of the OM (n = 147; 86%), psychometric properties (n = 91; 54%), and integration of the OM in the electronic health record (EHR) (n = 88; 52%).

TABLE 3. - Responses Focused on Outcome Measures
Parameter n (%)
Frequency of using an outcome measure
Consistently, 100%
Very frequent 75%-99%
Very often 50%-74%
Infrequently 25%-49%
Rarely, <25%
Never use, 0%

60 (35)
36 (21)
47 (28)
18 (11)
7 (4)
2 (1)
Reason for using outcomea
Physical function
Muscular strength
Cognitive function
Emotional well-being

163 (96)
78 (46)
28 (16)
11 (6)
4 (2)
Rationale for using an outcome measure
Track changes
Develop POC
Part of an established protocol
Employer requires
Required for next level of care
Motivational tool

134 (79)
91 (54)
53 (34)
55 (26)
58 (19)
25 (15)
33 (7)
Rationale for selecting an outcome measure
Length of time
Clinical utility
Integrated in EHR
Required training
Cost of outcome

150 (88)
147 (86)
91 (54)
88 (52)
60 (35)
43 (25)
7 (4)
Support development of core outcome set
Did not respond

147 (86)
19 (11)
4 (2)
Please provide any recommendations or feedback for development of an acute care physical therapy core outcome measure set.
Open-ended response, respondents = 45; n = 77 distinct comments:
Clinical utility
Time (length to complete aligns with practice, “quick”)
Recommendation for a specific outcome measure(s)
Measures should be based on performance and, or physical function

20 (26)
12 (16)
12 (16)
9 (12)
Psychometrics (eg, high predictive validity)
Dissemination (eg, resources, Web site, and easy access)
Based on current standard of care
Based on interdisciplinary approach/professional collaboration
Attentive to cognitive changes
9 (12)
5 (6)
5 (6)
2 (3)
2 (3)
1 (1)
Please provide an explanation as to why you believe a core outcome set is not necessary.
Open-ended response, respondents = 17; n = 27 distinct comments:
Clinical judgment does not warrant
Patient diagnoses are too complex or too diverse
Patient length of stay is too short
Staff overburden, understaffed, or no time
Insurance/payer issues and denials
Recommend a specific outcome measure (not a core)
Recommend using core already published (neuro)

7 (26)
7 (26)
4 (15)
4 (15)
2 (7)
2 (7)
1 (4)
EHR, electronic health record; POC, plan of care.
aRespondents were able to select multiple answers.

Strong support was found for the development of a core OM set for acute physical therapist practice (n = 147, 86%; see Table 3). The respondents preferred that core sets of OMs be organized first by diagnosis and then by the ICF framework, domains of health, and settings/location (see Table 4).

TABLE 4. - Preferred Organization of the Proposed Core Outcome Measurementa
Organization Format Rank
1 2 3 4 5
Diagnosis 58 34 21 25 7
ICF model 35 48 24 41 1
Domains of health 33 27 48 34 0
Setting/location 16 31 49 48 3
Otherb 11 12 12 11 10
aResponses are ranked with the top priority (1) and the least priority (5).
bRespondents who selected “other” as the top priority were provided open text to elaborate: clinical judgment (n = 2); prior level of function (n = 4); use measures associated with the IMPACT Act (n = 1); patient willingness (n = 1); predictive validity to assist in discharge destination (n =1); and no response (n = 2).

Forty-five individuals responded to the final open-ended question: Do you have any recommendations or suggestions for the development of an acute care core OMs set? Seventy-seven distinct responses were analyzed, yielding 10 themes (see Table 3). The most commonly cited theme recommended that the core OM set should consider clinical utility components (n = 20/77, 26%), including easy to implement, cost-efficient, minimal required training, and integrated into the EHR. Clinicians' time (n = 12/77, 16%), recommendations for a specific OM (n = 12/77, 16%), based on performance of physical function (n = 9/77, 12%), and psychometric properties (n = 9/77, 12%) were the next most commonly mentioned themes. In addition, 17 individuals who did not believe a core outcome set was necessary responded to the open-ended question: Please provide an explanation as to why you believe a core outcome set is not necessary. Twenty-seven distinct comments identified 7 different themes (see Table 3). The major themes included clinical judgment does not warrant a core OM set (n = 7/27, 26%), patients' diagnoses are too complex or too diverse in acute care (n = 7/27, 26%), patients' length of stay are too short (n = 4/27, 15%), and staff are overburdened with no time to complete (n = 4/27, 15%).


This study's findings suggest that most physical therapists practicing in the acute care setting are using OMs in their practice, and the most commonly reported reason for using OMs is to quantify physical function. Several rationales for using OMs were reported, including to track changes in patient status and to develop a plan of care. The majority of respondents indicated the rationales for selecting an OM were the length of time to perform, clinical utility, psychometric properties, and the integration within the EHR. The majority of respondents supported developing a core OM set for acute physical therapy practice organized by clinical diagnosis.

OMs are integral for physical therapist practice due to their ability to provide objective measurements of function, track responses to interventions over time, and compare patient data with available normative data for the healthy population.1 Our findings that 84% of physical therapists practicing in the acute care setting reported using OMs is in stark contrast to the 2009 physical therapist practice analysis indicating that 16% of physical therapists practicing in acute care setting used OMs.7 This remarkable increase in the use of OMs in the acute care setting in the past decade might reasonably be attributed to several factors. First, recognition of the importance of OMs has been growing, and endorsement for the use of OMs has occurred in the past few years. A recent systematic review identified 14 psychometrically tested OMs for assessing physical function in patients admitted to the intensive care unit.6 While further validation of these OMs is needed, this report emphasizes the growing demand for and use of OMs to quantify physical function in the critically ill. Support for the use of OMs in acute care physical therapy practice is also provided in the 2015 edition of the Core Competencies for Entry-Level Practice in Acute Care Physical Therapy that endorses the use of OMs to determine the patient's appropriateness for rehabilitation and to guide interventions.16 A second potentially contributing factor is the recognized importance of OMs by third-party payers such as clinicians required to justify the need for postacute care inpatient rehabilitation.11,17,18

Moreover, health care administration and professional associations use OMs to perform comparative analyses. OMs provide objective data to administration to evaluate the effect or effectiveness of physical therapy services and thus can be used to benchmark against similar health care institutions. Taken together, research, professional guidance, and policy-related factors have potentially contributed to the enhanced use of OMs by physical therapists practicing in the acute care setting.

Our finding that 79% of acute care physical therapists reported their rationale for using OMs was to track changes in function over time is consistent with previous reports in which 75% of physical therapists across all practice settings reported using OMs to determine progress and outcomes of individual patients.7,19–23 This comparison indicates that physical therapists practicing in the acute care setting are demonstrating practice patterns consistent with the profession as a whole.

Clinical utility, a broad term that encompasses the multiple dimensions of clinical usefulness and effectiveness of OMs, was endorsed by the vast majority of our respondents as a factor when selecting OMs. Clinical utility refers to important components of the OM such as appropriateness of the test, acceptability of the test, patient's tolerance and ability to complete the measure, and the required time and cost to administer the measure.2,24,25 The length of time required to complete an OM was the most frequent criterion for selecting an OM. Time to complete OMs has been mentioned previously.5,7 OMs that require too much time to complete are less likely to be used because therapists perceive that the performance of OMs takes away from the clinicians' time to perform other more important tasks.7,22,26 Furthermore, respondents highly valued OM properties of the relative ease of use and the ability to be integrated into the EHR, lending further support for the importance of high clinical utility to facilitate increased use of OMs.

When selecting an OM, over 50% of respondents reported that they consider the OM's psychometric properties. Psychometric properties include the reliability, validity, responsiveness, and minimal clinically important difference of an OM. Consideration of the OM psychometric properties is important, and our findings indicate psychometric properties are being considered by physical therapists practicing in acute care settings when selecting OMs. Over the last 2 decades, researchers and clinicians have improved the selection process for OMs with established criteria to measure the quality of OMs.27 This work includes developing an evidence-based approach for selecting OMs that considers important psychometric properties,28,29 and reaching agreement on terminology and taxology initiated by the COnsensus-based Standards for the selection of health Measurement INstructions (COSMIN).30,31 The COSMIN provides a framework to improve the selection of OMs by streamlining terms and definitions of measurement properties. Since the inception of the COSMIN, the international and interdisciplinary initiative has continued to standardized the use of OMs through the “use of transparent methodology and practical tools for selecting the most suitable OM instrument in research and clinical practice.”32

This survey's secondary focus was to determine the respondents' interest in a core OM set for acute physical therapy practice. Our data demonstrate strong support for developing an acute care core OM set organized according to patient diagnosis or the ICF model. In 2018, the Academy of Neurologic Physical Therapy (ANPT) developed and published a clinical practice guideline (CPG) describing a core set of OMs to promote best practice.1 This CPG was established to push neurologic physical therapy toward achieving the Institute of Medicine recommendation for developing a “Learning Healthcare System” that collects and analyzes measurement data in clinical practice to improve and strengthen public health and generate knowledge.33–35 The primary scope of the ANPT CPG was to standardize practice by providing recommendations for OMs to assess physical function for adults with neurologic conditions that can be routinely used in all settings and for all diagnoses.1 Development of a parallel and perhaps overlapping set of core OMs for acute care physical therapy practice has been considered at prior APTA Acute Care meetings and conferences, and this survey supports continued work in this direction.

The development of a set of core OMs in acute care physical therapist practice may be perceived as challenging due to patient populations' heterogeneity, the range of complexities, and the short lengths of stay. However, the purpose of core OM sets is to serve as a “minimum collection of outcomes,” and thus, does not remove or limit clinical reasoning.36,37 Physical therapists may still need to perform additional OMs for specific or targeted deficits or functional impairments. However, the core set recognizes and consistently assesses crucial outcomes specific to the setting and patient population to reduce heterogeneity in practice. Eliminating or reducing unwarranted variations in clinical practice leads to an enhanced ability to perform comparative analyses.

Moreover, the core set has the potential to reduce biases that may be present during “selective” reporting (eg, clinicians only reporting the OMs that demonstrate positive outcomes).38,39 Finally, a set of core OMs has the potential to increase recognition of the importance of OMs, streamline education, and provide resources through knowledge translation initiatives. This study's findings suggest that a core set of OMs for acute care physical therapy practice should be developed and consider the unique environment with potential for diverse patient populations.

Our study is not without limitations. A primary limitation of this study design is the self-report of OM use by acute care physical therapists instead of observing actual OM use during practice. Additionally, convenience sampling may lead to bias, as only physical therapists who participate in the AcutePT listserv or are active on social media were invited to participate. Sampling bias may prevent the generalizability of the results, as the respondents to this survey may not represent the entire acute care physical therapy profession. Although an accurate survey response rate cannot be determined due to the study design, it is likely not greater than approximately 10%, thus potentially preventing the extrapolation of these findings. Prior Internet-based and email-based surveys have reported lower response rates than traditional mail-based surveys, with some data suggesting an expected 25% to 30% response rate for email surveys.40,41 Finally, the questions presented in this survey did not capture respondents' prior knowledge, experience, and understanding of psychometric properties of OMs. Additional research of OMs in acute care physical therapy practice is necessary to address these apparent limitations. However, the findings of this study do support a preliminary understanding of current perspectives on the use of OMs in acute care physical therapy practice analyses.


The majority of physical therapists practicing in acute care settings use OMs to assess physical function objectively, track patient performance over time, and develop plans of care. Clinical utility and psychometric properties are important considerations when physical therapists select OMs. Given the strong grassroots support, the APTA Acute Care CPD Committee will facilitate developing recommendations for a core OMs set for use in acute care clinical practice.


We would like to thank James Smith and Audrey Johnson for their support of this study.


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