I was recently asked to participate in the Academy's Certificate Program on Clinical Applications of Gait Analysis. My assigned topic was “Using Gait Analysis to Justify Care.” In preparing for that conversation, I found my thoughts returning to a single fundamental, yet unanswered, question. What is the value proposition associated with orthotic and prosthetic (O&P) care?
Particularly in today's health care climate, the costs associated with our interventions are well known and clearly defined by an array of existing contracts. Our value, however, is less defined. Given the current competition that exists for every health care dollar spent, this constitutes a tremendous concern. The health care leviathan knows exactly what our services cost but has little idea what they are worth.
The recent work of Dobson et al.1 has shed some light on the matter. Their analysis of Medicare data suggests that in the 18 months after a medical episode, patients who received lower-limb orthoses had fewer acute care hospitalizations and emergency department admissions than did matched controls who did not receive orthotic care, as well as a greater ability to return to their homes rather than facility-based settings. Even with the costs of the orthotic services included, these factors contributed to a 10% overall reduction in incurred Medicare expenditures.1
Similar trends were observed among individuals with lower-limb amputation. Those who received lower limb prosthetic care were more likely to receive extensive outpatient therapy and experienced fewer acute care hospitalizations, emergency department admissions, and facility-based care. These factors were such that the comparatively more expensive costs of prosthetic care were nearly amortized in the 12 months after their provision by the other reductions in health care services.1
This type of data should inspire the profession to further explore its value proposition. Value can be defined as the relative benefits provided by an intervention divided by its associated costs. Unfortunately, despite the initial observations of the Dobson/DaVanzo report, any recent increases in the value associated with O&P services have largely come at the expense of decreasing reimbursement. If we as a profession want to increase the value of our services while maintaining or increasing the associated reimbursement, we must clearly define the benefits of our interventions.
What is the value of an ankle-foot orthosis (AFO) to an individual after a stroke? Assuming a stable cost, it will depend on the relative benefits the patient experiences. A recent meta-analysis has asserted that the use of an AFO leads to increased gait velocity.2 Thanks to the dedicated efforts of a number of rehabilitation researchers, the value of that statement has increased in recent years. The literature now suggests that within the stroke community, increased gait speeds are associated with expanded walking environments3 and a greater number of steps taken each day.4 Furthermore, those who experience an increase in gait speed during their stroke rehabilitation report improved mobility, engagement in activities of daily living, and community participation.5
With additional research, the benefits of AFOs within the stroke population might be well summarized as increasing gait speeds, expanding walking environments, augmenting daily activity, and facilitating community participation. Considerations such as these define a set of benefits that pay sources, care providers, and patients collectively value.
Given the increasing scrutiny that accompanies every expenditure in today's health care marketplace, the field must continue to define the value associated with its interventions. We cannot reasonably defend the cost of our services until we have better defined just how much they are worth.
Phillip M. Stevens, MEd, CPO, FAAOP
Salt Lake City, Utah
2. Tyson SF, Kent RM. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Arch Phys Med Rehabil
2013; 94: 1377–1385.
3. Lord SE, McPherson K, McNaughton HK. Community ambulation after stroke: how important and obtainable is it and what measures appear predictive? Arch Phys Med Rehabil
2004; 85: 234–239.
4. Bowden MG, Balasubramanian CK, Behrman AL. Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabil Neural Repair
2008; 22: 672–675.
5. Schmid A, Duncan PW, Studenski S, et al. Improvements in speed-based gait classifications are meaningful. Stroke
2007; 38: 2096–2100.