The Significance of Clinical Change and Clinical Change of Significance: Issues and Methods Kenneth J. Ottenbacher, Mary Beth Johnson, Margaret Hojem Key Words: accounting. documentation. patient outcome assessment The emphasis on systematic methods of demonstrat- ing accountability in health care is affecting the de- livery of human services at all levels, from hospitals and community centers to individual private prac- titioners. New procedures are being proposed to meet the accountability demands encountered by therapists. Several recently developed methods for documenting clinical change in patient status are presented, and the relationship of this documenta- tion to traditional research methods is briefly ex- plored. A clinical illustration of the procedures is provided along with a discussion of advantages and limitations. Kenneth J. Ottenbacher, PhD, OTR, is Associate Professor of Occupational Therapy, School of Allied Health Profes· sions, University of Wisconsin, Madison, Wisconsin 53706. Mary Beth Johnson, OTR, and Margaret Hojem, MS, LPT, are practicing therapists in the DeForest public school sys· tern, DeForest, Wisconsin. O ccupational therapists practice their profes- . sion in a dynamic and evolVing health care environment. Therapists are expected not only to be aware of the changes occurring in health care, but also to participate in implementing and doc- umenting change. Accountability and documentation are areas of contemporary health care practice that are receiving a great deal of attention from health care proViders, policy makers, and consumers. In relation to occupational therapy, Gillette (1982) observed that "documentation of actual occupational therapy ser- vices, leading toward the development of a data base upon which to base the practice claims of the field, is the most effective means of establishing occupational therapy as an essential, and reimbursable service" (p. 499). Gillette (1982) went on to argue that the "es- tablished procedures" of scientific inquiry and clini- cal research represent the usual method of demon- strating efficacy and accountability. Although traditional methods of clinical research can proVide useful information regarding the efficacy of intervention strategies used by occupational thera- pists, behavioral scientists have recently questioned the exclusive reliance on traditional methods to dem- onstrate the therapeutic utility of many practice pro- cedures (Kazdin, 1983; Ottenbacher, 1986; Strupp, 1981). Kazdin and Wilson (1978) argued that tradi- tional studies evaluating outcome in clinically based fields infer treatment effects based on the statistical comparison between two or more groups or condi- tions. They contend that these studies have two pri- mary limitations as methods of establishing therapeu- tic accountability. First, results of these studies are based on the average improvement scores for all sub- jects and provide no information on individual patient performance. Second, the criterion of statistical sig- nificance, conventionally used as the basis for making inferential judgments regarding empirical impor- tance, has little clinical or practical relevance. Underlying the statistical versus clinical signifi- cance debate is a fundamental "philosophical" differ- ence that separates traditional clinical research and practice. The goal of the practicing therapist is, and must be, to help patients get better as qUickly as possi- ble. The nature, length, and intensity of any interven- tion is tailored to the individual patient and his or her disability (d. Yeaton & Sechrest, 1981). Therapists in clinical settings will alter treatment strategies as soon as it seems reasonable and beneficial to the patient and will base this decision on continuous monitoring of the patient's performance. In traditional group comparison research, pa- tients are randomly assigned to fixed treatment con- ditions. Treatment is standardized and administered continuously irrespective of progress (or lack of prog- ress) , and measurements of the patients' performance March 1988, Volume 42, Number 3 156 Downloaded From: http://ajot.aota.org/ on 11/16/2018 Terms of Use: http://AOTA.org/terms