Outcomes information contributes to the provision of quality services: sharing that information requires speech-language pathologists (SLPs) to use terminology readily understood by professions ranging from health and education to social and voluntary services. The Therapy Outcome Measure (TOM) provides a way of presenting outcome data in a digestible form, comprising part of a range of multiple measures used to collect information on the structures, processes, and outcomes of care. TOM was developed to provide a practical method of measuring outcomes in routine clinical practice. Furthermore, it has been used in a number of research studies as an outcome indicator. As an example of its utility in research, the article cites a benchmarking study, together with examples of internal and external benchmarking of outcomes intended to illustrate how the benchmarking of TOM data can inform practice. The TOM can therefore inform SLPs on their own outcomes, the outcomes for specific client groups, and, by benchmarking TOM data, can contribute to the delivery of better, more efficient services.

OBJECTIVES:to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR). DESIGN:pragmatic randomised controlled trial. SETTING:four geriatric day hospitals and four home rehabilitation teams in England. PARTICIPANTS:eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460. INTERVENTION:multidisciplinary rehabilitation either in the home or in the day hospital. MEASUREMENTS:the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers. RESULTS:at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty. CONCLUSION:taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.

OBJECTIVES:To test the hypotheses that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR) and that HBR is less costly. DESIGN:Two-arm randomised controlled trial. SETTING:Four trusts in England providing both HBR and DHR. PARTICIPANTS:Clinical staff reviewed consecutive referrals to identify subjects who were potentially suitable for randomisation according to the defined inclusion criteria. INTERVENTIONS:Patients were randomised to receive either HBR or DHR. MAIN OUTCOME MEASURES:The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) scale. Secondary outcome measures included the EuroQol 5 dimensions (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Therapy Outcome Measures (TOMs), hospital admissions and the General Health Questionnaire (GHQ-30) for carers. RESULTS:Overall, 89 subjects were randomised and 42 received rehabilitation in each arm of the trial. At the primary end point of 6 months there were 32 and 33 patients in the HBR and DHR arms respectively. Estimated mean scores on the NEADL scale at 6 months, after adjustment for baseline, were not significantly in favour of either HBR or DHR [DHR 30.78 (SD 15.01), HBR 32.11 (SD 16.89), p = 0.37; mean difference -2.139 (95% CI -6.870 to 2.592)]. Analysis of the non-inferiority of HBR over DHR using a 'non-inferiority' limit (10%) applied to the confidence interval estimates for the different outcome measures at 6 months' follow-up demonstrated non-inferiority for the NEADL scale, EQ-5D and HADS anxiety scale and some advantage for HBR on the HADS depression scale, of borderline statistical significance. Similar results were seen at 3 and 12 months' follow-up, with a statistically significant difference in the mean EQ-5D(index) score in favour of DHR at 3 months (p = 0.047). At the end of rehabilitation, a greater proportion of the DHR group showed a positive direction of change from their initial assessment with respect to therapist-rated clinical outcomes; however, a lower proportion of HBR patients showed a negative direction of change and, overall, median scores on the TOMs scales did not differ between the two groups. Fewer patients in the HBR group were admitted to hospital on any occasion over the 12-month observation period [18 (43%) versus 22 (52%)]; however, this difference was not statistically significant. The psychological well-being of patients' carers, measured at 3, 6 and 12 months, was unaffected by whether rehabilitation took place at day hospital or at home. As the primary outcome measure and EQ-5D(index) scores at 6 months showed no significant differences between the two arms of the trial, a cost-minimisation analysis was undertaken. Neither the public costs nor the total costs at the 6-month follow-up point (an average of 213 days' total follow-up) or the 12-month follow-up point (an average of 395 days' total follow-up) were significantly different between the groups. CONCLUSIONS:Compared with DHR, providing rehabilitation in patients' own homes confers no particular disadvantage for patients and carers. The cost of providing HBR does not appear to be significantly different from that of providing DHR. Rehabilitation providers and purchasers need to consider the place of care in the light of local needs, to provide the benefits of both kinds of services. Caution is required when interpreting the results of the RCT because a large proportion of potentially eligible subjects were not recruited to the trial, the required sample size was not achieved and there was a relatively large loss to follow-up. TRIAL REGISTRATION:Current Controlled Trials ISRCTN71801032.

ObjectivesTo develop an assessment tool for use in intercenter audit studies of cleft speech and to test its acceptability, validity, and reliability. The tool is to be used systematically to record and report speech outcomes, providing an indication of treatment needs and continuing burden of care.SettingRegional Cleft Center, U.K.MethodsThe Cleft Audit Protocol for Speech—Augmented (CAPS-A) was developed by three cleft speech experts who identified the key features required from existing assessment measures. Criterion validity was assessed by comparing the Cleft Audit Protocol for Speech—Augmented outcomes reported for 20 cases with clinical assessment results and other investigations. Intra- and interrater reliability were tested following the training of specialist speech and language therapists who used the Cleft Audit Protocol for Speech—Augmented on two occasions to assess 10 cases. The raters evaluated acceptability and ease of using a questionnaire.ResultsThe mean percentage agreement for criterion validity in each section was 87% (range 70% to 100%). Both intra- and interexaminer reliability were rated as good/very good (Kappa 0.61 to 1.00) for seven sections and moderate (Kappa 0.41 to 0.60) for three sections. Raters reported that the Cleft Audit Protocol for Speech—Augmented was acceptable and easy to use with appropriate training.ConclusionAn acceptable, valid, and reliable cleft speech audit tool has been developed based on a small sample. The Cleft Audit Protocol for Speech—Augmented is recommended for use in intercenter audit studies in the U.K. and Ireland and could be used in other English-speaking countries. In addition, it has wider applicability for use in reporting speech outcomes of surgical procedures.

The quality cycle requires clinicians to assess the outcomes of interventions. Benchmarking is an approach that has been advocated to compare current performance across different services to identify commonalities and significant differences. This article gives the results of a study of outcomes in speech and language therapy (SLT) using the therapy outcome measure (TOM) for patients with voice disorder (dysphonia) comparing outcomes of seven separate speech and language therapy services. The study aimed to identify the similarities and differences in outcomes of care provided by different services. Two hundred and forty patients with dysphonia (age range 3-87.5 years, average 51.9 years) were treated. The results indicated that although there was no significant difference in the profile of the severity of symptomology of patients referred to speech and language therapy in different geographical areas, there was a significant difference in the treatment outcomes across the services and in the stated reason for discharge from treatment:. Nevertheless, most patients with dysphonia had a good outcome and this was associated with completion of the course of treatment. There were significant differences in the number of treatment contacts provided by the different services and in the duration (between admission and discharge) of treatment across the services. Benchmarking can provide useful information through use of routinely collected clinical data.

Background: Quality improvement in health care seeks to drive equitable, effective, and appropriate services. Benchmarking can be used as a tool for acquiring clinical information to inform and monitor change in order to identify commonalities and significant differences. Aims: This study reports on a benchmarking study of eight speech and language therapy services providing interventions for persons with dysphasia, addressing three questions related to equity of access to treatment; changes associated with treatment; and profiles on discharge. Methods & Procedures: The Therapy Outcome Measure (TOM) (Enderby & John, 1997) was used as the indicator. The SLTs were trained and inter-rater reliability checked. Data were collected on consecutively referred cases on entry to treatment and on discharge. Outcomes & Results: No difference was found in the profiles of patients referred to the different services on entry to treatment. While a significant difference was found between the services in the number of cases changing in impairment and disability/activity, the final outcomes reported were similar on discharge on impairment, disability/activity, and participation, but showed significant statistical difference on well-being. The number of contacts and duration of treatment varied across the services, even on cases with mild impairment. Conclusions: The results indicated equity of access, a difference in the effects of treatment on the different dimensions, and a significant difference on the dimension of well-being at discharge. Each service was able to compare their outcomes with those of the other services, observe the variations, and exchange information with those services in order to the identify reasons for the results.

Abstract This paper explores the construct validity of a measure of clinical outcomes, the Therapy Outcomes Measures (TOM). The work took place within a randomized controlled trial of pre-school children with speech and language difficulties in community clinics. Assessments of 159 children pre-randomization covered aspects of the children's expressive and receptive language, phonology, attention, play and socialization. The analysis investigated the relationship between the TOM and the various assessments. The sample, which included a range of primary speech and language difficulties, was stratified according to children's baseline scores on receptive and expressive language and their phonology. This made possible an assessment of the TOM against the pattern of the children's difficulties rather than against a single criterion. The pattern of correlation found between the TOM impairment ratings and the assessments reflected the child's predominant difficulty suggesting that the TOM ratings do have construct validity for this client group.

Comparing outcome data derived from patients receiving treatment in different sites can identify different practice worthy of further examination. This paper illustrates an approach to benchmarking with data collected on 1,711 patients who have received occupational therapy in nine healthcare trusts. Detailed results of 288 patients indicate that there were differences between the services in the patients referred for occupational therapy, they were discharged at different points in their recovery and different amounts of gain were achieved during the treatment period. In order to interpret the reasons for the variation meaning needs to be added to the data. While casemix is an important consideration and may account for many of these differences, it would also appear that investigation of the different processes of care in different trusts may warrant further study.

Benchmarking is one approach to quality improvement by comparing best practice, which requires appropriate process and outcome indicators. A benchmarking study to identify best practice was designed to investigate the use of Therapy Outcome Measure (TOM) as an outcome indicator. To ensure comparison of like with like, one study objective was to establish the reliability of the speech and language therapists (SLTs) using the TOM. This article describes this important aspect. One hundred and twenty-five SLTs from eight services, spanning seven National Health Service Trusts, participated in both the TOM training and interrater reliability assessments, where they independently rated 10 cases using composite case histories and videotape recordings. The acceptable level of reliability for participating in this benchmarking study was set as substantial (ˇ- 0.61) using an interclass correlation and was met on 52/53 TOM dimensions. On well-being, one adult team's reliability was below the required level, but this was resolved by an additional training session and reliability check. Following this, of the 53 domain results, 36 (68%) were almost perfect, and 17 (32%) were satisfactory. The reliability study found that SLTs could be trained to be consistent in their use of the TOM for benchmarking purposes. It was found that training was important for consistency and to eradicate bias; additionally, the method of assessing reliability, and the adequacy of the available information, all affected reliability.

The purpose of the study was to provide British data relating to the 54-item Quality of Life Profile Adolescent Version (QOLPAV; Raphael et al., 1996, Journal of Adolescent Health, 19, 366-375) and to explore the underlying factor structure of the questionnaire. The relationship between demographic variables (such as social economic status, gender and ethnicity) and quality of life (QOL) were investigated. Eight hundred and ninety-nine young people aged 12-16 were recruited from secondary schools in the south of England to participate in the study. Factor analysis highlighted eight dimensions embedded within the scale, which were largely consistent with the QOL model proposed by Raphael et al. (1996, Journal of Adolescent Health, 19, 366-375). A notable exception concerned items from the subdomain of "spiritual being", which did not cluster together but dispersed across multiple factors. Exclusion of complex items and those with low loadings on subdomains resulted in a briefer scale consisting of 32 items. Of the demographic variables examined, only age was significantly associated with quality of life scores.

Recent restructuring in the national health service (NHS) aimed to effect cultural and organisation changes that would ensure fair and equal access for service users to effective and efficient services. Clinical governance has been introduced as a means of delivering quality improvement. One element of this is the use of benchmarking to assess current process and outcome and to use comparative information to inform about current and best practice. The use of the Therapy Outcome Measure (TOM) (Enderby and John 1997) was investigated as an indicator to benchmark the outcomes of treatment for different client-groups and compare patterns of outcomes from different speech and language therapy (SLT) services. The study recruited eight SLT trust sites and ran for eighteen months. The TOM data was analysed to note similarities and differences in cases entering treatment, in the direction of change resulting from treatment, and on completing treatment. Variation was found on these points between cases with different disorders and across the trusts. TOM data could be used to provide a benchmark for a disorder against which services could make comparisons. However, for benchmarking to succeed there is a need for support and commitment from every level of an organisation.

The Therapy Outcome Measure (TOM) aims to provide Speech and Language Therapists (SLT) with a practical tool to measure outcomes of care by providing a quick and simple measure which can be used over time with patients and clients in a routine clinical setting. The TOM allows therapists to reflect their clinical judgement on the dimensions of impairment, disability/activity, handicap/participation and well-being on an 11-point ordinal scale. The purpose of this paper is to examine the reliability and the influences on reliability of SLT using this measure. Three studies are presented and give information on 73 SLT using the measure with different client groups. Study one assesses the degree of reliability of six SLT using the TOM following training and practice. Reliability was studied on three occasions and the results demonstrate the influence of training and practice. Study two included 56 SLT to examine reliability over a broader range of client groups and to investigate the effect of the SLT specializing on rating patients from within or -out that specialism. Eleven therapists were included in the study, which examined the influence of a specific training approach. The participating SLT achieved a substantial-moderate level of reliability; this was established in all domains. The degree of reliability achieved on the TOM was affected by some, but not extensive, training and experience.

This report presents outcome data from 3,176 consecutive prospective patients referred to physiotherapy for the treatment of soft tissue injuries. The results detailed here are part of a larger study collecting data from different NHS trusts in a benchmarking study. The Therapy Outcome Measure was used to collect data on each patient in four domains: Impairment, Disability/activity, Handicap/participation, and Distress/wellbeing on the entry and the exit from physiotherapy. The study concludes that patients do not have equal opportunity of accessing therapy for their specific condition according to their abilities and needs. Therapy provided in the Trusts did not produce similar changes in the patients' abilities and some dimensions appeared to improve more significantly in some locations. Furthermore this study would suggest that there are no common criteria for discharge of patients with similar conditions from physiotherapy across the Trusts as measured by the Therapy Outcome Measure.

Background: The use of outcome measures to monitor improved quality of care has been advocated for 20 years but has only achieved prominence with the increasing resource pressures and related changed in health service provision in the past 6 years. Objective: This paper describes the development of an approach to outcome measurement suitable for all patients receiving speech and language therapy. The measure, which is based on rating the dimensions of impairment, disability, handicap and well-being, is tested to assess whether it can usefully be used to compare the services of diVerent providers. Method: Five trusts volunteered for the study. Service descriptions suggest that these services are typical for the purposes of providing speech and language therapy. Twenty-eve therapists were trained to use the Therapy Outcome Measure (TOM); their reliability was assessed and they provided prospective data on clients with speech and language impairments related to dysphasia, stammering and dysphonia. Results: The study provides evidence indicating the diVerences in the types of patients being referred to diVerent providers of speech and language therapy. DiVerent services have diVerent impacts on the number and type of domains and that services discharge patients at diVerent points in their recovery. Discussion: DiVerent outcomes by diVerent providers may be associated with diVerent referral policies, base populations, skills and work policies of therapists. DiVerences in outcomes associated with certain therapy services can initiate the task of analysing attributions and progress endeavours to provide equitable

BACKGROUND The use of outcome measures to monitor improved quality of care has been advocated for 20 years but has only achieved prominence with the increasing resource pressures and related changed in health service provision in the past 6 years. OBJECTIVE This paper describes the development of an approach to outcome measurement suitable for all patients receiving speech and language therapy. The measure, which is based on rating the dimensions of impairment, disability, handicap and well-being, is tested to assess whether it can usefully be used to compare the services of different providers. METHOD Five trusts volunteered for the study. Service descriptions suggest that these services are typical for the purposes of providing speech and language therapy. Twenty-five therapists were trained to use the Therapy Outcome Measure (TOM); their reliability was assessed and they provided prospective data on clients with speech and language impairments related to dysphasia, stammering and dysphonia. RESULTS The study provides evidence indicating the differences in the types of patients being referred to different providers of speech and language therapy. Different services have different impacts on the number and type of domains and that services discharge patients at different points in their recovery. DISCUSSION Different outcomes by different providers may be associated with different referral policies, base populations, skills and work policies of therapists. Differences in outcomes associated with certain therapy services can initiate the task of analysing attributions and progress endeavours to provide equitable quality of care which is the philosophy underpinning the move towards benchmarking in health service delivery.

Speech and language therapists (SLTs) seek to meet the needs of the clients/patients and carers attending therapy. Part of the process of providing appropriate interventions is understanding the areas which the client/patient and their carers perceive as important issues. There is a need to know their views, expectations and desired outcomes if intervention is to be effective. Since the 1980s the National Health Service has placed emphasis on the need to include the views of users of health care in assessing service delivery and the outcomes of care. This paper explores the issues concerning measuring client perceptions, existing approaches to capturing client and carer views and summarises initial work from a pilot project to develop a Client Outcome Measure.

ABSTRACT Speech and language therapy aims to effect different aspects of the patient's difficulties according to the underlying disorder. This pilot study aimed to investigate whether different patterns of change were reflected in various client groups receiving speech and language therapy, whether these changes concurred with the views of experts and whether the results were meaningful to purchasers. Ten pilot sites were involved in the study. After training, therapists developed scales which they felt reflected the domains as indicated by the World Health Organization (WHO)/Enderby approach. Over a 3‐month period therapists collected data on patients for the pilot study. Nine hundred and ninety results were collected during this period. The results show noticeable differences in the impact of speech and language therapy according to the client group. Some client groups show the greatest impact on the area of impairment, whereas others show greater impact in the domains of disability and handicap. The changes were in accordance with what was expected by experts and showed some agreement between districts. Purchasers were able to understand the nature of the speech and language therapists' work with different client groups. Whilst this method appears to be able to reflect the different emphasis for speech and language therapy in an appropriate fashion, there are concerns about its sensitivity. The pilot study was flawed in some respects, being held over a short period of time, during the summer holidays, and asking therapists to judge the start score on reflection. Further studies are necessary so that outcome measures can be made over a more protracted period of time and the base course can reflect the therapist's opinions at the beginning of treatment. Purchasers have a tendency to make decisions on data rather than information. Outcome measurement can only provide data and this, on its own, can be misinforming.

ABSTRACT One aspect of the introduction of the National Health Service (NHS) internal market is the need to target finite funds as effectively as possible. Information from data collection is being used as one means for judging whether purchasers should buy services and, if so, which services. Presently, data collection concentrates on recording inputs, throughputs and so on. Whilst the effectiveness of routine interventions has proved difficult to measure, such measurements are nevertheless necessary because outcomes form an important part of the cycle of quality assurance. In speech and language therapy, single measures of outcome, such as standard tests, have proved inadequate; rather, multiple measures are required, reflecting change in those areas targeted for treatment. Work is required in further developing the methodology to measure outcomes. An example of such a methodology is being developed, based on work by Enderby (1992).