4 Reasons to Use Questionnaires
Watch the video for this weeks blog here!
In our practice, short standardized questionnaires for
common ocular conditions help us focus on patient symptoms and begin a discussion with them about how to treat their problem. In this weeks post, I will focus on the 4 main reasons to use a standard symptom questionnaire and cover the clinical and billing aspects of utilizing a well designed questionnaire for ocular surface disease (OSD).
ONE - History of Present Illness (HPI)
By using a standard questionnaire we can have patients quickly report their symptoms which can provide us with a significant part of our history score (HPI) when coding an examination. If we look at the Standard Patient Evaluation of Eye Dryness (SPEED), we will see that it covers enough information to satisfy an extended level of HPI.
If we modified it to ask two additional review of systems (ROS) questions:
Do you ever get dry mouth?
Do you ever have pain in your fingers or knees?
And also asked about one element of past history:
Have you ever used Accutane?
We would have enough history to satisfy the history component of a 99203 or a 99214! I make this point to illustrate that it is completely reasonable to obtain a level 4 history for an established patient, simply by asking questions that are the standard of care for ocular surface disease management.
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TWO - Correlates to Clinical Signs and Quality of Life (QOL) Scores
One of the most consistent things I have found over the last 9 years of treating patients with ocular surface disease is that if I ask them about their symptoms in a non-standardized way, they rarely correlate to clinical signs. Questions like:
How severe is your dry eye?
How often does your dry eye bother you?
Are too open-ended and difficult for patients to judge since they don't know (remember) what "normal" feels like. As we all know, this is because ocular surface disease typically has a gradual and chronic nature (rather than acute) and also can lead to desensitization of the ocular surface.
When we use a standardized questionnaire like the Ocular Surface Disease Index (OSDI) or SPEED we eliminate a large portion of this ambiguity.
The OSDI has been shown to inversely correlate to QOL scores - as OSDI score decreases QOL increases.
The OSDI and SPEED have been shown to correlate well to clinical signs, and also to each other - as OSDI score increases, SPEED increases.
SPEED has been shown to correlate well with signs of MGD - specifically, as corneal staining, meibomian gland score, and meibomian glands yielding liquid secretion score improve, SPEED improves.
THREE - Establish Symptom Severity
I always tell my patients with OSD that I will likely not be able to completely eliminate their symptoms, but I can typically help them keep those symptoms in the mild range. By using a standardized questionnaire we can classify patients into different categories based on these scores. As an example, for SPEED, a score of:
1-5 is mild
6-10 is moderate
11-28 is severe
Four - Monitor Treatment
When I see a patient back to monitor our treatment effect it can be challenging for them to compare the way their eyes feel currently to how they felt prior to treatment. This is for many of the same reasons listed above and additionally because symptom improvement is often a gradual process.
A standardized symptom questionnaire allows you to more objectively assess their symptoms and compare it to previous scores. This is helpful because most patients will not know how they answered the questions on the initial visits and small movements in improvement can be seen - even when a patient does not realize that there has been an improvement. I occasionally have patients who return after a treatment has been initiated and we see clinical signs improve, but they say that their symptoms have barely improved, or have not improved at all. Most of the time when this occurs, however, I will see that their questionnaire score has improved, which helps us with our next treatment option and also helps show the patient their symptomatic improvement.
There are many standardized symptom questionnaires, and I may discuss them in a future blog post. However, in our practice we use SPEED for the following reasons:
It is quick, takes most patients 1-2 minutes to complete.
It is focused on symptoms associated with evaporative disease (MGD) - 80-90% of all OSD has an evaporative component.
It is simple to calculate.
My recommendation is to pick one for your practice and be consistent with it, you will find that it helps you focus on patient symptoms and track those symptoms effectively over time. Have a great week!