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Key Words: Decision making; Diagnosis; Physical therapy profession, professional issues.
I
n 1986, Rothstein and Echternach1 published a
clinical decision and documentation guide called contemporary practice.
the Hypothesis-Oriented Algorithm for Clinicians
(HOAC), which they contended offered clinicians
addressing goals noted by someone other than the
a pragmatic, scientifically credible approach to patient
patient.
management. Since that algorithm was first published,
radical changes have occurred in the health care system.
The focus on patient-centered outcomes was, however,
For example, there is now widespread discussion of the
an innovation in HOAC and laid a foundation for the
importance of physical therapists making diagnoses,2
implementation of the HOAC in clinical decision mak-
and there is also general acceptance of the need to view
ing in the context of currently used disability models.
patients and clients within the context of one of the
The disablement model that we believe currently offers
disability models.3,4 In addition, therapists often have to
the greatest utility for clinical practice is the Nagi
relate to practice guides and guidelines.5 We argue that
model.7(pp223–241) A common element in both the old
what is needed is a patient management system that
and new versions of the HOAC is that therapists using
involves the patient in decision making and can be used
the terms of the Nagi model are called upon to identify
to provide payers with better justifications for interven-
impairments, when appropriate; to examine how these
tions, including occasions when therapists may disagree
impairments relate to functional deficits; and to exam-
with practice guidelines. Compatibility with the Guide to
ine whether interventions designed to ameliorate or
Physical Therapist Practice’s (Guide’s) patient manage-
reduce impairments result in changes in function and
ment model, including the formulation of diagnoses, is
changes in levels of disability. In some cases, therapists
also desirable.6
also can hypothesize that factors other than impairments
may lead to functional loss. For example, a societal
The purpose of this article is to present HOAC II, a
limitation such as high curbs may contribute to a
revised algorithm designed to meet the needs of con-
patient’s inability to walk to school. We also believe
temporary practice. The algorithm, we believe, is com-
therapists have a role in prevention7(pp84 – 89) and that in
patible with the American Physical Therapy Association’s
a responsibility-focused health care system clinicians
(APTA’s) Guide to Physical Therapist Practice,6 including
should identify the hypotheses that underlie interven-
the therapists’ need to diagnose and to offer interven-
tions used for prevention.
tions designed to prevent problems. In the context of
the HOAC II, a problem is almost always a functional
We believed that the original HOAC could serve both as
deficit. Although we attempted to be consistent with
a template for documentation and as a conceptual
Guide terms, there are instances where we used alternate
model for decision making and, therefore, could link
terms for the sake of clarity.
documentation and practice. This does not mean, how-
ever, that we believe either the original HOAC or the
Although the original HOAC was a first effort at bring-
HOAC II must be implemented in the exact form we
ing scientific decision making into a user-friendly prac-
have written it, for all patients, in all settings. Rather, we
tical context for clinical decision making, it has some
contend that elements can be selected based on practi-
cumbersome elements as well some logical and proce-
cality and the expected benefit of using a system in
dural flaws. The algorithm offered no guidance on how
which all elements of patient management are explicitly
to determine when an intervention designed primarily
detailed. The HOAC II, we contend, provides a means
for prevention was appropriate and how risk factors
for not only using evidence in decision making, but also
could be eliminated. The algorithm also did not ade-
for documenting the nature and extent of evidence
quately provide a means for identifying problems and
used. Within the new version, elements related to justi-
JM Rothstein, PT, PhD, FAPTA, is Professor, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago,
1919 W Taylor St, 4th Fl, Room 456, Chicago, IL 60612 (jules-rothstein@attbi.com). Address all correspondence to Dr Rothstein.
JL Echternach, PT, EdD, ECS, FAPTA, is Professor and Eminent Scholar, School of Physical Therapy, Old Dominion University, Norfolk, Va.
DL Riddle, PT, PhD, is Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth University,
Richmond, Va.
All authors provided concept/idea/project design, writing, and project management. The authors acknowledge the efforts of Andrew Guccione,
PT, PhD, FAPTA, Julie Fritz, PT, PhD, ATC, and David Scalzitti, PT, MS, OCS, for reviewing an earlier draft of the manuscript.
This article was submitted March 12, 2002, and was accepted December 2, 2002.
Figure 1.
The initial steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
Figure 3.
The algorithm for reassessment of existing problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).
Plan Intervention Strategy and Tactics The steps in Part 2 can be used for documentation, or
If the therapist thinks muscle weakness is the impair- they can be used to less formally guide decision making.
ment contributing to a disability, the most obvious The most important element, however, is that, by using
approach would be to use exercise to increase the Part 2, the therapist must account for all changes in
force-generating capacity of the involved muscles. The goals, tactics, strategies, and hypotheses. In addition, the
strategy would be the use of exercise. Describing the therapist needs to document whether the criterion mea-
strategy alone is insufficient, because many types of sure chosen is still viable and whether it is still reasonable
exercises exist. The HOAC II asks therapists to describe to expect to see the desired change in the criterion
the tactics (specific exercises and frequency) they would measure. Part 2 not only assists in the evaluation process,
use. If we were dealing with an anticipated problem it provides the logical framework for examining the
(such as the development of postoperative pneumonia), effects of all interventions. Use of Part 2 requires the
there might be 2 strategies: (1) teach the patient how to therapist to document what happened to a patient, even
clear his or her airway and (2) teach the patient preven- if the result is an acknowledgment that the result was less
tive measures such as frequent ambulation and use of an than was expected. Documentation may be particularly
inspirometer. The tactic for the first strategy (airway useful on occasions when factors outside of the thera-
clearance) may be to have the patient cough a specified pist’s control led to a termination of the intervention.
number of times per hour (and the patient could be For example, by following the steps in Part 2, a therapist
shown how to determine if the cough is productive). The can make an argument to a payer that goals were not
tactic for generalized prevention might be correct use of achieved (even though progression was being made on
an inspirometer 5 times daily and ambulation 5 times the criterion measure) because there was too little time
daily. Strategies are broad statements of what types of allowed for the intervention.
things need to be done, whereas tactics are the elements
of the intervention. Tactics specify the frequency, dura- Part 2 consists of 2 flow diagrams. The first diagram
tion, and intensity of the interventions. (Fig. 3) leads the therapist through a series of questions
for all existing problems (regardless of who generated
Implement Tactics them). The second diagram (Fig. 4) also consists of a
Once tactics have been identified, they need to be series of questions, but these questions relate to antici-
implemented. Most often the therapist will be doing the pated problems (regardless of who generated the prob-
implementation. Sometimes, as when a person has a lem list). The peculiar nature of prevention (ie, thera-
home exercise program, the patient may be doing the pists may take credit for what does not occur by making
When a therapist thinks a problem has multiple causes 3 Jette AM. Introduction: physical disability. Phys Ther. 1994;74:379.
and generates multiple hypotheses, it is impossible to say 4 Jette AM. Physical disablement concepts for physical therapy
with certainty whether achieving appropriate levels of all research and practice. Phys Ther. 1994;74:380 –386.
the testing criteria led to attainment of a goal. The 5 Feder G, Eccles M, Grol R, et al. Clinical guidelines: using clinical
possibility exists, for example, that if there were 3 guidelines. BMJ. 1999;318:728 –730.
hypotheses, 2 of the hypotheses were correct and the 6 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:
third hypothesis was either redundant or unnecessary. 9 –744.
When all testing criteria are achieved, the therapist has 7 Pope A, Tarlov A, eds. Disability in America: Toward a National Agenda
no way of knowing what would have happened with this for Prevention. Washington, DC: National Academy Press; 1991:84 – 89,
patient if only 2 hypotheses had been met. 223–241.
8 Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving: An
Following a CVA, a patient might be incapable of Analysis of Clinical Reasoning. Cambridge, Mass: Harvard University
dressing. Among the many possible causes of this deficit Press; 1978.
could be: (1) weakness, (2) lack of coordination, and (3) 9 Payton OD. Clinical reasoning process in physical therapy. Phys Ther.
poor position sense. All 3 might be hypothesized as 1985;65:924 –928.
causes of the problem. Testing criteria for weakness 10 Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy.
could be a force level obtainable on a hand dynamom- 3rd ed. Philadelphia, Pa: WB Saunders Co; 2000.
eter. For the lack of coordination, the testing criteria 11 Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology:
might be a level of performance on a coordination test, A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass: Little, Brown
and, for position sense, the testing criteria might be the and Co Inc; 1991.
Appendix.
Terms Used in the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)
Anticipated Problems:
These can be identified by the patient, the physical therapist, or any Non–Patient Identified Problems (NPIPs):
other person and are statements that describe deficits that the therapist These are problems identified (at least initially) by people other than the
believes will occur if an intervention is not used for prevention. patient but that are added to the patient’s problem list after consultation
with the patient (these can be existing or anticipated problems).
Examination Strategy:
This is the plan for examination that a physical therapist uses based on Patient-Identified Problems (PIPs):
the therapist’s experience, available data relating to the patient, and These are problems identified by the patient (these can be existing or
information on similar patients. Because not all possible tests and anticipated problems), and because they are generated by the patient,
measures are used, the choice is considered a hypothesis-driven strat- they cannot be removed from the problem list without the patient’s
egy in the HOAC II. consent.