Notes from the 1997 Special Interest Division 4 (Fluency and Fluency Disorders)
Leadership Conference in Tucson
Nan Bernstein Ratner , U. of Maryland-College Park
Bob Quesal, Western Illinois University
At the 1997 Leadership Conference, affliates of Special Interest Division 4 considered a number of issues that bear on stuttering treatment outcome. Guided by Dr. Lee Sechrest, the group noted that stuttering outcomes might be measured by efficacy studies or by effectiveness studies. In the first case, clinicians discover whether treatments have their intended outcomes under optimal circumstances (such as might occur during a carefully controlled clinical trial). In effectiveness studies, one measures whether stuttering treatments achieve their intended effects under ordinary circumstances.
A number of issues relate to the outcomes of any therapeutic process. First, we need to ascertain whether a therapy approach achieves its behavioral goals. This is a primary goal of the ASHA FACs being developed for the spectrum of communicative disorders and their treatment. However, providers, clients and third-party payers often have other concerns about outcomes. For example, one may be concerned that the functional status of the individual undergoes change: that they are able to achieve functional performance in aspects of their lives that previously were denied them. Less easily measured but no less important is "quality of life", a concept for which epidemiologists are now beginning to develop procedures to measure bjectively (as in "quality-adjusted life years"). Finally, both society and the individual increasingly weigh the cost (financial charges and/or time expended) of any treatment against its benefits. The individual, society, and third-party payers for therapeutic services may weight these costs and benefits differently. In any event, it is imperative that providers of stuttering therapy establish tangible and measurable desired outcomes for their services. The establishment of such outcomes allows individual providers and clients to gauge whether a particular therapeutic regimen achieves its goals, and if so, whether it does so in a cost- or time-effective manner. Desired therapeutic outcomes for stuttering services should include those valued by clients, by service providers, by society and by third-party payers.
With these issues in mind, the attendees of the Fourth Annual Leadership Conference broke into study groups to formulate desired outcomes of treatment for stuttering. The groups were divided to consider how various constituent groups might view desired outcomes. The constituent groups under consideration were: the individual who stutters (client), the service provider (clinician), the individual who pays for services, third-party payers (such as managed care organizations (MCOs)), and society at large. Each working group developed a list of desired outcomes. A large focus of discussion in group and plenary sessions was whether the desired outcome of fluency services could be gauged solely by the measurable fluency of the client before and after therapy. There was large consensus that desired outcomes must also reflect changes in the affective and cognitive states of the client following therapy. A list of desired outcomes was presented for each constituent group, in plenary for discussion and comment, and amended following open discussion. The list below reflects the consensus that the plenary session attendees achieved on desired outcomes of fluency therapy. (Some of the outcomes listed below have been edited to achieve editorial consistency.)
Preferred client outcomes
As a result of therapy, the client should be able to positively rate the following outcomes:
(These outcome statements presume an adult client. Though time did not permit formal discussion, it was recognized that outcomes for therapy provided to children would have to be adjusted to reflect their particular concerns, and those of their parents).
Preferred clinical outcomes
The preferred treatment outcome relative to the clinician is that the client will demonstrate feelings, behaviors, and thinking that lead to improved communicative performance and satisfaction with the therapy process.
These outcomes can be operationally defined to include the following:
Societal outcomes of therapy should include a reduction in the negative impact of stuttering, allowing increased options for the client in one or more of the following areas: education, vocation, societal.
Financial outcomes of therapy should include:
MCO and other funding sources
The preferred fluency treatment program is cost-effective and results in the clients satisfaction with the services provided.
Preferred outcomes of stuttering treatment relative to the payer are that:
These outcome statements should be considered as "works in progress" rather than absolutes. These statements will form the basis for the 1998 Leadership Conference at Marco Island, FL, during which Division 4 affiliates will determine mechanisms whereby these outcomes can be measured. Determining means for measuring these outcomes may prove more daunting than developing the outcome statements.