EVALUATION REPORT
Trial of the Activity
Performance Measure (APM)
in Occupational Therapy in
the Stroke Early Supported
Discharge service of
Gloucestershire Care Services
NHS Trust
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Introduction
This is a report on the trial of the Activity Performance Measure (APM) outcome measure by
occupational therapists in the Stroke Early Supported Discharge (ESD) team of Gloucestershire Care
Services NHS Trust (GCS). The ESD team provides a time-limited (6 week) service to people
discharged from hospital to the community and one of its primary aims is to promote recovery while
reducing hospital inpatient length of stay.
The APM is an innovative measure of ADL performance and participation (defined as involvement in
life situations). The focus of the report is on the outcomes achieved by service users during the OT
ESD admission as identified by the APM.
The response of the ESD OTs to trialling the APM was positive – they intend to keep using it, and are
hopeful that the results can provide supporting evidence for a less intensive follow-up service to
their current six-week model.
Background and evaluation design
In the summer of 2016, OTs the ESD team volunteered to trial the APM. Like many therapists, they
are keen to find new and better ways of demonstrating the value of their service in these
increasingly challenging times. The aim was to evaluate the results achieved by the APM in terms of
capturing clinically significant change during the OT admission. This evaluation follows on from a
similar process in one of GCS’ Integrated Community Teams.
The OTs were given one hour’s training in how to collect the information required and score the
APM, and deidentified results were sent to Phil Murgatroyd (developer of the APM) who produced
this report. No changes in treatment were received by the SUs as a result of the trial.
In total data on 13 SUs has been collected and processed in this report. These represent consecutive
referrals of people who completed OT in the ESD and therefore this sample can be considered to be
representative of the work completed by ESD OT.
See Appendix 1 for a note on the statistics used.
Brief description of the Activity Performance Measure (APM)
The APM consists of 28 ADL activity items, and covers how a person performs in terms of mobility,
community mobility, personal care, domestic tasks and community and leisure activities. Each item,
if relevant to the service user’s lifestyle, is scored between 4 (no limitation) and 0 (total limitation).
The scoring is based on concrete aspects of activity limitation like independence/preferred lifestyle,
the use of adaptive equipment or techniques, receiving supervision and assistance from carers, or
stopping participating in an activity altogether.
The 28 items scores are combined to produce 2 summary scores of Activity Performance and
Participation, and also can be used to produce more detail about how a person’s ADL performance
and participation change during an episode of care.
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Results - averages for sample
Activity Summary score
(this summary score indicates the amount of limitation in a person’s overall activity performance,
with 100 indicating no impairment, 15 indicating full nursing care).
Admission: 52.9
Discharge: 74.8
Average Change:+ 21.9 ( p≤ 0.05)
What this means:
The sample of 13 service users achieved a high average reduction in limitation in ADL performance
during the admission - the fact that this was statistically significant with so few participants gives
more confidence that this is a real change rather than random variation. All 13 service users saw a
reduction in ADL limitation during the admission (see chart below).
Activity Summary: 13 patients
120
100
80
Activity summary
60
score
Admission
Discharge
40
20
0
1
2
3
4
5
6
7
8
9
10 11 12 13
Service users 1-13
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Participation Summary
This score is the number of activities, in which a person is involved in. The maximum would be 28
(exceptionally high number of activities) and the minimum would be around 5 (full nursing care
only).
Admission: 10.5
Discharge: 14.4
Average change: + 3.9 ( p≤ 0.05)
What this means: On average, service users were involved in nearly 4 more activities at discharge
each, compared with their situation at admission. Twelve of the 13 patients participated in more
activities at the end of the episode of OT, compared with admission. Some of these changes were
very high e.g. patients 5 (7 new activities) and 9 (6 new activities) - in other words a radically
expanded lifestyle returning close to premorbid.
Participation Summary: 13 patients
20
18
16
14
12
Participation
Summary 10
Score
8
Admission
Discharge
6
4
2
0
1
2
3
4
5
6
7
8
9
10 11 12 13
Service users 1-13
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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More detail on the improvement achieved during the admission
The APM has the potential to produce additional details about how people’s lives change during an
occupational therapy admission.
Amount of change
At discharge, the 13 service users were participating in a total of 187 activities combined. They had
made an improvement in 112 of these 187 activities, in other words a remarkable 60% of activities
were performed with less limitation after the episode of OT.
Return to independence or preferred lifestyle
The 13 service users had regained independence or returned to their preferred lifestyle in 58
activities at discharge compared to their performance at admission (31% of total activities
performed at discharge).
No longer received assistance or supervision
People ceased having physical assistance or supervision from carers in 41 activities (23% of activities
performed at discharge.
Equipment change
On average, each service user had 1.9 pieces of equipment changed during the OT admission.
Return to participation
At discharge, people had resumed in participation in 54 activities (possibly in a modified way or with
support), which they had not been participating in when they were admitted to ICT OT) (approx. 27%
of activities performed at discharge).
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Areas of change during the admission
The 13 ESD service users in the study improved across a large range of activity items. The chart
below shows how many service users improved their performance in each activity category. The
most frequent area of change was showering/bathing, where 9 of the 13 service users improved
their performance. The chart below shows the areas of improvement starting with the most
frequent at the top.
Number of service users who improved on
each item (total sample = 13)
0
2
4
6
Shower or bath
Prepare meals
Mobility in the home
Mobillity < 500m
Steps (<3 steps)
Toilet including continence…
Mobility > 500m
Stairs (>3 steps)
Use car as passenger (incl. Transfers)
Dress
Light housework
Shop
Media usage (TV, reading, Internet)…
Public transport
Eat and drink
Heavy housework
Groom
Medication management
Religious & volunteer
Sport/fitness
Activities with others outside home
Other leisure activities in the home…
Drive
Paid work
Education
Home maintenance and gardening
Child and adult care
Solitary leisure outside home
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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10
Number service users
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Another way of looking at the improvement made during the admission is the average size of
improvement per activity category. Here again, showering/bathing saw the biggest average change
together with going up and down steps. The ranking of items in terms of amount of change is shown
in the chart below:
Average Activity Summary change per item
during admission
Average Activity Summary change during admission
Steps (<3 steps)
Shower or bath
Mobillity < 500m
Mobility > 500m
Use car as passenger (incl. Transfers)
Light housework
Prepare meals
Media usage (TV, reading, Internet) (main activity…
Shop
Toilet including continence management
Mobility in the home
Heavy housework
Stairs (>3 steps)
Dress
Public transport
Activities with others outside home
Other leisure activities in the home (main activity…
Eat and drink
Religious & volunteer
Sport/fitness
Groom
Drive
Paid work
Education
Home maintenance and gardening
Child and adult care
Solitary leisure outside home
Medication management
-0.2
1.5
1.5
1.4
1.4
1.4
1.3
1.1
1.1
1.0
0.9
0.8
0.8
0.8
0.8
0.7
0.5
0.5
0.5
0.5
0.5
0.2
0.2
0.0
0.0
0.0
0.0
0.0
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Comparing discharge with premorbid performance and participation
The APM is designed to help contextualise a person’s performance by comparing it with premorbid
performance, when there has been a clear deterioration (as is the case with stroke). This also allows
rehabilitation to be viewed individually in the light of how close to premorbid levels people were at
the time of discharge. For the ESD service, the average figures are given below.
Activity Summary averages
Premorbid
96.9
Admission
52.9
Discharge
74.8
Participation Summary averages
Premorbid
Admission
20.6
10.5
Discharge
14.4
These averages conceal quite different levels of recovery towards premorbid levels, as can be seen
in the following charts. Some of these Sus have returned to very close to premorbid levels (e.g. 9, 11
or 13) in terms of the amount of limitation during the ESD admission, while others made more
modest gains. However, the trade off for this seemed to have often been reducing the range of
activities people participated in.
Activity
Summary - 13 Patients
120
100
Activity Summary Score
Pre
mo
rbid
80
Ad
mis
sio
n
60
40
20
0
1
2
3
4
5
6
7
8
Service users 1-13
9
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
10
11
12
13
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Participation Summary - 13 Patients
30
25
20
Participation
15
Summary Score
Premorbid
Admission
Discharge
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Service users 1-13
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Areas of biggest loss in performance at discharge, compared with premorbid
The chart below shows the areas of biggest loss of performance at discharge from the ESD service,
compared with premorbid. For example the sample showed no return to education activities, home
maintenance and child care. On the other hand essential functional activities generally had lower
losses of performance at discharge, compared with premorbid. These functional activities are
generally priority rehabilitation goals immediately after illness. The areas of low improvement seem
to be strong evidence of outstanding rehabilitation needs continuing after the 6-week ESD
admission, as would be expected given the lengthy recovery periods following stroke. (NB these data
needed to be treated with caution given the size of the sample).
Activities with largest performance decline at
discharge compared with premorbid
Activity summary decline at discharge compared with premorbid
Education
Home maintenance and gardening
Child and adult care
Solitary leisure outside home
Drive
2.0
Public transport
1.8
Shop
1.5
Shower or bath
1.1
Heavy housework
1.0
Religious & volunteer
1.0
Sport/fitness
1.0
Medication management
0.9
Prepare meals
0.9
Mobility > 500m
0.9
Stairs (>3 steps)
0.8
Mobillity < 500m
0.7
Light housework
0.7
Dress
0.6
Mobility in the home
0.5
Eat and drink
0.5
Steps (<3 steps)
0.5
Groom
0.5
Media usage (TV, reading, Internet) (main activity…
0.4
Toilet including continence management
0.4
Paid work
0.0
Activities with others outside home
0.0
Other leisure activities in the home (main activity… 0.0
Use car as passenger (incl. Transfers)
-0.1
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
4.0
4.0
4.0
4.0
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Summary
The service users included in this trial of the APM showed clear gains during the occupational
therapy admission in both reducing the amount of limitation in their activity performance, and also
increasing the range of activities they were involved in.
Statistically, these changes were significant and the amount of change achieved was high.
The response of the ESD OTs to trialling the APM was positive – they intend to keep using it, and are
hopeful that the results can provide supporting evidence for setting up a less intensive follow-up
service to their current six-week model.
The changes achieved with OT were varied - for example in some activities service users returned to
independence, in others the need for carer input was ceased, while in other cases they returned to
involvement in a valued parts of their lifestyle but in a modified way. People improved in a range of
important functional tasks and mobility, but also in more complex and individual community and
leisure tasks important for quality of life, autonomy and choice in a broader sense.
In general, it appeared that these service users made bigger gains in reducing the amount of
limitation in the activities they were involved in, and made somewhat smaller gains in returning to
previous participation patterns. Further details about the areas where people had not returned to
premorbid activities are given above and support the idea that these stroke survivors have ongoing
rehabilitation needs beyond a 6-week period, as would be expected.
There are of course limitations in a study of this nature, in particular the size of the sample (although
the fact that these service users are consecutive referrals means the information is more
representative of the true population figures). However, the potential for demonstrating more
about the progress achieved by service users receiving occupational therapy in the Stroke ESD
setting appears clear.
It is also interesting to note that as would be expected these stroke service users achieved bigger
gains in both performance and participation than the service users in the integrated community
team trial (especially in the slow-stream service). No doubt that this is partly connected with the fact
that, to judge by the premorbid performance and participation scores, many of the service users
referred to the ESD team appear to have been relatively fit and healthy prior to the stroke. However,
the fact that a significant proportion of them remained below premorbid levels at the end of the 6week rehabilitation period suggests they have clear ongoing rehabilitation needs and potential.
Given the high sensitivity to change seen in the APM, routine collection of APM scores for all OT
referrals appears unnecessary to report more definitively on the ESD service. Instead a truly
representative sample of 50 or so referrals would produce reliable information. However, it would
be necessary to ensure that resources are available for training, monitoring data quality, processing
the data and turning it into a meaningful report.
Author: Phil Murgatroyd, March 2017
APM Evaluation GCS Stroke Early Supported Discharge 31.3.2017
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Appendix 1 - Statistical note
Statistical significance was tested using the Wilcoxon test.
For both the Activity and Participation summaries, the difference in the results between admission
and discharge were statistically significant at a level of p<0.05. In non-technical terms, this means:
“Statistically significant results are those that are interpreted to not occur purely by chance and
therefor have other underlying causes for their occurrence.”
In terms of the size of the change was seen in the Activity and Participation summaries between
admission and discharge, the effect size was high (Robust nonpooled Cohen’s D of over 0.7). This
means that not only was there a non-random change between admission and discharge, but
furthermore the amount of change was high.
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