Introduction

There is an increasing shift in the United States towards value-based care that emphasizes improving outcomes that matter most to patients. Value-based care is viewed as a common goal among patients, clinicians, employers, insurers, and government organizations [1]. Value, in this context, can be established by measuring improvements in patients’ health relative to the expenses incurred to attain those outcomes [2]. Outcome measures (OMs) are standardized tools that physical therapists (PTs) and other health professionals can use to evaluate aspects of patients’ health before, during, and after an intervention [3]. Use of OMs allows PTs to engage in value-based practices by objectively assessing tangible changes in a patient’s health outcomes over the course of their care [4].

Despite the benefits of using OMs in physical therapy, prior evidence has indicated that they are not administered routinely in clinical practice. In 2009, Jette and colleagues surveyed a large national sample of PTs in the United States and found that fewer than 50% of the respondents used standardized OMs with their patients [5]. A key limitation of this study, however, is that the survey developed by the investigators asked PTs only about their use and opinions of one type of OM, health status questionnaires (i.e., self-report surveys). The survey administered did not include questions about performance-based tests, another type of OM commonly used in physical therapy practice. The findings reported by Jette et al., therefore, likely underestimate the overall use of standardized OMs among PTs in the United States in the late 2000s. This notion is supported by evidence from a study of OM use among PTs in Korea published in late 2023 [6]. Lim and colleagues surveyed 220 PTs and found that just over half (n = 126, 57.3%) of respondents used self-report surveys alone or in combination with performance-based tests in their practices. However, a larger majority (n = 165, 75.0%) used performance-based tests either alone or in combination with self-report surveys.

Including performance-based tests in assessments of OM utilization among PTs is important because performance-based tests provide information that is distinct from and complementary to self-report surveys [7,8]. However, performance-based tests also require additional resources like access to space (e.g., open rooms or long corridors) and equipment (e.g., chairs or stairs) and may, therefore, be more challenging to administer in some of the settings in which PTs practice. In 2022, Morgan and colleagues conducted a study to evaluate the use of both self-report surveys and performance-based tests among prosthetists in the United States [9]. While respondents (n = 375) indicated relatively high utilization of standardized OMs overall (93%), limited time and space were reported to be barriers to routine use of OMs. As the developed survey included questions specific to the time, space, and equipment available to prosthetists for outcomes measurement, the authors were able to propose specific OMs suited to these constraints. Understanding the resources available to PTs can similarly aid in identifying OMs suitable for administration in the clinical environments in which PTs practice.

The goal of this study was, therefore, to assess the current state of outcomes measurement in the PT profession, including professional expectations, practice habits, and general opinions regarding the value of self-report surveys and performance-based tests. Additionally, PTs were queried regarding the availability of resources, such as time, space, and equipment (including mobile technology) for administering both types of OMs in clinical practice.

Materials and methods

A cross-sectional study was conducted between March 2023 and April 2023 with PTs across the United States. A local institutional review board reviewed the study protocol and determined it qualified for exempt status.

Results

Participants

Invitations were sent to 3674 individuals from the APTA mailing list with valid addresses. 595 respondents completed the self-screening process. 71 respondents did not complete the survey (15 were not eligible, 32 were eligible but did not start the survey, and 24 were eligible but did not complete the survey). No records were removed for inaccuracies or missing data. A total of 524 respondents completed the survey, with a response rate of 14.3%. 10 respondents indicated that they do not typically treat patients and were removed from the final dataset (n = 514) used for this analysis (Table 1).

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Table 1. Demographic and professional characteristics of the study sample (N = 514).

https://doi.org/10.1371/journal.pone.0330528.t001

The median age of the sample was 41 years (range 25–73 years), and the median time in practice was 13 years (range <1–47 years). The majority of respondents were women (66%) and of White race (86%). The study sample was similar to that reported in the APTA Practice Profile Analysis based on demographic characteristics such as median age (study sample: 41 years, practice analysis sample: 43 years), woman gender or female sex (66%, 65%), race (American Indian or Alaskan Native: 0%, < 1%; Asian: 5%, 7%; Black or African-American: 1%, 3%; Native Hawaiian or Other Pacific Islander: 0%, < 1%; White, 86%, 84%) and ethnicity (Hispanic or Latino: 4%, 4%) [12].

Most survey respondents worked in outpatient settings (63%); fewer worked in acute care (15%), long-term care (11%), or other (11%) settings. The majority of respondents (80%) treated primarily adult patients, and many (68%) had a patient load of more than 20 patients per week. Nearly all respondents (95%) reported they had training in outcomes measurement. Most (65%) indicated they had received formal training while at college/university, but more than half of respondents also said they had taken continuing education courses (53%), received informal training from others (52%), or self-trained (57%) in the administration of OMs.

Motivations for using outcome measures

The three most endorsed reasons for the routine use of performance-based tests (Fig 1) included “to evaluate patient progress” (80%), “to inform clinical decisions” (76%), and “to communicate with patients” (68%). The three most endorsed reasons for the routine use of self-report surveys were “to evaluate patient progress” (52%), “to justify service to payers” (46%), and “to communicate with patients” (38%) (Fig 1). The two least endorsed reasons for routine use of OMs were similar for performance-based tests and self-report surveys “for facility or provider accreditation” (20% and 19%, respectively) and “for research purposes” (11% and 7%, respectively).

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Fig 1. Reasons for using outcome measures.

https://doi.org/10.1371/journal.pone.0330528.g001

Perspectives on use of outcome measures

The large majority of respondents agreed or strongly agreed that performance-based tests and self-report surveys “are within my scope of practice” (98% and 95%, respectively), “can be administered with knowledge that I have” (96% and 88%), and “are inexpensive” (82% and 85%) (Table 2). However, less than half the sample agreed or strongly agreed that these types of OMs “are administered in a standardized way throughout my profession” (48% and 46%, respectively). Perspectives on the different types of OMs differed markedly in three key areas, however. Most respondents agreed or strongly agreed that performance-based tests are “a good use of my time” (90%), “help me make clinical decisions” (89%), and “are meaningful or motivating to my patients” (78%). Agreement was lower for self-report surveys, with 52%, 61%, and 47% endorsing these statements, respectively.

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Table 2. Perspectives on use of outcome measures.

https://doi.org/10.1371/journal.pone.0330528.t002

Time available for administering outcomes measures

Respondents indicated their median (25^th-75^th percentiles) clinical appointment times for evaluation, re-evaluation, and discharge were as follows: 50 min (45–60), 40 min (30–45), and 30 min (30–45), respectively. Respondents were generally willing to spend more time administering performance-based tests than self-report surveys during these clinical appointments (Table 3). Only about one-quarter of the respondents (24–27%) indicated they were willing to spend 20 minutes or more administering performance-based tests during each of these clinical appointments, but many more (62–64%) were willing to spend between 5 and 20 minutes with these tests. Less than one-tenth of respondents (6–9%) were willing to spend 10 minutes or more administering self-report surveys; however, the large majority of respondents (85–87%) were willing to spend less than 10 minutes administering surveys at these appointments. Finally, nearly all respondents (96–98%) said they would be willing to spend time communicating results from a performance-based test or self-report survey to a patient and documenting results in the patient’s record, but most (83–86%) indicated they would not spend more than 10 minutes doing either of these activities.

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Table 3. Time available to administer, communicate, and document outcome measures.

https://doi.org/10.1371/journal.pone.0330528.t003

Clinical resources available for administering outcome measures

The large majority of respondents (81%) reported having access to spaces where patients could walk short distances (i.e., up to 10m) (Table 4). Fewer respondents indicated they had indoor spaces where patients could walk longer distances (e.g., 30m) or run/jog (<38% and 46%, respectively). However, 69% of respondents indicated they had access to a treadmill. More than half of respondents (50–92%) indicated they had access to small-to-medium sized rooms or narrow hallways where they could administer performance-based tests. Fewer (7–42%) had access to wide hallways, L-shaped areas, or gyms where they could administer these tests. Most respondents (84%) also had access to some type of stairs, but far fewer (38%) had access to a low-grade ramp (with or without handrails). Two-thirds of respondents (66%) noted they had access to a tablet computer for administering OMs.

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Table 4. Space available to administer outcome measures.

https://doi.org/10.1371/journal.pone.0330528.t004

Discussion

The present study examined outcomes measurement practices among PTs in the United States. Almost all respondents (97%) reported using standardized OMs (i.e., performance-based tests and/or self-report surveys) with their patients. These findings confirm our expectation that Jette and colleagues likely underestimated the overall use of OMs among PTs, as their survey focused solely on self-report surveys and did not include questions about respondents’ use of performance-based tests [5]. Results from the present study also suggest that PTs now use self-report surveys more frequently than they did 15 years ago (i.e., more than 80% use now compared to less than 50% previously) [5]. The marked increase in the use of self-report surveys is likely driven by changes in physical therapy education standards, particularly the requirement to select and competently administer a variety of OMs during examination, evaluation, and diagnosis [15]. This educational requirement aligns with the ongoing shift toward value-based care in the U.S. healthcare system, which aims to improve the quality of patient care by rewarding positive patient outcomes [16].

PTs’ reasons for using OMs appear to be largely clinically motivated, as respondents’ most frequently endorsed reasons for using self-report surveys and performance-based tests were evaluating patient progress, informing clinical decisions, and communicating with patients. Many respondents also indicated they used both types of OMs to justify service to providers. Collectively, these findings reinforce the role that routine measurement of patient outcomes can play in value-based care [4]. Overall, few respondents described using OMs for other reasons like practice management, facility accreditation, or research. This implies that outcomes measurement may be more effective at the patient level than at the practice or profession levels. However, it should be noted that the use of self-report surveys for reasons related to practice management and research in the present study was nearly twice that reported by PTs in 2009 [5], suggesting an evolving appreciation of OMs for these practices- or profession-level activities.

Although PTs in the present study used both types of OMs with their patients, there did appear to be a notable preference for performance-based tests. In addition to a modest difference in overall utilization (i.e., 97% vs. 83%), respondents indicated they used performance-based tests more often than self-report surveys for all of the clinical activities included in the survey (Fig 1). PTs in South Korea also reported greater use of performance-based tests than self-report surveys (75.0% and 57.3%, respectively) [6], albeit with lower overall utilization than PTs in the present study practicing in the United States. Less frequent use of self-report surveys may reflect PT’s perception that these OMs offer limited value towards patient management. When compared to performance-based tests, fewer respondents in the present study viewed self-report surveys as a good use of their time (90% vs. 52%), helpful for making decisions (89% vs. 61%), or meaningful to their patients (78% vs. 47%). Similar findings reported in the literature suggest that the perceived limited value of self-report surveys remains a key barrier to their use [17]. As few respondents in the present study were willing to dedicate more than five minutes to administering self-report surveys (32%−41%) compared to performance-based tests (86–90%), these concerns appear valid. Given that many respondents in the present study perceived self-report surveys as less clinically useful than performance-based tests, efforts should be made to demonstrate their value, both individually and in combination with performance-based tests. For example, self-report measures can provide rich information about how an individual functions in their home and/or community [7,8]. Such information can then be compared to results from performance-based tests, which provide greater information about a patient’s functional capacity in a controlled environment. Collectively, these distinct but complementary pieces of information can provide a more comprehensive view of a patient’s overall functioning. Education on the purpose and benefits of self-report surveys may be useful but may not be sufficient on its own to promote widespread changes in practice habits among clinicians [18]. More comprehensive approaches (e.g., audit and feedback from management [19]) may be required to stimulate the routine use of self-report surveys in physical therapy practice.

While the large majority of respondents (95–98%) in this study reported that administration of performance-based tests and self-report surveys was within their scope of practice and could be done using knowledge they possessed, far fewer (46–48%) agreed that these measures are administered in a standardized manner across the profession. These findings are consistent with opinions recently reported by U.S. prosthetists [9], raising additional concerns about OM standardization across different healthcare professions. Evidence to substantiate concerns with the standardization of performance-based tests exists. A study of PTs working with patients with neurological conditions found wide variability in how the 6-minute walk test (6MWT) was administered, including configuration and length of the walkway, as well as how distance was measured (i.e., following the patient with a measuring wheel or counting laps of a fixed distance) [20]. Similarly, a study of prosthetists working with patients with limb loss found notable differences in walkway length, presence of potential obstacles, how distance was measured, and instructions provided to patients during administration of the 2-minute walk test (2MWT) [21]. While evidence to support respondents’ concerns of standardization with self-report surveys is limited, issues common to all OMs (e.g., time of day they are administered, patients’ exposure to recent experiences, variations in scoring methods) can still affect survey responses and scores. Given that PTs and prosthetists identified concerns with both types of OMs, future efforts should focus on obtaining cross-disciplinary consensus on standardized protocols for administering both performance-based tests and self-report surveys to patients that might be seen by clinicians from multiple disciplines.

Examination of the spaces available to PTs for outcomes measurement was also an objective of the present study. The large majority of respondents (>80%) reported access to rooms or spaces up to 10m in length, spaces sufficient for administering OMs advocated for use in physical therapy practice [22]. For example, a small room or 5-meter space can accommodate performance-based tests like the Timed-Up and Go (TUG) test [23] or the Berg Balance Scale (BBS) [24], OMs that have been used to assess basic mobility, balance, and fall risk in a range of clinical populations [25,26]. Ten-meter spaces are generally sufficient to administer tests like the 10-meter walk test (10mWT) [27], a performance-based test designed to measure walking speed – a health indicator that is widely recognized for its broad clinical utility [28]. Access to these moderately-sized spaces also allows PTs to administer components of comprehensive performance-based tests, like the Functional Gait Assessment (FGA) [29], that require patients to walk short distances under different conditions (e.g., while stepping over a small obstacle or while walking with a narrow base-of-support). The FGA is often recommended for use in PT practice, given its broad applicability to a variety of clinical populations [30]. Far fewer (≤50%) respondents in the present study had access to larger spaces, like long hallways, gyms, or spaces to run or jog. While performance-based tests rarely necessitate larger spaces, tests of walking capacity, like the 6-minute walk test (6MWT) [31], require a straight 30-meter hallway according to published protocols [32]. PTs without access to these larger spaces may be required to modify the test [20], contributing to the issues of non-standardization raised by many respondents in the present study.

Resources like stairs may also be needed to administer select OMs. Stairs are required to administer performance-based tests that include stair tasks like the FGA [29] or standalone tests of stair performance like the Timed Stair Test (TST) [33] or the Stair Climb Test (SCT) [34]. While the large majority of respondents (>80%) in the present study reported having access to stairs, only about half had access to the longer stairwells (i.e., 9 or more stairs) typically required for timed stair tests like the TST or SCT [33]. For PTs with access to only shorter sets of stairs, timed stair tests with as few as 4–6 steps are available and may be viable alternatives [35,36]. However, variability in the types and lengths of stairs available to PTs may be one reason why tests that allow flexibility in the number of stairs (e.g., the FGA [29]) are more often included among those OMs recommended for use in clinical practice [22].

Computerized administration of OMs has been advocated as a means to improve the overall ease and efficiency of outcomes measurement [5]. While only 7% of respondents in a prior study reported using computers for administering and analyzing OMs [5], data from the present study suggests that two-thirds of PTs have access to tablet computers with internet access for this purpose. This marked increase in the use of mobile devices may help promote administration of outcome measures on digital platforms that integrate with existing electronic medical records systems in rehabilitation settings [37]. Mobile devices and outcome measure applications have the potential to enhance the efficiency and reduce the administrative burden of outcomes measurement by standardizing instructions, automatically scoring OMs, generating reports, and providing the ability to directly transmit or download reports into patients’ electronic medical records. As the majority of respondents in the present study acknowledged they had limited time (<5 min) to communicate OM results to patients or document OM results in patients’ clinical records, use of mobile applications – particularly those that are directly integrated with electronic health record systems – may offer the means to more efficiently collect, convey, and document health outcomes in day-to-day practice. However, research is needed to determine whether mobile devices (i.e., tablets or smartphones) and applications can facilitate use of OMs in routine physical therapy practice.

Limitations to the present study include the targeted sample (i.e., APTA members from select special interest groups) and a relatively low (i.e., 14.3%) response rate, which may introduce a response bias, as those who chose to participate could differ systematically from non-respondents. For instance, participants may have had more exposure to or interest in the topic, which could have influenced their responses and, in turn, the study findings. Although the targeted sample size was exceeded, it is possible that the sample was biased toward PTs most interested in using OMs in clinical practice. If so, these results may overestimate the use of OMs among PTs in the U.S. However, the study included a large sample of PTs with characteristics (e.g., age, gender, race, and ethnicity) closely aligned with those reported for the profession in the APTA Practice Profile Analysis [12], suggesting that study respondents are generally representative of APTA members and PTs in the U.S. Future studies may consider strategies such as sending additional mail reminders and incentivizing respondents to complete the survey in order to improve the survey response rate. Another limitation is that most respondents worked in one of three settings (i.e., acute care hospitals, hospital-based outpatient facilities, or private outpatient offices/ group practices). Relatively few respondents worked in settings like skilled nursing or inpatient rehabilitation facilities. Thus, additional research is needed to determine if the results of this study generalize to PTs working in these settings. Lastly, this study did not investigate specific performance-based tests or self-report surveys used by PTs in routine clinical practice. Understanding which OMs are most frequently used or considered valuable for specific patient populations can enhance knowledge of current clinical practices, identify gaps in OM use, and inform strategies to optimize assessment and care across diverse patient groups. Future research should assess the type of OMs most commonly used by PTs for different patient populations, ideally identifying those with the greatest perceived value.

Conclusion

Collectively, the results of this study offer a comprehensive view of the current state of outcomes measurement among physical therapists in the United States. Almost all respondents in the present study reported using OMs with their patients, suggesting outcomes measurement has become a standard of practice in physical therapy, shaped in part by professional expectations. While the use of self-report surveys has grown over the past 15 years, they remain underused relative to performance-based tests, reflecting prevailing practice habits in physical therapy. This study highlights the perception among clinicians that self-report surveys offer limited clinical value, which may hinder their use. Efforts to support implementation should include strategies that help demonstrate the relevance of these tools in clinical decision-making.

Despite efforts by the physical therapy profession to make recommendations on OMs suited to specific patients or settings, PTs still perceive a lack of standardization with respect to how self-report surveys and performance-based tests are administered. Work is needed to obtain consensus on the specific protocols for administering these different types of OMs, ideally in partnership with other professionals who provide rehabilitation care. Improving standardization may help promote more consistent use of outcome measures in practice and support broader implementation efforts. The large majority of PTs appear to have access to the spaces and resources needed to administer performance-based tests that are often recommended for use in daily practice. Many PTs also report access to mobile devices that could be used to streamline administration, scoring, and interpretation of OMs, but research is needed to confirm that these technologies can be successfully integrated into routine care.

Supporting information

Acknowledgments

The authors would like to acknowledge Dana Wilkie and Alexandra Hinson for their assistance with data collection and verification of respondents’ state licensure.