Abstract
Keywords
Recently, the Institute of Medicine (Eden, Wheatley, McNeil, & Sox, 2008; Sox & Greenfield, 2009) publicly called for increased effectiveness research to determine the most effective and cost-efficient health care methods. This mandate corresponds to the American Occupational Therapy Association’s Centennial Vision (AOTA, 2007), in which the profession is exhorted to demonstrate through research that its services effectively help people maintain participation in work, school, and family and community roles despite illness, injury, or disability.
Sharon A. Gutman, PhD, OTR
Occupational therapy scholars have called for effectiveness and efficiency research for more than two decades (e.g., Baum, 2006; Case-Smith & Powell, 2008; Christiansen, 1983; Corcoran, 2004; Holm, 2000; Kielhofner, Hammel, Finlayson, Helfrich, & Taylor, 2004; Law, 2002; Mosey, 1996; Moyers, 2007). In this article, effectiveness is defined as an examination of practice to determine whether and how well a specific intervention works as intended. Efficiency is defined as an examination of practice to determine matters such as cost and time efficiency, safety, patient satisfaction, and patient adherence.
As a health care profession, occupational therapy has an inherent obligation to demonstrate to society that its services are effective and safe. In today’s era of health care, managed care representatives have usurped the decision-making role from health care providers (including occupational therapists) and now oversee critical decisions, such as who receives treatment, when treatment begins and ends, how often treatment is provided, and whether service reimbursement will be denied or approved (Mariner, 2000; Mattke, Seid, & Ma, 2007; Willmarth, 2005). This situation has arisen largely because, as a profession, occupational therapy (like many other health care professions) has not answered questions about treatment effectiveness and efficiency though empirical research. Without research demonstrating the effectiveness of occupational therapy interventions with specific clinical populations, occupational therapy has enabled third-party payers to decide who receives which interventions and at what time in the rehabilitation course. A body of research documenting effectiveness and efficiency is needed to provide the profession with leverage to dispute adverse third-party payer decisions and to ensure that occupational therapists are not cut from insurer and legislator lists of approved providers.
Publication Priorities
In an attempt to build the evidence base needed to meet these challenges, the American Journal of Occupational Therapy’s (AJOT’s) publication goals have been realigned to match the profession’s most needed research.
High-Quality Effectiveness Studies
AJOT seeks to publish high-quality effectiveness studies using the following designs:
Pilot or small randomized controlled trials (with or without intention-to-treat analysis)
Nonrandomized, controlled pretest–posttest designs
Crossover designs, repeated-measures designs, randomized block designs, follow-up designs
Multiple-baseline, multiple-participant, single-subject designs (>5 participants)
Feasibility studies that pilot and test preliminary outcomes
Case studies that report truly novel intervention.
When several high-quality effectiveness studies exist for a specific intervention with a homogeneous population, systematic reviews or meta-analyses can then be performed to determine a consensus regarding best practice. Systematic reviews and meta-analyses are considered to be the highest level of evidence (Akobeng, 2005). As researchers increasingly implement studies with higher levels of experimental rigor, AJOT will begin to reduce the number of case studies and Level V evidence. Only case studies describing truly novel interventions will be considered for publication.
Efficiency Studies
AJOT also seeks to publish efficiency studies on the following topics:
Cost and time efficiency
Patient satisfaction
Safety
Patient adherence and tolerance.
Efficiency studies can be implemented through secondary analysis of large datasets or through individual studies carried out with the intent to answer specific questions about the preceding bulleted items.
Preliminary Qualitative Needs Assessments for Patients and Caregivers
Needs assessments that unearth unique information about the clinical needs of nontraditional populations and that identify emerging occupational therapy roles are valued by the journal. The in-depth exploration of a particular population’s clinical needs is often best examined through qualitative methods that allow a rich understanding of a group’s experience. Examples of populations that could benefit from newly emerging or nontraditional occupational therapy services include children and adolescents in the school system with behavioral and emotional disorders and elderly people who require driving safety reevaluation and rehabilitation secondary to disease or disability.
Studies Showing a Correlation Between Occupational Engagement and Specific Health Status Indicators
Perhaps one of the greatest potentials of occupational science is the demonstration of relationships between participation in desired occupations and positive health benefits. Some of this research has been generated outside of the profession. For example, a growing body of research has shown a direct positive correlation between engagement in everyday cognitive tasks requiring the brain to prune and generate new neuronal connections and cognitive preservation into old age (Ball et al., 2002; Singh-Manoux, Richards, & Marmot, 2003). AJOT’s editorial board greatly desires studies that reveal a link between participation in occupation and the promotion of health (using specific health status indicators).
Studies Establishing the Psychometric Properties of Occupational Therapy Instruments
A long-time priority of AJOT has been the publication of studies that describe the development and testing of occupational therapy instruments. Without reliable and valid instruments, occupational therapists would be unable to measure the effectiveness of intervention. This publication priority will remain critical as the profession strives to build the body of evidence needed to support the effectiveness and efficiency of practice.
Analysis Articles Exploring a Currently Debated Topical or Professional Issue (The Issue Is Articles)
The Issue Is department is intended to provide scholars with a forum in which to debate professional issues that have significant impact on the profession’s direction and growth. Examples of past and current topical questions include the following:
Should the entry-level practice degree be a master’s degree or a doctorate?
Should the American Council for Occupational Therapy Education endorse the removal of the hard sciences (e.g., anatomy, neuroscience, and kinesiology) from occupational therapy curricula for alternate placement of those courses at the undergraduate, prerequisite level?
Should the American Occupational Therapy Foundation use limited funds to support research that cannot contribute to the evidence base regarding practice effectiveness and efficiency?
Because the Issue Is department is one of the only written forums in which scholars can openly debate a topical issue, this type of discussion article will remain a key publication priority.
Qualitative, Quantitative, or Mixed Methods?
The question of whether to use a qualitative, quantitative, or mixed-method design depends on the type of research question. Quantitative designs best answer research questions about intervention effectiveness and cost and time efficiency. Quantitative designs are also needed to demonstrate correlations between occupational engagement and health and to establish levels of reliability and validity of instruments.
Mixed-method designs often best answer questions about safety, patient satisfaction, adherence, and tolerance. Mixed-method designs can also provide important information about the effectiveness of novel interventions for which the patient perspective has not been previously examined.
Qualitative designs best answer questions about the clinical needs of patients and caregivers who make up novel populations for which occupational therapy services are newly emerging.
The type of research method should be chosen only after the research question has been generated. AJOT does not favor one research method over another. Instead, the Editorial Board seeks research that matches the previously described priorities and studies in which the research method best allows the research question to be answered.