Data mining: gathering data from a pediatric occupational therapy practice

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DATA MINING:
GATHERING DATA FROM A PEDIATRIC OCCUPATIONAL
THERAPY PRACTICE

by

Kailey Ellis

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(OCCUPATIONAL THERAPY)

May 2016

2
Table of Contents
Abstract ........................................................................................................................................... 3
Introduction ..................................................................................................................................... 3
Research Questions ......................................................................................................................... 5
Methods........................................................................................................................................... 5
Results ............................................................................................................................................. 6
Table 1: Most Common Interventions used in 171 Clients with ASD ..................................... 7
Breakdown of Interventions ............................................................................................................ 7
Neurodevelopmental Treatment: ................................................................................................ 7
Oral Motor/Feeding Intervention: ............................................................................................... 7
Figure 1: Oral Motor/ Feeding Interventions in 63 clients with ASD ................................... 8
Behavioral Intervention .............................................................................................................. 8
Figure 2: Behavioral Interventions used in 147 clients with ASD ......................................... 9
Sensory Integration Treatment: ................................................................................................... 9
Figure 3: SIT Adaptive Responses in 159 clients with ASD ................................................. 10
Developmental/ Sensory Motor Intervention ............................................................................ 10
Figure 4: Developmental/Sensory Motor Intervention in 162 clients with ASD ................. 11
Combinations of Interventions ...................................................................................................... 11
Table 2: Combinations of Interventions used in clients with ASD ....................................... 12
Discussion ..................................................................................................................................... 12
Conclusion .................................................................................................................................... 13
References ..................................................................................................................................... 14

3
Data Mining: Gathering Data from a Pediatric Occupational
Therapy Practice
Abstract
Objectives: Examine patterns of occupational therapy interventions for clients with Autism
Spectrum Disorder (ASD).
Method: Retrospective analysis of electronic treatment notes gathered in a community pediatric
occupational therapy clinic. Descriptive statistical analysis was used to identify the most
common occupational therapy intervention approaches utilized with clients with ASD.
Results: Out of the 420 clients and 8,689 notes, a total of 171 clients and 2,677 treatment notes
met the inclusion criteria. Either singularly or in combination with other interventions, Sensory
Integration Treatment (SIT), Developmental/Sensory Motor, and Behavioral interventions were
used in more than half of all the treatment sessions by occupational therapists. The other
intervention approaches commonly utilized included: Neurodevelopmental Treatment (NDT),
and Oral Motor. In addition, these combinations of interventions were also used by occupational
therapists: NDT and Oral-motor interventions, SIT and NDT, SIT and Interventions focusing on
oral-motor skills, SIT and Cognitive approaches, SIT and Behavioral.
Conclusion: Using a web-based program, data mining proves to be an efficient way to examine
daily occupational therapy practice in clients with ASD. This type of record keeping can ease
the burden of documentation and allow practitioners to analyze their own data from everyday
clinical treatments.
Introduction

The number of children with Autism Spectrum Disorder (ASD) is constantly evolving
and has intensified the demand for effective interventions (Wong, et al., 2015). The increasing
number of children with ASD may ultimately impact the amount of children requiring
occupational therapy services. According to estimates from CDC's Autism and Developmental
Disabilities Monitoring (ADDM) Network, it has been estimated 1 in 68 children has been
identified with ASD (Baio, 2014). Understanding and implementing efficient treatment is
paramount in allowing these children to grow up and become successful adults in our society.
Therefore, occupational therapists and other service providers would benefit from being aware of
their practice patterns and staying current on the most widely used interventions for clients with
ASD. In this study we examine intervention patterns in a clinic setting by mining electronic
treatment notes with the purpose of providing a guide for therapists that may help them
determine an intervention for clients with ASD.
As we confront this potentially growing concern, the need for evidence in supporting
daily practice has been identified as of high importance in all health professions including
Occupational Therapy (AOTA Centennial Vision, 2006). Researchers have identified that the
4
best evidence is obtained from Randomized Controlled Trials (RCT) with large number of
patients (Barton, 2000). However, due to RCT’s being costly and difficult to implement, other
alternatives need to be explored (Sanson-Fisher, Bonevski, Green, & D'Este, 2007). These
alternatives need to be equally effective, as well as more clinician friendly, so as to not detract
from the quality of treatment that each patient deserves. Thus, one such alternative for collecting
evidence has been to reassess the type of documentation used by therapists and how it can be
improved.
Recently, the quality of paper documentation has been challenged and a move to
electronic record keeping has been advised (Newgard, Zive, Jui, Weathers, & Daya, 2012).
Having instant access to electronic health records allows occupational therapists access to data
and interventions used in previous therapy sessions. Now, with the enormous amounts of data
stored in these databases, it is becoming necessary to develop a means for analysis and extraction
of meaningful data that could help in the decision-making process of the OT in their proposed
treatment plan.
Since the emergence of electronic record keeping and data mining, clinics have a way to
collect data in a structured manner that allows them to later analyze their own practice methods
more systematically and at a potentially faster rate than if the records were on paper. The
purpose of this study is to analyze a community pediatric Occupational Therapy practice by
mining their existing electronic database in order to assess the most widely used interventions in
clients with ASD.
Therapists must stay abreast of research evidence, as well as new developments in
methods of collecting data, in order to access and integrate the most widely used interventions
from daily practices. Horn and colleagues (2012) created a novel method of gathering evidence
from daily practice called Practice Based Evidence (PBE). This new method is an alternative to
RCT. With PBE, practitioners are able to collect data from daily practice that can be translated
into research findings. In this method, interveners are provided with a systematic manner to
collect data that are later utilized to examine the effectiveness of specific practice methods. Horn
and colleagues (2012) studied the strengths and weaknesses of various research methods, which
included RCT, traditional observational methods, and PBE. It was determined that the natural
limitations found in RCTs and Observational Method, such as small sample size and selection
biases, may be alleviated in PBE. Horn and Gassaway (2007) came to the conclusion that
through PBE the researcher can examine interventions that are effective and useful in a clinical
setting. RCTs are important for determining if a new intervention or treatment will be successful
in practice but, unlike PBE, are generally unable to identify the effectiveness of intervention
combinations (Horn & Gassaway, 2007). To truly realize the benefits of patient-centered care,
the health care community needs to be able to analyze their own data (Epstein, Fiscella, Lesser,
& Stange, 2010). Therefore, developing structured ways to collect data and using them to
analyze current practice will be an efficient way to prepare for a PBE study and an effective
guideline for maximizing patient care within that clinical setting.

5
Research Questions

In the process of analyzing the data, these research questions were identified and used to
guide the data analysis process:
• What are the most common interventions utilized in clients with ASD?
• What combinations of interventions were most widely used by occupational therapists in
clients with ASD?
Methods

This is a retrospective analysis of data within a community pediatric occupational
therapy clinic. The community pediatric clinic used in this study provides occupational,
physical, and speech/language therapy in the home, school, and community. The clinic was
built around the philosophy of contemporary research, intervention trends, and health
education policy. Their occupational therapists have advanced training and specialized
certifications in sensory integration, neurodevelopmental treatment, and feeding to address
concerns of a child’s ability to actively participate in daily activities.
The purpose of this study was to gain an understanding of the intervention methods
utilized in everyday pediatric practice by analyzing 2,677 electronic treatment notes from 19
therapists treating 171 pediatric clients with ASD. The present descriptive study is comprised
of the following three stages:

Stage One: Analysis of FileMaker Pro Data Collection

In this study, we used the database from a community pediatric clinic utilizing Metrics
(Sensory Metrics, 2014), a systematized electronic note writing system. Metrics is a pediatric
occupational therapy note writing program that requires clinicians to identify the intervention
approaches utilized, the treatment modalities utilized within each treatment approach identified,
and the number of minutes in each session that the treatment approach identified was utilized.
The note writing program was developed utilizing the database platform FileMaker Pro®.
Metrics is in a testing phase.
The initial analysis of Metrics data in FileMaker Pro® format was comprised of 8,689
entries collected from March 1
st
, 2013 to December 31
st
, 2015. A total of 2,677 treatment notes
met the inclusion criteria and were transferred to Excel for analysis. The data chosen for analysis
in this study included an ASD diagnosis and the following main categories of interventions:
Behavioral, Developmental/Sensory Motor, Sensory Integration, Oral Motor/Feeding,
Neurodevelopmental Treatment.
Behavioral interventions methods included the use of reinforcement, extinguishing, and
backward chaining. Sensory Integration Treatment was differentiated from other sensory based
approaches and included the identification of the sensory experiences utilized and the adaptive
responses addressed. Sensory motor focused on visual processing, fine motor/hand use, and daily
6
activities. Oral Motor interventions were separated into 4 categories: eating/feeding, oral motor
movements, textures utilized, and food groups utilized. NDT interventions included the use of
alignment/weight bearing, postural control in place, alignments, transportation/movements in
space, and reach/grasp/release/carrying.

Stage Two: Cleaning and transferring of Data

The first step in stage two was to review the data, then place it into appropriate
categories. Entries that did not meet the criteria listed below were deleted and excluded from the
study.
• Treatment sessions from March 1
st
, 2013 to December 31
st
, 2015
• Must have a diagnosis of Autism Spectrum Disorder
The second step entailed the placement of notes into 5 different pre-established categories
and 5 combinations of pre-established categories based on their specific intervention(s). These
categories include:
• Sensory Integration Treatment (SIT)
• Neurodevelopmental Treatment (NDT)
• Oral Motor Interventions
• Behavioral Interventions
• Developmental/ Sensory Motor
• NDT and Oral Motor Interventions
• SIT and NDT
• SIT and Oral Motor Interventions
• SIT and Cognitive
• SIT and Behavioral Interventions
Stage Three: Descriptive Statistical Analysis

In this study, descriptive statistical analysis was used to present the categorized data in a
more organized way, which allowed a simpler, yet effective interpretation of the data trends.
Patterns of the most widely used interventions emerged after the data was sorted and placed into
charts and tables.
Results

Table 1 presents the 5 most common interventions used in this study, number of clients,
and number of notes per intervention. The following 3 interventions emerged as the most widely
used interventions in clients with ASD: Behavioral interventions, Developmental/Sensory Motor,
and Sensory Integration Treatment (SIT). Oral Motor Intervention and Neurodevelopmental
7
treatments, were the least commonly used interventions in this client pool.
Table 1: Most Common Interventions used in 171 Clients with ASD
Intervention Number of Clients Number of Notes
Neurodevelopmental
Treatment 49 1,390
Oral Motor 63 1,422
Behavioral 147 2,591
Sensory Integration Treatment 159 2,650
Developmental/Sensory Motor 162 2,662

Breakdown of Interventions

As a reference to Table 1, the following section describes the breakdown of each
intervention use and what the therapist worked on during the treatment sessions.
Neurodevelopmental Treatment: Based on the child’s range of motor skills and responses, NDT
intervention as used in the Database that refers to the treatment approach originally developed by
the Bobath’s to address movement and posture (Knox & Evans, 2002). In this study, it was noted
that 49 out of 171 clients with ASD received NDT as part of an intervention. This intervention
focuses on 6 treatment strategies used in NDT. Out of the 1,390 treatment notes, clients worked
on the following:
• Alignment/ Weight bearing—65 treatments from 46 clients
• Postural control in place—45 treatments from 35 clients
• Alignments—11 treatments from 9 clients
• Transportation/ movements in space—11 treatments from 10 clients
• Reach/ grasp/ release/ carrying—6 treatments from 6 clients
• Gait training—0 treatments from a total of 0 clients
During the data mining process, it was apparent that NDT had the least amount of
treatment notes documented. In 171 clients with ASD, 49 clients received NDT as part of the
intervention, compared to 159 clients that received SIT intervention. However, of those who did
require NDT, it was found that most therapists focused on Alignment/Weight Bearing as the
main type of NDT intervention. As movement and posture were not part of the core symptoms
in children with ASD, the lower number of children receiving this type of interventions is
expected.

Oral Motor/Feeding Intervention: Oral Motor/Feeding Intervention is an important aspect of
this study because clients with ASD may exhibit both oral hypersensitivity and oral motor
8
difficulties. During this type of intervention, occupational therapists include foods or flavors to
stimulate taste receptors as well as facilitate the integration of both sensory and motor skills for a
functional response (Case-Smith & O’Brien, 2010). In this data analysis, 63 clients received oral
motor/feeding as an intervention. It was recorded that oral motor/feeding had 1,422 treatment
notes out of the 2,677 notes. Figure 1 illustrates the breakdown of 4 oral motor/feeding
intervention types: eating/feeding, oral motor movements, textures, and food groups utilized and
the number of clients that received each intervention.
Figure 1: Oral Motor/ Feeding Interventions in 63 clients with ASD

Therapists addressed oral motor/feeding issues in 63 clients with ASD. The most
common oral motor difficulty targeted out of the 1,422 notes was eating/feeding with 130
treatment notes gathered from 48 clients.
Behavioral Intervention: It was determined that 147 clients with ASD received some type of
behavioral intervention during all treatment sessions. There were 3 types of behavioral
interventions used for clients with ASD. These types included the following: Backward chaining,
Reinforcing, and Extinguishing. It was shown that reinforcing was the most widely used
intervention for behavioral interventions.
9
Figure 2: Behavioral Interventions used in 147 clients with ASD

Figure 2 illustrates that out of the 2,591 treatment notes, 681 notes from 143 clients fell under
the category of reinforcing, followed by extinguishing with 552 treatment notes from 134 clients,
and then backward chaining with 187 treatment notes from 96 clients. Children with ASD often
require additional behavioral approaches, such as Applied Behavior Analysis (ABA) (Hagopian,
Hardesty, & Gregory, 2005).

Sensory Integration Treatment: This type of intervention is based on the understanding that
disruptions in neurodevelopmental processing and integration of sensory information disrupt the
formation of purposeful behaviors (Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011).
In SIT, occupational therapists provide the client with a controlled sensory experience, so an
adaptive response is produced. Sensory integration and adaptive responses are the building
blocks for vestibular, tactile, proprioceptive, and visual perception development, which enhance
the child’s maturation and foundational skills (Case-Smith & O’Brien, 2010). In this study, 159
out of 171 clients with ASD had treatment involving a sensory experience. In this intervention,
the 4 main types of input utilized included:

• Vestibular Integration- 559 treatment notes from 125 clients
• Vestibular Input- 1,176 treatment notes from 140 clients
• Tactile Input- 535 treatment notes from 132 clients
• Tactile Tolerance- 167 treatment notes from 85 clients
• Proprioceptive Input- 1,262 treatment notes from 155 clients
• Proprioceptive Discrimination- 310 treatment notes from 103 clients
• Visual Perception-112 notes from 65 clients
Through the use of data mining, as Figure 3 illustrates, it was revealed that the most
common adaptive responses utilized, within the SIT modality, were the organization of behavior,
fine motor/ handwriting, and motor planning-feedback. It was noted that all clients received
some form of Sensory intervention. Figure 3 also illustrates the SIT adaptive responses targeted
10
with clients with ASD.

Figure 3: SIT Adaptive Responses in 159 clients with ASD

Figure 3 demonstrates that more than half of the treatment notes included Organization of
Behavior, Fine Motor/Handwriting, and Motor Planning-feedback related gross motor.
Developmental/ Sensory Motor Intervention: The development of visual processing and fine
motor/hand skills is crucial to an individual’s ability to perform well on daily living tasks.
Clients with ASD are able to detect sensory signals from muscles and joints but there is often a
disconnect when interpreting and integrating the information from the senses when completing
motor plan actions (Versfeld, 2014).
11
Figure 4: Developmental/Sensory Motor Intervention in 162 clients with ASD

In this study, the most widely used intervention was Developmental/Sensory Motor with
162 clients. This type of intervention included 3 types of intervention focus: visual processing,
fine motor/hand use, and activities of daily living. It was found that the therapist used Fine
Motor/Hand Use intervention in 1,319 treatment sessions from 159 clients. Out of the 2,662
notes, 592 treatment notes from 131 clients focused on activities of Daily Living and 126
treatment notes from 77 clients worked on Visual Processing.
Combinations of Interventions

Though singular treatment modalities can often times be effective in many clients, there
are those more complex cases where a combination approach of various treatments becomes
necessary. It would be very easy if our clients fell into diagnoses where a singular therapy could
be implemented, but the clients with ASD can be more complex than that. Often times we
encounter varying diagnoses and thus, combinations of therapy become vitally important in our
strategy to help treat these clients with ASD.
Descriptive statistical analysis revealed that many clients with ASD received multiple
interventions. The treatment combinations included the following 5 interventions: NDT and
Oral, SIT and NDT, SIT and Oral, SIT and Cognitive, SIT and Behavioral.

12
Table 2: Combinations of Interventions used in clients with ASD
Intervention
Number of
Clients Number of Notes
NDT and Oral 31 933
SIT and NDT 49 1,394
SIT and Oral 62 1,420
SIT and
Cognitive 124 2,419
SIT and
Behavioral 139 2,570

Table 2 shows the combination of interventions used, number of clients and number of notes.
The most widely used combination was SIT and Behavioral with 139 clients with 2,570
treatment notes, followed by SIT and Cognitive with 124 clients with 2,419 treatment notes.
Discussion

The highly complex, specialized area of occupational therapy challenges the therapist to
synthesize information from many sources in order to keep up with the advancing demand for
effective and efficient treatment. In this study, we provide evidence that supports the use of data
mining as a way to aide practitioners to analyze their practice preferences. After examining the
data, it was revealed that most clients with ASD were treated with Developmental/Sensory
Motor, SIT, and Behavioral interventions. In addition, it was noted that SIT was the most widely
used type of intervention when used in tandem with another intervention such as Behavioral,
NDT, Oral Motor/feeding, Cognitive and Developmental/Sensory Motor.

One limitation of the study includes reliance on therapists entering the data. For example,
it was observed during the initial analysis that some of the therapists were not consistent in their
record keeping. Many clients had blank treatment notes and some of the diagnoses were either
left blank or labeled with N/A. These inconsistencies in record keeping excluded some of the
clients from meeting the criteria for this study and thus reducing the sample size. Another
limitation of this study is that the pediatric OT clinic in which the data was collected specializes
in Sensory Integration. This specialization can potentially cause intervention bias, which may
effect the data results. Finally, the age and gender of the client was not part of the information
when the data were collected. The age of the client will also have an impact on the success of the
intervention, as what works well on a 4-year-old may not be appropriate for a 13-year-old, and
the number of minutes that each intervention was utilized was not taken into account in this
analysis. The results are primarily intended to assess what types of interventions are generally
employed.
13
Conclusion

The primary concern when treating clients with ASD is trying to deduce what
intervention(s) are going to be introduced and implemented. ASD is not a definitive disorder that
one simple entity can treat. Rather, it is an extremely complex disorder that is as unique as the
patient itself. This data analysis evaluates the intervention options and provides a reference for
the practitioner as to what therapy was most widely used in this community pediatric practice. It
can be concluded that in varying degrees, clients with ASD received intervention in the
following categories: developmental/sensory motor, sensory integration, behavioral, oral
motor/feeding, and neurodevelopment treatment. Developmental/sensory motor, sensory
integration, and Behavioral motor were used 2-3 times more frequently than oral motor/feeding
and neurodevelopmental therapies. Also, due to the complexity of ASD, singular interventions
are not always the best option. Using a combination of various interventions can enhance the
care for the patients, allowing the therapist to address multiple issues at once. Since there are
symptoms that could interrelate to each other, often times combined therapy will collectively
manage them more effectively. Therefore, it is important to look at the most widely used
intervention patterns in everyday occupational therapy practice. Descriptive statistical analysis
will give occupational therapists the opportunity to highlight the patterns of treatment modalities
through the use of data mining. This type of data collection and analysis has the potential to
enhance the efficiency of daily practice in a pediatric occupational therapy practice. I believe that
the findings of this study will offer the support that is needed for continued research and
development of data mining in association with Practice Based Evidence.
14
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Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States,
2010. Retrieved from
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Barton, S. (2000). Which clinical studies provide the best evidence?: The best RCT still trumps
the best observational study. BMJ : British Medical Journal, 321(7256), 255–256.
Case-Smith, J., & O'Brien, J. C. (2010). Occupational therapy for children (6th ed.). Maryland
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Epstein, R., Fiscella, K., Lesser, C., & Stange, K., "Why the nation needs a policy push on
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Hagopian, L., Hardesty, S., & Gregory, M. (2005). Applied behavior analysis: overview and
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programs/neurobehavioral-unit-nbu/applied-behavior-analysis

Horn, S., Dejong, G., & Deutscher, D., "Practice-based evidence research in rehabilitation:
an alternative to randomized controlled trials and traditional observational studies."
Archives of Physical Medicine and Rehabilitation 93.8 (2012): n.pag. Web.

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Knox, V., & Evans, A. L. (2002), Evaluation of the functional effects of a course of Bobath
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Abstract (if available)

Abstract Objectives: Examine patterns of occupational therapy interventions for clients with Autism Spectrum Disorder (ASD). ❧ Method: Retrospective analysis of electronic treatment notes gathered in a community pediatric occupational therapy clinic. Descriptive statistical analysis was used to identify the most common occupational therapy intervention approaches utilized with clients with ASD. ❧ Results: Out of the 420 clients and 8,689 notes, a total of 171 clients and 2,677 treatment notes met the inclusion criteria. Either singularly or in combination with other interventions, Sensory Integration Treatment (SIT), Developmental/Sensory Motor, and Behavioral interventions were used in more than half of all the treatment sessions by occupational therapists. The other intervention approaches commonly utilized included: Neurodevelopmental Treatment (NDT), and Oral Motor. In addition, these combinations of interventions were also used by occupational therapists: NDT and Oral-motor interventions, SIT and NDT, SIT and Interventions focusing on oral-motor skills, SIT and Cognitive approaches, SIT and Behavioral. ❧ Conclusion: Using a web-based program, data mining proves to be an efficient way to examine daily occupational therapy practice in clients with ASD. This type of record keeping can ease the burden of documentation and allow practitioners to analyze their own data from everyday clinical treatments.

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Asset Metadata

Creator Ellis, Kailey (author)

Core Title Data mining: gathering data from a pediatric occupational therapy practice

School School of Dentistry

Degree Master of Arts

Degree Program Occupational Therapy

Publication Date 04/18/2016

Defense Date 04/15/2016

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag ASD,autism spectrum disorder,data mining,electronic record keeping,FileMaker Pro,metrics,OAI-PMH Harvest,Occupational Therapy,sensory integration interventions,sensory integration treatment,SIT

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Blanche, Erna (committee chair), Bodison, Stefanie (committee member), Thompson, Barbara (committee member), Vigen, Cheryl (committee member)

Creator Email kaileyel@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-229430

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