Comparing Outcomes of Voice Therapy - Stimm-und-sprachtherapie ...

Comparing Outcomes of Voice Therapy: A 

Benchmarking Study Using the Therapy Outcome 

Measure 

*Alexandra John, *Pamela Enderby, and †Anthony Hughes 

Sheffield and Bristol, United Kingdom 

Summary: The quality cycle requires clinicians to assess the outcomes of 

interventions. Benchmarking is an approach that has been advocated to compare 

current performance across different services to identify commonalities 

and significant differences. This article gives the results of a study of outcomes in 

speech and language therapy (SLT) using the therapy outcome measure (TOM) 

for patients with voice disorder (dysphonia) comparing outcomes of seven 

separate speech and language therapy services. The study aimed to identify 

the similarities and differences in outcomes of care provided by different 

services. Two hundred and forty patients with dysphonia (age range 3–87.5 

years, average 51.9 years) were treated. The results indicated that although 

there was no significant difference in the profile of the severity of symptomology 

of patients referred to speech and language therapy in different geographical 

areas, there was a significant difference in the treatment outcomes across the 

services and in the stated reason for discharge from treatment. Nevertheless, 

most patients with dysphonia had a good outcome and this was associated 

with completion of the course of treatment. There were significant differences 

in the number of treatment contacts provided by the different services and in the 

duration (between admission and discharge) of treatment across the services. 

Benchmarking can provide useful information through use of routinely collected 

clinical data. 

Key Words: Benchmarking—Speech and language therapy—Therapy outcome 

measures—Voice outcomes. 

Accepted for publication January 26, 2004. 

From the *The University of Sheffield, United Kingdom; 

†Speech and Language Therapy Research Unit of North Bristol 

NHS Service, United Kingdom. 

Address correspondence and reprint requests to Alexandra 

John, Research Associate, University of Sheffield, Institute of 

General Practice and Primary Care, Community Sciences Centre, 

Northern General Hospital, Herries Road, Sheffield S5 7AU, 

UK. E-mail: a.k.john@sheffield.ac.uk 

Journal of Voice, Vol. 19, No. 1, pp. 114–123 

0892-1997/$30.00 

2005 The Voice Foundation 

doi:10.1016/j.jvoice.2004.01.008 

INTRODUCTION 

Political imperatives resulting from the U.K. 

Government White Paper “The NHS: Modern and 

Dependable” 1 have placed an emphasis on quality 

improvement, and to this end, different strategies 

have been put in place to promote the better use 

of existing resources (White Paper: “A First Class 

Service” 2 ). Clinical governance has been placed as a 

framework for such quality improvement, and 

although much of health care monitors outcomes 

and quality implicitly, there is a move to ensure 

114

THERAPY OUTCOME MEASURE 115 

that all health care professionals actively monitor 

quality and effectiveness of their services in an explicit 

and coordinated fashion. This would ensure 

that services provide appropriate interventions and 

that variable quality is identified to improve confidence 

to users and purchasers of services. 

Swange 3 identified five areas to address to improve 

the quality of health services: the culture of 

the organization, inequity and variability in the provision 

of services, involvement of users, sharing 

good practice, and detecting and dealing with poor 

performance. Benchmarking can assist with four of 

these areas by making comparisons to identify best 

practice, providing a baseline for a repeated measure, 

facilitating the capacity to learn from variation, 

and contributing to the knowledge base. It has utility 

in the absence of other information on, for example, 

what works best for whom, and when relationships 

between processes and outcomes of care are not 

well understood. 4,5 

Benchmarking begins with the identification of 

the specific area of the service to be investigated 

and compared. It requires four fundamental steps: 

planning the study, collecting the data, analyzing 

the data, and adapting services. 6 For valid comparisons 

to be made, it is essential that suitable process 

and outcome indicators are selected and data are 

collected in a systematic way. 7 

Health services internationally have a longer tradition 

of using benchmarking in financial and nonclinical 

services. 8 However, when it has been used 

for clinical practice, it has been found to be a useful 

tool. 9,10 In speech and language therapy, the few 

benchmarking studies reported in the literature have 

focused on internal benchmarking of services 11,12 

rather than external benchmarking, which compares 

one service against other services. 

This article describes the results of one client 

group studied within a larger benchmarking exercise, 

whichusedthetherapyoutcomemeasure(TOM) 13,14 

as an outcome indicator to compare the outcomes of 

speech and language therapy for individuals with a 

voice disorder across different United Kingdom 

National Health Service (NHS) Speech and Language 

Therapy Service sites. 

This study aimed to investigate the question 

whether there was variability between seven sites 

offering speech and language therapy services for 

people with a voice problem in terms of their severity 

on entry to treatment, if they changed in similar 

ways during treatment and whether they had similar 

profiles in terms of abilities and/or difficulties 

on discharge. The study addressed only the first three 

steps of benchmarking—planning, data collection, 

and analysis. The results of the analysis were fed 

back to the speech and language therapy services 

in each of the Services. How the services used 

this information and what changes resulted are not 

reported in this article. 

METHOD 

This benchmarking study was designed as a longitudinal 

cohort study covering a 20-month period. 

Voice specialists from seven speech and language 

therapy services were recruited. Service A provided 

a children’s service and Service B an adult service. 

The other Services covered both children and adults 

from the populations that they served. 

The TOM was selected as the outcome indicator. 

This is a single measure with four dimensions, specifically 

the Impairment (the degree of severity of 

the voice disorder), Disability/Activity (the degree 

of limitation in use of voice to communicate), Handicap/Participation 

(amount of disadvantage to social 

participation), and Well-being of the patient (affect 

on emotion/level of distress). The first three dimensions 

are based on the WHO ICIDH. 15 The speech 

and language therapists (SLTs) were trained to use 

their clinical judgment based on the assessment and 

case history to rate the patient independently on each 

of these four dimensions. Each TOM dimension has 

an ordinal 11-point rating scale. Each scale has six 

integers defined by operational descriptors (see 

example in Appendix) with undefined half points 

that are included to increase the sensitivity of the 

measure. The development and psychometric properties 

of the TOM have been described in the 

Therapy Outcome Measures: Speech & Language 

Pathology Technical Manual. 14 The measure allows 

a quick, reliable representation of a clinician’s view 

of the speech and language condition and its impact. 

The participating speech and language therapists 

were adequately trained in the use of TOM 16 and 

achieved good levels of inter-rater reliability. 

Journal of Voice, Vol. 19, No. 1, 2005

116 

ALEXANDRA JOHN ET AL 

TABLE 1. Number, Percentage, Mean Age and Age Range for “All Cases” and Cases by Service 

Voice disorder Service A Service B Service C Service D Service E Service F Service G All cases 

Number of cases 5 68 29 46 6 46 40 240 

Percentage 2.1% 28.3% 12.1% 19.2% 2.5% 19.2% 16.7% 100% 

Mean age*** 14.6 56.8 51.9 50.2 49.6 46.5 51.7 50.3 

Age range 11.9–16.5 28.4–87.6 18.4–79.6 7.2–78.3 3–82.8 10–76.6 5.62–86.7 3.1–87.6 

***p 0.001. 

The speech and language therapists used the TOM 

to rate consecutive new cases on admission to treatment, 

at the end of each episode of care and on 

discharge from therapy. 

The analysis of the data aimed to answer the 

study questions. 

Do clients have an equal opportunity of accessing 

voice therapy regardless of where they are 

treated? 

Does the application of voice therapy produce 

similar changes in clients’ abilities and/or disabilities, 

regardless of where the treatment is 

provided? 

Do clients have similar profiles of abilities and/ 

or disabilities on discharge regardless of where 

they are treated? 

Is there a difference in the quantity and duration 

of treatment and is this associated with amount 

of change? 

Ordinal data were analyzed using a Kruskal– 

Wallis statistic, and interval data were analyzed 

using ANOVA. 

RESULTS 

At the end of the 18-month data collection period, 

TOM data for 240 cases had been coded by the SLTs 

as having a voice disorder. Of these, although 183 

(76%) had completed their treatment, 57 (24%) were 

still in treatment at the end of the study period. 

Table 1 shows the numbers of cases entered by each 

participating Service. 

There were a number of etiologies associated with 

dysphonia requiring a referral to speech and language 

therapy (see Figure 1). The diagnosis was 

provided by the SLTs from their clinical records and 

denotes SLT opinion based on assessment and 

medical information. Vocal misuse represented the 

largest group. 

Results related to Question 1 

Do clients have an equal opportunity 

of accessing voice therapy regardless of where 

they are treated? 

To address the first study question, the analysis 

investigated the age of patients on admission to treatment 

and the initial ratings for all patients (to act as 

a benchmark and, by Service, to provide comparison 

with the overall benchmark). The age profile is 

shown in Table 1. 

The median age on entry to treatment for all patients 

was 51.9 years with an overall range of 3.1– 

87.6 years. The data analysis found a significant 

difference across the Services in the age of patients 

on entry to treatment (ANOVA F 4.0; df 6; p 

0.001). This may be explained, in part, by Service 

A providing services only to a pediatric population, 

whereas Service C did not rate any pediatric patients 

during the study. The other Services (B, D, E, F, C) 

showed a more similar profile of ages (within a 6- 

year spread of ages). The initial TOM admission 

ratings showed variation with age. There was a 

tendency for the younger patients to have a higher 

initial rating on Participation and Well-being than 

older patients. Analysis showed a significant difference 

in the age of patients on admission to treatment 

and the initial start rating on Disability/Activity 

(Kruskal–Wallis H 104.5; df 73; p 0.009) and on 

Participation (Kruskal–Wallis H 93.5; df 73; p 0.05). 

However, there were no significant differences in the 

age of patients on admission and contacts or for age and 

duration of treatment for those completing treatment. 

Inspection of the data for patients with a structural 

voice pathology showed a tendency for patient to 

have a lower initial rating than the other conditions 

causing dysphonia, but this was not statistically significant. 

The analysis of the initial admission ratings 

data for all patients with dysphonia did not indicate 

any significant difference across the Services on 



FIGURE 1. Etiologies associated with voice disorders. 

the dimensions of Impairment, Disability/Activity, 

and Participation/Handicap, although there were 

significant differences on the Well-being (Kruskal– 

Wallis H 12.8; df 6; p 0.04). Table 2 shows the 

mean, median, and range of the initial admission 

ratings for the Services. 

The results of analysis indicate that patients 

tended to enter treatment for voice therapy at similar 

points on the TOM with the exception of Well-being. 

This suggests that there was equity of access to 

treatment for patients with a voice disorder across 

these Services. The results do not indicate that the 

severity of the dysphonic condition, as rated on 

the TOM, produced any inequality in a client’s opportunity 

to access voice therapy. 


Does the application of voice therapy produce 

similar changes in clients’ abilities and/or 

disabilities, regardless of where the 

treatment is provided? 

Most patients made positive progress during 

treatment; a few made a negative change; and some 

sustained their positions on the rating scale; of 

these, the dimension of Participation had the highest 

number of patients sustaining the initial rating. The 

patients who were rated at “5” at the start and end 

of treatment (in other words, had no difficulties on 

this dimension) were subtracted from the total sustained 

and the number shown in brackets in Table 

3. The number of patients showing positive improvement, 

sustaining their TOM rating, or changing negatively 

were analyzed using the Kruskal–Wallis 

statistic. There was a significant difference across 

Services on Impairment (Kruskal–Wallis H 13.2; df 

6; p 0.04) and a significant difference on Participation 

(Kruskal–Wallis H 24.7; df 6; p 0.0001). On 

this measure, the TOM ratings showed no significant 

differences between the Services on the dimensions 

of Disability/Activity, and Well-being. The dimension 

of Participation showed many patients (42%) 

were not rated as experiencing social disadvantages 

as a result of their dysphonia. The study findings indicated 

that most patients made a positive change 

and that the application of voice therapy produced 

variations in changes on specific dimensions dependant 

on where the patient was treated. 


118 


TABLE 2. Initial Admission Rating Mean, Median, and Range for “All Cases” and by Service 

Statistic Service A Service B Service C Service D Service E Service F Service G All cases 

Impairment 5 68 29 46 6 46 40 240 cases 

Mean 2.6 2.9 2.8 2.9 2.8 2.9 2.7 2.8 

Median 3 3 3 3 3 3 3 3 

Range 1–3.5 1–4 1–4 1–4 1.5–4 0–5 0–4.5 0–5 

Disability/activity 

Mean 2.5 2.8 3 2.9 2.6 3.1 3 2.9 

Median 3 3 3 3 2.7 3 3 3 

Range 1–3.5 1–5 2–4 0–5 1.5–3.5 1–5 0–4 0–5 

Participation/handicap 

Mean 4 3.7 3.7 4.1 4 3.9 4 3.9 

Median 4 4 4 4 4 4 4 4 

Range 3–5 1–5 .5–5 3–5 3–5 1.5–5 2.5–5 .5–5 

Well-being 

Mean 2.7 3.4 3.5 3.1 3.3 3.2 2.9 3.2 

Median* 3 3.5 4 3 3.5 3.3 3 3.5 

Range 1–4 1–5 1–5 1–4.5 1–5 0–5 1–5 0–5 

*p 0.05. 


Do clients have similar profiles of abilities 

and/or disabilities on discharge regardless 

of where they are treated? 

At the end of the study, 183 patients had completed 

treatment and were discharged from voice 

therapy. The mean, median, and range of final TOM 

ratings are shown in Table 4. 

Statistical analysis found a significant difference 

across the Services on all TOM dimensions, a significant 

difference on all dimensions of the TOM; 

the results for Impairment were Kruskal–Wallis H 

19.9; df 6; p 0.003, Disability/Activity Kruskal– 

Wallis H 24; df 6; p 0.001, Participation Kruskal– 

Wallis H 23.9; df 6; p 0.001; and Well-being 

Kruskal–Wallis H 22; df 6; p 0.001. The results 

show a significant variation across the Services in 

the outcomes of treatment, for example, in one Service 

(Service G), patients were discharged when 

the TOM rating was at 5 (normal), whereas other 

Services discharged patients when some difficulties 

still remained. 

Analysis on the reason patients were discharged 

from treatment showed that those who had completed 

their treatment were the majority (83%) 

(Table 5). Nevertheless, there were significant differences 

across the Services in the reason for discharge. 

For example, Service B had patients in six of the categories 

for “Reason for discharge.” This contrasted 

with Service D where all patients were discharged as 

“Treatment complete.” On the overall benchmark, 

the categories of “Self discharge” and “Non attendance” 

were the main alternative reasons provided 

for discharge, comprising 5% of the cases. Analysis 

of the reason for discharge and each TOM dimension 

showed significant differences between the final ratings 

and the reason for discharge (Table 5). It was 

also noted by the authors from reviewing the data 

that patients who had completed their treatment 

achieved higher final ratings on all TOM dimensions, 

indicating a more positive outcome. 


Is there a difference in the quantity and 

duration of treatment and is this associated 

with amount of change? 

Table 6 shows the contacts and duration of treatment. 

There was a significant difference in the 

number of contacts received by the voice patients 

ANOVA F 2.4; df 6; p 0.03 and an even more 

significant different across the Services (ANOVA F 

5.6; df 6; p 0.001) for the duration of treatment. It 

can be seen that the benchmark for all patients shows 

5.9 contacts SD 3.9 and a duration of 5 months SD 



TABLE 3. Voice: Cases Completing Treatment; Direction of Change for All Cases and by Service# 

Direction of Service Service Service Service Service Service Service 

TOM dimension change A B C D E F G All cases % All cases 

Number of cases 5 48 29 23 4 43 31 183 — 

Impairment* Negative change 0 0 0 0 0 1 0 1 0.5% 

Sustained 1 7 (2) 2 0 0 8 (2) 2 20 (4) 13% 

Positive change 4 39 27 23 4 32 29 158 86% 

Disability/activity Negative change 0 0 0 0 0 1 0 1 0.5% 

Sustained 0 4 (2) 2 1 (1) 0 7 (3) 2 16 (6) 12% 


Participation*** Negative change 0 0 0 0 0 1 0 1 0.5% 

Sustained 2 (1) 10 (3) 2 (2) 1 (5) 3 (1) 8 (15) 1 (11) 27 (38) 36% 


Well-being Negative change 0 0 0 1 0 1 0 2 1% 

Sustained 0 6 (3) 3 (3) 1 0 (1) 8 (3) 0 (1) 18 (11) 16% 


#(The number of cases rated ‘5’ at start and finish are shown separately in the brackets). 

*p 0.05. 

***p 0.001. 

4.4, showing variation in the intervention provided 

to patients. Of all of the Services, Service G had a 

tendency to provide more intervention over a similar 

duration than the other Services. 

DISCUSSION 

This benchmarking study collected routine clinical 

outcome data on nonselected consecutively referred 

patients from seven speech and language 

therapy services using the TOM. Analysis of the data 

found that patients with voice disorders entered into 

the study and appeared to have equity of access 

to treatment regardless of location. Most patients referred 

were middle aged, but there was a wide overall 

age range represented. The literature relating to the 

epidemiology of voice disorders indicates a wide 

variation in the age profile in the general population. 

Various studies quote different figures. 17,18 In this 

study, the analysis of initial rating showed variation 

with age across the TOM dimensions. There was a 

tendency for the younger patients to have a higher 

initial rating on Participation and Well-being than 

older patients. One might speculate that voice problems 

in children cause less impact on their social life 

in general than found in adults. One interpretation 

of these results is that voice disorders may present 

different difficulties to people at different stages in 

their life. 

The analysis of change over time in treatment 

found a significant difference across the Services 

only in the dimension of Handicap/Participation. 

There were differences in the number of patients who, 

on presentation to therapy, were graded as having 

no disadvantage in Participation versus those who 

were disadvantaged and sustained that disadvantage. 

The profile across the Services varied, for example, 

Services B and G show a markedly different 

pattern. The overall benchmark shows that most 

made a positive change on each of the dimensions. 

It has proved difficult to compare the TOM findings 

directly with other research studies because of 

the variation in the way other studies were conducted 

and reported and reviewed. The findings of this study 

showed positive change, and this reflects the findings 

from studies on effectiveness, which report that most 

patients do benefit from treatment. 17–20 

This study found significant variation across the 

Services in the outcomes to treatment. The variation 

appeared to relate to SLTs discharging patients at 

differing points. This suggests that SLTs use different 

judgments when discharging patients. Considerable 

variation in the frequency and duration of 

treatment was reported in the literature. 18 The use 


120 


TABLE 4. Voice Cases’ Final TOM Ratings; Mean, Median, and Range 

Statistic Service A Service B Service C Service D Service E Service F Service G All cases 

Number of cases 5 48 29 23 4 43 31 183 

Impairment 

Mean 3.9 4.4 4.2 4.5 4 4 4.6 4.3 

Median** 4.5 4.5 4.5 4.5 4 4 5 4.5 

Range 2–5 2–5 2.5–5 4–5 3–5 1.5–5 2–5 1.5–5 

Disability/activity 

Mean 3.8 4.4 4.2 4.6 4 4.1 4.7 4.3 

Median*** 4.5 4.5 4.5 5 4 4.5 5 4.5 

Range 2.5–5 3–5 2.5–5 4–5 3–5 2–5 3–5 2–5 

Participation 

Mean 4.6 4.6 4.6 4.9 4.2 4.4 4.8 4.6 

Median*** 5 4.5 5 5 4 5 5 5 

Range 4–5 4–5 2–5 4.5–5 4–5 2–5 3.5–5 2–5 

Well-being 

Mean 4.2 4.6 4.2 4.5 4.2 4.3 4.9 4.5 

Median*** 4.5 5 5 5 4.5 4.5 5 5 

Range 2.5 3.5–5 1.5–5 0–5 3–5 2–5 4–5 0–5 

**p 0.01. 

***p 0.001. 

of different measures in studies makes direct comparisons 

difficult; some studies reported sessions, 

others reported the actual time, and a few studies 

report the duration of treatment. The range varied 

considerably in the studies reported and reviewed by 

Pannbacker, 18 for example, 4 contacts to 51 contacts, 

whereas the duration of treatment ranged from 2 

weeks to 2 years. Few studies quoted both the 

number of contacts and the duration of treatment. 

For those studies that reported both, the intensity 

and duration ranged from 5 contacts in 5 days to 1 

contact a week over 3 to 7 months (approximately 12 

to 28 contacts). This is in contrast to this study 

where the range for all patients varied from 1 to 23 

contacts with the duration from 0.1 month to 20.2 

months. This variation shows the need to collect 

data routinely and systematically on contacts and 

duration if valid comparisons between profiles of 

intervention intensity are to be gathered to inform 

and change practice to effect better care. 

We found a marked variation in the reasons for 

discharge from treatment, and in the final rating, 

with a highly significant difference across the Services. 

This study indicates that patients completing 

their full treatment had the best outcomes. However, 

some Services had more patients discharged for alternative 

reasons. It would have been useful to know 

why these patients chose not to complete their treatment 

(most self-discharged or did not attend) when 

they still had difficulties as reflected in the poorer 

outcomes recorded at the time they ceased attending 

for treatment. A future study might usefully follow 

up such patients to identify why they chose to end 

attendance. The different profiles on all dimensions 

on the TOM on discharge from treatment were dependent 

on location of treatment. The reason for 

this result is unknown and related to a number of 

factors such as the type of treatment used in the 

intervention, the patients’ or SLTs’ characteristics, 

the etiology, or case management. However, the 

study results indicate that despite the variations in 

the outcomes of care on TOM across the Services, 

speech and language therapy treatment for patients 

with voice disorders is generally effective. 

This finding concurs with a number of studies conducted 

on voice disorders. 18–21 

CONCLUSION 

This study has shown the results of benchmarking 

outcomes in a specific client group. The analysis of 

the TOM data to answer the study questions has 

highlighted similarities and differences between SLT 

Services. The benchmarking process enabled the 



TABLE 5. Summary of Median TOM Ratings by Reason for Discharge Code 

Discharge code and number 

Disability/ 

of cases Number Percentage Impairment*** Activity*** Participation*** Well-being*** 

Remains on caseload 3 2% 4 4 4 4.5 

Treatment complete 151 83% 4.5 4.5 5 5 

Self-discharge 10 5% 3.5 4 4.5 4 

Transfer 4 2% 4.3 4 4 4.3 

Unlikely to reach potential 4 2% 2.3 3.0 4.3 4.5 

Did not attend 10 5% 3.5 3.8 4.3 4.3 

Other 1 0.5% 3 3 2 3 

All cases 183 100% 4.5 4.5 5 5 

***p 0.001. 

TABLE 6. Mean Contacts and Duration of Treatment 

for All Cases and by Service 

Duration of 

Service and cases Statistic Contacts* therapy*** 

A Mean 6.6 4.7 

n 5 SD 3.6 0.6 

B Mean 5.5 7.9 

n 48 SD 3.5 5.7 

C Mean 5.9 3.8 

n 29 SD 4.0 3.6 

D Mean 4.6 3.2 

n 23 SD 2.6 2.1 

E Mean 6.0 4.0 

n 4 SD 1.4 2.1 

F Mean 5.4 4.5 

n 43 SD 2.7 3.2 

G Mean 8.0 4.1 

n 31 SD 5.7 4.0 

All cases Mean 5.9 5.0 

n 183 SD 3.9 4.4 

*p 0.01. 

***p 0.001. 

participating SLTs to compare their data with that 

of the overall benchmark for all patients and then 

to compare this with other services to identify 

best performance. 

A future benchmarking study would aim to complete 

the benchmarking process by investigating 

how the information was used to effect change and 

link the process of care to that of outcomes. Ideally, 

this benchmarking process would be repeated once 

changes have been effected to identify whether better 

outcomes resulted. Benchmarking has the potential 

to inform SLTs on aspects of their practice and performance 

by using those tools in routine clinical 

practice. This can help SLTs to build a picture of 

performance and engender change for quality 

improvement. 

REFERENCES 

1. Secretary of State for Health. The New NHS, Modern, Dependable. 

London, UK: HMSO; 1997. 

2. Secretary of State for Health. A First Class Service, Quality 

in the New NHS. London, U.K.: HMSO; 1998. 

3. Swage T. Clinical Governance in Healthcare Practice. 

Oxford, U.K.: Butterworth & Heinemann; 2000. 

4. Bullivant J. (1996) Benchmarking in the UK NHS. Int. J 

Health Care Quality Assurance. 1996;9:9–14. 

5. Bullivant J, Roberts A. Service benchmarking: to choose 

to improve. Health Service Manager (Special Report no. 

14). Kingston upon Thames, U.K.: Croner Publications 

Ltd; 1997. 

6. MacDonald J, Tanner S. Understanding Benchmarking. 

London, U.K.: Hodder & Stoughton; 1998. 

7. Johnson J. Making self-regulation credible through benchmarking, 

peer review, appraisal and management. Brit Med 

J. 1998;316:1847–1848. 

8. Franklin R. When Will the Penny Drop-the State of Benchmarking 

in the NHS? Manchester: McClean Jones McCarthy 

Ltd; 1995: 1–12. 

9. Higgins I. Benchmarking in health care: a review of the 

literature. Australian Health Rev. 1997;20:60–68. 

10. Ellis J. Sharing the evidence: clinical practice benchmarking 

to improve continuously the quality of care. J Adv 

Nursing. 2000;32:215–225. 

11. Yaruss J, La Salle L, Conture E. Evaluating stuttering in 

young children: diagnostic data. Amer J Speech-Lang Pathol. 

1998;7:62–76. 

12. Hunt J, Slater A. From start to outcome—and beyond. 

Speech Lang Therapy Practice. 1999;Autumn:4–6. 


122 


13. Enderby P. Outcome measures in speech therapy: impairment, 

disability, handicap, and distress. Health Trends. 

1992;24:61–64. 

14. Enderby P, John A. Therapy Outcome Measures: Speech- 

Language Pathology. San Diego, CA: Singular Publishing 

Group, Inc.; 1997. 

15. World Health Organisation. International Classification of 

Impairments, Disabilities, and Handicaps (ICIDH). 

Geneva, Switzerland: WHO; 1980. 

16. John A. Therapy Outcome Measures for Benchmarking in 

Speech and Language Theraphy. PhD dissertation (unpublished). 

University of Sheffield; 2001. 

17. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. 

J Speech Lang Hear Res. 1998;41:101–116. 

18. Pannbacker M. Voice treatment techniques: a review and 

recommendations for outcome studies. Am J Speech Lang 

Pathol. 1998;7:49–64. 

19. Carding P, Horsley I, Docherty G. A study of the effectiveness 

of voice therapy in the treatment of 45 patients with 

non-organic dysphonia. J Voice. 1999;13:72–104. 

20. Verdolini K, Ramig LO, Jacobson B. Outcome measurement 

in voice disorders. In: Frattali CM, editor. Measuring 

Outcomes in Speech-Language Pathology, New York and 

Stuttgart: Thieme; 1998. p. 354–386. 

21. Enderby P, Emerson J. Does Speech and Language Therapy 

Work? London, U.K.: Whurr Publishers Ltd.; 1995. 

APPENDIX: DYSPHONIA 

Identify descriptor that is “best fit.” The patient does not have to have each feature mentioned. Use 0.5 

to indicate if patient is slightly better or worse than a descriptor. 

Impairment (as appropriate to age) 

0 Severe persistent aphonia. Unable to phonate. Does not phonate. 

1 Consistent dysphonia. Occasional phonation. May be dysphonic with aphonic episodes. 

2 Moderate dysphonia. Can phonate but frequent episodes of marked vocal impairment occurring. 

3 Moderate/mild dysphonia. Less frequent episodes of dysphonia (eg occurs some time each day/or 

slight persistent "huskiness"). 

4 Mild dysphonia. Occasional episodes of dysphonia occurring (eg on a weekly basis or less). 

5 No dysphonia. Appropriate/modal voice consistently used. 

Activity/Disability (as appropriate to age) 

0 Voice production is completely ineffective/inappropriate in all situations. 

1 Voice production is completely ineffective/inappropriate in most situations except occasionally with 

familiar listeners or modified environments. 

2 Voice production is effective/appropriate in modified environments (e.g. quiet situations, familiar 

situations). 

3 Voice production is effective/appropriate but can be unpredictable in some situations. Voice production 

requires less personal attention and effort in most situations. 

4 Voice production is effective/appropriate on most occasions. Rarely effortful. Very occasional difficulties 

experienced. 

5 Voice production is spontaneously effective and appropriate. 

Participation/Handicap (as appropriate to age) 

0 Unable to fulfil any social/educational/family role. Not involved in decision making/no autonomy/no 

control over environment. No social integration. 

1 Low self-confidence/poor self-esteem/limited social integration/socially isolated/contributes to some 

basic and limited decisions. Cannot achieve potential in any situation. 

2 Some self-confidence/some social integration/makes some decisions and influences control in familiar 

situations. 

3 Some self-confidence, autonomy emerging. Makes decisions and has control of some aspects of life. 

Able to achieve some limited social integration/educational activities. Diffident over control over 

life. Needs encouragement to achieve potential. 



4 Mostly confident, occasional difficulties integrating or in fulfilling social/role activity. Participating in 

all appropriate decisions. May have difficulty in achieving potential in some situations occasionally. 

5 Achieving potential, autonomous and unrestricted. Able to fulfil social, educational, and family role. 

Well-being/Distress (as appropriate to age) 

0 Severe constant: upset/frustration/anger/distress/embarrassment/concern/withdrawal. 

1 Frequently severe: upset/frustration/anger/distress/embarrassment/concern/withdrawal. 

2 Moderate consistent: upset/frustration/anger/distress/embarrassment/concern/withdrawal. 

3 Moderate frequent: upset/frustration/anger/distress/embarrassment/concern/withdrawal. 

4 Mild occasional: upset/frustration/anger/distress/embarrassment/concern/withdrawal. 

5 No inappropriate: upset/frustration/anger/distress/embarrassment/concern/withdrawal.

Comparing Outcomes of Voice Therapy - Stimm-und-sprachtherapie ...

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