Do patients have a say? A narrative review of the development of patient-reported outcome measures used in elective procedures for coronary revascularisation

Preparation for cardiac procedures: a cross-sectional study identifying gaps between outpatients' views and experiences of patient-centred care

BACKGROUND

To examine and identify gaps in care perceived as essential by patients; this study examined outpatients': (1) views on what characterizes essential care and (2) experiences of care received, in relation to cardiac catheterization and subsequent cardiovascular procedures.

METHODS

Cross-sectional descriptive study. Surveys were posted to outpatients who had undergone elective cardiac catheterization in the prior 6 months at an Australian hospital. Participants completed a 65-item survey to determine: (a) aspects of care they perceive as essential to patients receiving care for a cardiac condition (Important Care Survey); or (b) their actual care received (Actual Care Survey). Numbers and percentages were used to calculate the most frequently identified essential care items; and the experiences of care received. Items rated as either 'Essential'/'Very important' by at least 80% of participants were determined. A gap in patient-centred care was identified as being any item that was endorsed as essential/very important by 80% or more of participants but reported as received by <80% of participants.

RESULTS

Of 582 eligible patients, 264 (45%) returned a completed survey. A total of 43/65 items were endorsed by >80% of participants as essential. Of those, for 22 items, <80% reported the care as received. Gaps were identified in relation to general practitionerconsultation (1 item), preparation (1 item) subsequent decision making for treatment (1 item), prognosis (6 items), and post-treatment follow-up (1 item).

CONCLUSIONS

Areas were identified where actual care fell short of patients' perceptions of essential care.

Integrating post-fracture care into the primary care setting (interFRACT): Protocol for a mixed-methods study to co-design a care program to improve rates of osteoporosis and fracture treatment

INTRODUCTION

Despite evidence showing that timely diagnosis and appropriate pharmacological treatment of osteoporosis reduces subsequent fracture rates, osteoporosis remains significantly underdiagnosed and undertreated. The large and ongoing treatment gap for osteoporosis and associated fragility fractures could be addressed by considering systematic approaches for post-fracture care in the primary care setting. This study will develop the Integrating Post-Fracture Care into Primary Care (interFRACT) care program that aims to enhance diagnosis and treatment of osteoporosis and improve initiation and adherence to fracture prevention strategies for older adults in the primary care setting.

METHODS AND ANALYSIS

This mixed-methods study will follow an established co-design approach that involves six steps; the first three aim to gain an understanding of the consumer experience and needs, while the latter three focus on how to improve that experience through design and action. This will include: development of a Stakeholder Advisory Committee to provide guidance on all aspects of study design, including implementation, evaluation and dissemination; interviews with primary care physicians to explore beliefs and attitudes towards osteoporosis and fracture treatment; interviews with consumers (older adults with a diagnosis of osteoporosis and/or fragility fracture) to identify current needs for osteoporosis treatment and fracture prevention; a series of co-design workshops to develop the components of the interFRACT care program based on published guidance and findings from interviews; and a feasibility study with primary care physicians to determine the usability and acceptability of the interFRACT care program.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Deakin University Human Research Ethics Committee (approval number: HEAG-H 56_2022). Study results will be published in peer-reviewed journals, presented at national and international conferences, and collated in reports for participating primary care practices.

Effects of an 18-month community-based, multifaceted, exercise program on patient-reported outcomes in older adults at risk of fracture: secondary analysis of a randomised controlled trial

This study identified that an 18-month community-based, multifaceted, exercise program consisting of resistance, weight-bearing impact, and balance/mobility training combined with osteoporosis education and behavioural support can improve health-related quality of life (HRQoL) and osteoporosis knowledge in older adults at risk of fracture, but only for those adherent to the exercise regime.

PURPOSE

To evaluate the effects of an 18-month community-based exercise, osteoporosis education and behaviour change program (Osteo-cise: Strong Bones for Life) on HRQoL, osteoporosis knowledge and osteoporosis health beliefs.

METHODS

This was a secondary analysis of an 18-month randomised controlled trial in which 162 older adults aged ≥ 60 years with osteopenia or increased falls/fracture risk were randomized to the Osteo-cise program (n = 81) or control group (n = 81). The program consisted of progressive resistance, weight-bearing impact and balance training (3 days/week); osteoporosis education to facilitate self-management of musculoskeletal health and behavioural support to enhance adherence to exercise. HRQoL, osteoporosis knowledge and osteoporosis health beliefs were assessed using the EuroQoL questionnaire (EQ-5D-3L), Osteoporosis Knowledge Assessment Tool and Osteoporosis Health Belief Scale, respectively.

RESULTS

Overall, 148 participants (91%) completed the trial. Mean exercise adherence was 55% and mean attendance for the three osteoporosis educational sessions ranged from 63-82%. After 12 and 18 months, there were no significant effects of the Osteo-cise program on HRQoL, osteoporosis knowledge or health beliefs relative to controls. Per protocol analyses (≥ 66% exercise adherence; n = 41) revealed a significant net benefit in EQ-5D-3L utility for the Osteo-cise group relative to controls after 12 months (P = 0.024) and 18 months (P = 0.029) and a significant net improvement in osteoporosis knowledge scores at 18 months (P = 0.014).

CONCLUSION

This study supports the importance of adherence to exercise regimes, as adherence to the Osteo-cise: Strong Bones for Life program was associated with improvements in HRQoL and osteoporosis knowledge in older adults at increased risk for falls and fractures.

TRIAL REGISTRATION NUMBER

ACTRN12609000100291.

Barriers to and Facilitators of Digital Health Among Culturally and Linguistically Diverse Populations: Qualitative Systematic Review

BACKGROUND

Health care systems have become increasingly more reliant on patients' ability to navigate the digital world. However, little research has been conducted on why some communities are less able or less likely to successfully engage with digital health technologies (DHTs), particularly among culturally and linguistically diverse (CaLD) populations.

OBJECTIVE

This systematic review aimed to determine the barriers to and facilitators of interacting with DHTs from the perspectives of CaLD population groups, including racial or ethnic minority groups, immigrants and refugees, and Indigenous or First Nations people.

METHODS

A systematic review and thematic synthesis of qualitative studies was conducted. Peer-reviewed literature published between January 2011 and June 2022 was searched across 3 electronic databases. Terms for digital health were combined with terms for cultural or linguistic diversity, ethnic minority groups, or Indigenous and First Nations people and terms related to barriers to accessing digital technologies. A qualitative thematic synthesis was conducted to identify descriptive and analytical themes of barriers to and facilitators of interacting with DHTs. Quality appraisal was performed using the Mixed Methods Appraisal Tool.

RESULTS

Of the 1418 studies identified in the electronic search, a total of 34 (2.4%) were included in this review. Half of the included studies (17/34, 50%) were conducted in the United States. There was considerable variation in terms of the CaLD backgrounds of the participants. In total, 26% (9/34) of the studies focused on Indigenous or First Nations communities, 41% (14/34) were conducted among ethnic minority populations, 15% (5/34) of the studies were conducted among immigrants, and 18% (6/34) were conducted in refugee communities. Of the 34 studies, 21 (62%) described the development or evaluation of a digital health intervention, whereas 13 (38%) studies did not include an intervention but instead focused on elucidating participants' views and behaviors in relation to digital health. From the 34 studies analyzed, 18 descriptive themes were identified, each describing barriers to and facilitators of interacting with DHTs, which were grouped into 7 overarching analytical themes: using technology, design components, language, culture, health and medical, trustworthiness, and interaction with others.

CONCLUSIONS

This study identified several analytic and descriptive themes influencing access to and uptake of DHTs among CaLD populations, including Indigenous and First Nations groups. We found that cultural factors affected all identified themes to some degree and that cultural and linguistic perspectives should be considered in the design and delivery of DHTs, with this best served through the inclusion of the target communities at all stages of development. This may improve the potential of DHTs to be more acceptable, appropriate, and accessible to population groups currently at risk of not obtaining the full benefits of digital health.

Use of co-design methodology in the development of cardiovascular disease secondary prevention interventions: A scoping review

INTRODUCTION

There is growing evidence to support the use of co-design in developing interventions across many disciplines. This scoping review aims to examine how co-design methodology has been used in the development of cardiovascular disease (CVD) secondary prevention interventions within health and community settings.

METHODS

We searched four academic databases for studies that used the co-design approach to develop their intervention. Studies were included if consumers (adults with CVD) and key stakeholders (e.g. clinicians, service providers) were involved in the co-design process. The review focused on methodology rather than traditional study outcomes; therefore, co-design processes and activities were extracted and evaluated against a selected co-design framework.

RESULTS

Twenty-two studies were included in this review. Studies were implemented across various settings with consumers and stakeholder groups most frequently consisting of patients and healthcare professionals, respectively. Most studies specifically stated that they used a 'co-design' approach (n = 10); others used terms such as participatory action research (n = 3), user-centred design (n = 3) and community-based participatory research (n = 2). Although there was variability in terminology, co-design processes, and participants, all studies adhered to the key principles of consumer engagement. Predominant co-design activities included semistructured interviews, focus groups, co-design/development workshops and advisory group meetings. Intervention effectiveness was assessed in eight studies showing mixed results.

CONCLUSIONS

This review provides an overview of how the co-design approach has previously been used in the development of CVD secondary prevention interventions. These findings provide methodological considerations that can guide researchers and healthcare services when implementing co-design to develop feasible and acceptable interventions that can improve outcomes for CVD populations.

PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers, people with lived experience or members of the public were involved in this scoping review. This review article was written by academics who have undertaken a significant amount of co-design work with consumers and stakeholders.

Patient-centered care in Coronary Heart Disease: what do you want to measure? A systematic review of reviews on patient-reported outcome measures

Background

The number of published articles on Patient-Reported Outcomes Measures (PROMs) in Coronary Heart Disease (CHD), a leading cause of disability-adjusted life years lost worldwide, has been growing in the last decades. The aim of this study was to identify all the disease-specific PROMs developed for or used in CHD and summarize their characteristics (regardless of the construct), to facilitate the selection of the most adequate one for each purpose.

Methods

A systematic review of reviews was conducted in MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews. PROQOLID and BiblioPRO libraries were also checked. PROMs were classified by construct and information was extracted from different sources regarding their main characteristics such as aim, number of items, specific dimensions, original language, and metric properties that have been assessed.

Results

After title and abstract screening of 1224 articles, 114 publications were included for full text review. Finally, we identified 56 PROMs: 12 symptoms scales, 3 measuring functional status, 21 measuring Health-Related Quality of Life (HRQL), and 20 focused on other constructs. Three of the symptoms scales were specifically designed for a study (no metric properties evaluated), and only five have been included in a published study in the last decade. Regarding functional status, reliability and validity have been assessed for Duke Activity Index and Seattle Angina Questionnaire, which present multiple language versions. For HRQL, most of the PROMs included physical, emotional, and social domains. Responsiveness has only been evaluated for 10 out the 21 HRQL PROMs identified. Other constructs included psychological aspects, self-efficacy, attitudes, perceptions, threats and expectations about the treatment, knowledge, adjustment, or limitation for work, social support, or self-care.

Conclusions

There is a wide variety of instruments to assess the patients’ perspective in CHD, covering several constructs. This is the first systematic review of specific PROMs for CHD including all constructs. It has practical significance, as it summarizes relevant information that may help clinicians, researchers, and other healthcare stakeholders to choose the most adequate instrument for promoting shared decision making in a trend towards value-based healthcare.

Reconciling validity and challenges of patient comfort and understanding: Guidelines to patient-oriented questionnaires

Background

Patient‐reported outcome measures (PROMs) are widely recognized as important tools for achieving a patient‐centred approach in health research. While PROMs are subject to several stages of validation during development, even questionnaires with robust psychometric properties may challenge patient comfort and understanding.

Aim

Building on the experience of patient engagement in the PriCARE research programme, this paper outlines the team's response to concerns raised by patient partners regarding the administration of the questionnaire.

Methods

Based on a participatory action research design and the patient engagement framework in the Strategy for Patient‐Oriented Research of the Canadian Institutes of Health Research, PriCARE team members worked together to discuss concerns, review the questionnaires and come up with solutions. Data were collected through participant observation of team meetings.

Results

This paper demonstrates how patient partners were engaged in PriCARE and integrated into the programme's governance structure, focusing on the challenges that they raised regarding the questionnaires and how these were addressed by PriCARE team members in a six‐step approach: (1) Recognizing patient partner concerns, discussing concerns and reframing the challenges; (2) Detailing and sharing evidence of the validity of the questionnaires; (3) Evaluating potential solutions; (4) Searching the literature for guidelines; (5) Creating guidelines; and (6) Sharing and refining guidelines.

Conclusion

This six‐step approach demonstrates how research teams can integrate patient partners as equal members, develop meaningful collaboration through recognition of individual experiences and expertise and ensure that the patient perspective is taken into consideration in research and healthcare innovation.

Patient or Public Contribution

All patient partners from the PriCARE programme were actively involved in the six‐step approach. They were also involved in the preparation of the manuscript.

What matters most to patients following percutaneous coronary interventions? A new patient-reported outcome measure developed using Rasch analysis

INTRODUCTION

Measuring patient reported outcomes can improve the quality and effectiveness of healthcare interventions. The aim of this study was to identify the final set of items that can be included in a patient-reported outcome measure to assess recovery of patients following percutaneous coronary interventions.

METHODS

A consecutive sample of 200 patients registered in the Victorian Cardiac Outcomes Registry participated in a telephone survey 30 days following their percutaneous cardiac procedure. Rasch analysis was used to select the best set of items to form a concise and psychometrically sound patient-reported outcome measure. Key measurement properties assessed included overall fit to the Rasch measurement model, unidimensionality, response formats (thresholds), targeting, internal consistency and measurement invariance.

RESULTS

Five items were identified as being reliable and valid measures of patient-reported outcomes: pain or discomfort, shortness of breath, confidence in performing usual activities, feeling unhappy and having trouble sleeping. Data showed overall fit to a Rasch model of expected item functioning (χ2 16.99; p = 0.07) and all items demonstrated unidimensionality (t-test less than 0.05 threshold value). Internal consistency was acceptable (equivalent Cronbach's α 0.65) given there are only five items, but there was a ceiling effect (mean logit score -1.24) with compromised score precision for patients with better recovery.

CONCLUSIONS

We identified a succinct set of items that can be used in a patient-reported outcome measure following percutaneous coronary interventions. This patient-report outcome measure has good structural validity and acceptable internal consistency. While further psychometric evaluations are recommended, the items identified capture the patient's perspective of their recovery following a percutaneous coronary intervention.

Symptoms and feelings valued by patients after a percutaneous coronary intervention: a discrete-choice experiment to inform development of a new patient-reported outcome

OBJECTIVE

To inform the development of a patient-reported outcome measure, the aim of this study was to identify which symptoms and feelings following percutaneous coronary intervention (PCI) are most important to patients.

DESIGN

Discrete-choice experiment consisting of two hypothetical scenarios of 10 symptoms and feelings (pain or discomfort; shortness of breath; concern/worry about heart problems; tiredness; confidence to do usual activities; ability to do usual activities; happiness; sleep disturbance; dizziness or light-headedness and bruising) experienced after PCI, described by three levels (never, some of the time, most of the time). Preference weights were estimated using a conditional logit model.

SETTING

Four Australian public hospitals that contribute to the Victorian Cardiac Outcomes Registry (VCOR) and a private insurer's claim database.

PARTICIPANTS

138 people aged >18 years who had undergone a PCI in the previous 6 months.

MAIN OUTCOME MEASURES

Patient preferences via trade-offs between 10 feelings and symptoms.

RESULTS

Of the 138 individuals recruited, 129 (93%) completed all 16 choice sets. Conditional logit parameter estimates were mostly monotonic (eg, moving to worse levels for each individual symptom and feeling made the option less attractive). When comparing the magnitude of the coefficients (based on the coefficient of the worst level relative to best level in each item), feeling unhappy was the symptom or feeling that most influenced perception of a least-preferred PCI outcome (OR 0.42, 95% CI 0.34 to 0.51, p<0.0001) and the least influential was bruising (OR 0.81, 95% CI 0.67 to 0.99, p=0.04).

CONCLUSION

This study provides new insights into how patients value symptoms and feelings they experience following a PCI.