Patients' experiences using a computerized program with a touch-sensitive video monitor for the assessment of health-related quality of life

Feasibility and acceptability of electronic EQ-5D-5L for routine measurement of HRQOL in patients with chronic musculoskeletal problems in Hong Kong primary care

BACKGROUND

Information on HRQOL can enhance patient diagnosis and management but it is rarely available in routine clinical practice. This mixed-method study evaluated the feasibility and acceptability of the electronic EQ-5D-5L measurement of HRQOL in patients with chronic musculoskeletal problems in primary care.

METHODS

In three primary care clinics, 665 patients with musculoskeletal problems completed the electronic EQ-5D-5L and Visual Analogue Scale (e-EQ-5D-5L/VAS), and a questionnaire on socio-demographics, perceived ease of use (PEOU), and perceived usefulness (PU) at baseline and two follow-ups. Patient completion and response rates, and time to complete the e-EQ-5D-5L/VAS were measured. During the same consultations, 49 doctors reviewed the e-EQ-5D-5L/VAS reports and completed a clinician questionnaire on PEOU, PU, and time spent to address each report. Individual interviews along with focus group discussions were conducted on patients, doctors, and research assistants for further exploration.

RESULTS

Mean completion time reduced from baseline to first and second follow-up (120.66, 83.99, and 105.22 s, respectively). Completion and response rates were high at each follow-up visit (> 99.8% and > 91.11%, respectively). Doctors needed less than 2 min to read the report but felt the time required to address the report was a significant barrier. Some patients had difficulties using e-platforms, in understanding or answering questions; but, PEOU improved with time (p < 0.001). Most patients found the e-platforms useful (> 85.3%). Clinicians agreed a great majority of the reports were easy to use (76.0-85.1%) and useful (69.2-72.0%), particularly aiding with a holistic view of the patient's musculoskeletal problem.

CONCLUSION

The e-EQ-5D-5L/VAS is a feasible and acceptable measurement of HRQOL of patients with chronic musculoskeletal problems in routine primary care in Hong Kong which can assist real-time management decisions.

TRIAL REGISTRATION

NCT03609762.

Interactive mental health assessments for Chinese Canadians: A pilot randomized controlled trial in nurse practitioner-led primary care clinic

INTRODUCTION

Mental health conditions like depression and anxiety are on the rise, but access to care remains a challenge. Immigrants and racialized communities including Chinese Canadians experience high level of access barriers including communication with clinicians. With the aim to facilitate mental health communications, we tested an Interactive Computer-assisted Client Assessment Survey (iCCAS) in Cantonese/Mandarin and English at a nurse practitioner-led primary care clinic in Toronto. The iCCAS offers a touch-screen, pre-consultation survey with questions on depression, anxiety, post-traumatic stress, alcohol abuse, and social context. The program generates point-of-care reports for the clinician and patient.

METHODS

A pilot randomized controlled trial examined the intervention impact on mental health discussion and symptom detection, compared with the usual care, followed by clinicians' qualitative interviews.

RESULTS

Fifty self-identified Chinese adult patients participated (iCCAS = 26, Usual Care = 24), response rate 79.4%. Participant mean age was 44.8 years and 92% were immigrants. There was an increase of 19% and 15% in the mental health discussion and detection of symptoms in the iCCAS group compared with the usual care. More participants in the iCCAS group were referred to a social worker or psychiatrist. Patients found the use of iCCAS easy and clinicians identified its benefits for themselves (eg, early identification and comfort) and patients (eg, self-awareness and anonymity) and proposed practice-integration.

DISCUSSION

The studied tool holds promise for enhancing clinician-patient mental health communications in primary care settings for overseas Chinese. Implications are discussed for in-person and virtual healthcare which could also inform responses to mental health crisis related to COVID-19.

Quality of Life in Patients with Gynecological Cancers: A Web-Based Study

Introduction:

Gynecological cancers are common in adult women. One of the most important goals in the management of these patients is to improve quality of life, along with survival as a traditional outcome. The aim of this study was to evaluate quality of life in gynecological cancers in Iran.

Methods:

This cross-sectional study was performed on a sample of patients with gynecological cancers including uterine, ovarian, cervical, and vulvovaginal attending a teaching hospital affiliated to Tehran University of Medical Sciences between 2014 and 2019. The data was collected by a web-based platform with validated self-administered questionnaires including demographic information, the EORTC QLQ-C30 and the Hospital Anxiety and Depression (HADS). The data were analyzed using appropriate tests.

Results:

In all 251 patients were studied. The mean age of patients was 52.8±12.4 years and 43% had uterine, 30% had ovarian, 25% had cervical, and 2% had vulvovaginal cancer. The mean global quality of life score as measured by the EORTC QLQ-C30 was 59.8 ± 24.9. Women with ovarian cancer had the highest and women with cervical cancer had the lowest global quality of life score. There were significant differences in emotional, cognitive and global quality of life by cancer diagnosis (p <0.05). Although not significant, overall physical, role, cognitive and social functioning was found to be better in women who had been treated with surgery. The mean anxiety and depression score were 8.7± 5.0 and 7.1 ± 5.2, respectively.

Conclusion:

The results demonstrated that patients with gynecological cancers had a low quality of life, and experience higher anxiety and depression.

Evaluating the impact of a 'virtual clinic' on patient experience, personal and provider costs of care in urinary incontinence: A randomised controlled trial

OBJECTIVE

To evaluate the impact of using a 'virtual clinic' on patient experience and cost in the care of women with urinary incontinence.

MATERIALS AND METHODS

Women, aged > 18 years referred to a urogynaecology unit were randomised to either (1) A Standard Clinic or (2) A Virtual Clinic. Both groups completed a validated, web-based interactive, patient-reported outome measure (ePAQ-Pelvic Floor), in advance of their appointment followed by either a telephone consultation (Virtual Clinic) or face-to-face consultation (Standard Care). The primary outcome was the mean 'short-term outcome scale' score on the Patient Experience Questionnaire (PEQ). Secondary Outcome Measures included the other domains of the PEQ (Communications, Emotions and Barriers), Client Satisfaction Questionnaire (CSQ), Short-Form 12 (SF-12), personal, societal and NHS costs.

RESULTS

195 women were randomised: 98 received the intervention and 97 received standard care. The primary outcome showed a non-significant difference between the two study arms. No significant differences were also observed on the CSQ and SF-12. However, the intervention group showed significantly higher PEQ domain scores for Communications, Emotions and Barriers (including following adjustment for age and parity). Whilst standard care was overall more cost-effective, this was minimal (£38.04). The virtual clinic also significantly reduced consultation time (10.94 minutes, compared with a mean duration of 25.9 minutes respectively) and consultation costs compared to usual care (£31.75 versus £72.17 respectively), thus presenting potential cost-savings in out-patient management.

CONCLUSIONS

The virtual clinical had no impact on the short-term dimension of the PEQ and overall was not as cost-effective as standard care, due to greater clinic re-attendances in this group. In the virtual clinic group, consultation times were briefer, communication experience was enhanced and personal costs lower. For medical conditions of a sensitive or intimate nature, a virtual clinic has potential to support patients to communicate with health professionals about their condition.

Preconsult interactive computer-assisted client assessment survey for common mental disorders in a community health centre: a randomized controlled trial

BACKGROUND

Access disparities for mental health care exist for vulnerable ethnocultural and immigrant groups. Community health centres that serve these groups could be supported further by interactive, computer-based, self-assessments.

METHODS

An interactive computer-assisted client assessment survey (iCCAS) tool was developed for preconsult assessment of common mental disorders (using the Patient Health Questionnaire [PHQ-9], Generalized Anxiety Disorder 7-item [GAD-7] scale, Primary Care Post-traumatic Stress Disorder [PTSD-PC] screen and CAGE [concern/cut-down, anger, guilt and eye-opener] questionnaire), with point-of-care reports. The pilot randomized controlled trial recruited adult patients, fluent in English or Spanish, who were seeing a physician or nurse practitioner at the partnering community health centre in Toronto. Randomization into iCCAS or usual care was computer generated, and allocation was concealed in sequentially numbered, opaque envelopes that were opened after consent. The objectives were to examine the interventions' efficacy in improving mental health discussion (primary) and symptom detection (secondary). Data were collected by exit survey and chart review.

RESULTS

Of the 1248 patients assessed, 190 were eligible for participation. Of these, 148 were randomly assigned (response rate 78%). The iCCAS (n = 75) and usual care (n = 72) groups were similar in sociodemographics; 98% were immigrants, and 68% were women. Mental health discussion occurred for 58.7% of patients in the iCCAS group and 40.3% in the usual care group (p ≤ 0.05). The effect remained significant while controlling for potential covariates (language, sex, education, employment) in generalized linear mixed model (GLMM; adjusted odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1-4.5). Mental health symptom detection occurred for 38.7% of patients in the iCCAS group and 27.8% in the usual care group (p > 0.05). The effect was not significant beyond potential covariates in GLMM (adjusted OR 1.9; 95% CI 0.9-4.1).

INTERPRETATION

The studied intervention holds potential for community health centres to improve mental health discussion. Further research with larger samples should examine the impact on detection and enhance generalizability. Trial registration: ClinicalTrials.gov, no: NCT02023957, registered on Dec. 12, 2013.

Computer-assisted client assessment survey for mental health: patient and health provider perspectives

BACKGROUND

The worldwide rise in common mental disorders (CMDs) is posing challenges in the provision of and access to care, particularly for immigrant, refugee and racialized groups from low-income backgrounds. eHealth tools, such as the Interactive Computer-Assisted Client Assessment Survey (iCCAS) may reduce some barriers to access. iCCAS is a tablet-based, touch-screen self-assessment completed by clients while waiting to see their family physician (FP) or nurse practitioner (NP). In an academic-community initiative, iCCAS was made available in English and Spanish at a Community Health Centre in Toronto through a mixed-method trial.

METHODS

This paper reports the perspectives of clients in the iCCAS group (n = 74) collected through an exit survey, and the perspectives of 9 providers (four FP and five NP) gathered through qualitative interviews. Client acceptance of the tool was assessed for cognitive and technical dimensions of their experience. They rated twelve items for perceived Benefits and Barriers and four questions for the technical quality.

RESULTS

Most clients reported that the iCCAS completion time was acceptable (94.5 %), the touch-screen was easy to use (97.3 %), and the instructions (93.2 %) and questions (94.6 %) were clear. Clients endorsed the tool's Benefits, but were unsure about Barriers to information privacy and provider interaction (mean 4.1, 2.6 and 2.8, respectively on a five-point scale). Qualitative analysis of the provider interviews identified five themes: challenges in Assessing Mental Health Services, such as case complexity, time, language and stigma; the Tool's Benefits, including non-intrusive prompting of clients to discuss mental health, and facilitation of providers' assessment and care plans; the Tool's Integration into everyday practice; Challenges for Use (e.g. time); and Promoting Integration Effectively, centered on the timing of screening, setting readiness, language diversity, and technological advances.

CONCLUSIONS

Participant clients and providers perceived iCCAS as an easy and useful tool for mental health assessments at the Community Health Centre and similar settings. The findings are anticipated to inform further work in this area.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02023957 ; Registered retrospectively 12 Dec. 2013.

Assessment of an Interactive Computer-Based Patient Prenatal Genetic Screening and Testing Education Tool

The Enhancing Patient Prenatal Education study tested the feasibility and educational impact of an interactive program for patient prenatal genetic screening and testing education. Patients at two private practices and one public health clinic participated ( N = 207). The program collected knowledge and measures of anxiety before and after use of the tool. Time in various prenatal visit activities was collected prior to and after the introduction of the education tool. Providers completed an assessment of their experiences with patients who had used the program. Results indicate that patient knowledge significantly increased from pre to post ( p = .0001) with no increase in anxiety ( p = .31). Time in clinic activities, including overall visit time, increased. A majority of providers indicated that the program disrupted clinic flow. This assessment suggests that the program increases patient knowledge and does not increase patient anxiety. However, challenges remain to using this program in a clinic setting.

The Psoriatic Arthritis Impact of Disease 12-item questionnaire: equivalence, reliability, validity, and feasibility of the touch-screen administration versus the paper-and-pencil version

BACKGROUND

Over the last few years, there has been a shift toward a more patient-centered perspective of the disease by adopting patient-reported outcomes. Touch-screen formats are increasingly being used for data collection in routine care and research.

OBJECTIVES

The aim of this study is to examine the equivalence, reliability, validity and respondent preference for a computerized touch-screen version of the Psoriatic Arthritis Impact of Disease 12-item (PsAID-12) questionnaire in comparison with the original paper-and-pencil version, in a cohort of patients with psoriatic arthritis (PsA).

METHODS

One hundred and fifty-nine patients with PsA completed both the touch screen- and the conventional paper-and-pencil administered PsAID-12 questionnaire. Agreement between formats was assessed by intraclass correlation coefficients. Spearman's rho correlation coefficient was used to test convergent validity of the touch screen format of PsAID-12, while receiver operating characteristic curve analysis was performed to test discriminant validity. In order to assess the patient's preference, the participants filled in an additional questionnaire. The time taken to complete both formats was measured.

RESULTS

A high concordance between the responses to the two modes of the PsAID-12 tested was found, with no significant mean differences. Intraclass correlation coefficients between data obtained for touch-screen and paper versions ranged from 0.801 to 0.962. There was a very high degree of correlation between the touch-screen format of PsAID-12 and composite disease activity indices (all at a P level <0.0001), Health Assessment Questionnaire, and Physician Assessment of disease activity. The discriminatory power of the touch-screen format of PsAID-12, assessed using the minimal disease activity - Outcome Measurements in Rheumatology Clinical Trials criteria, was very good, with an area under the receiver operating characteristic curve of 0.937 and a resulting cutoff value of 2.5. The touch-screen questionnaire was readily accepted and preferred. The mean time spent for completing the questionnaire on touch screen was 2 minutes and on paper was 2.7 minutes.

CONCLUSION

The touch-screen mode of administration of PsAID-12 can be a feasible and suitable alternative to the paper-and-pencil mode for the assessment of patients with PsA.

Validation of a modified FRAX® tool for improving outpatient efficiency--part of the "Catch Before a Fall" initiative

We have validated our touch-screen-modified FRAX® tool against the traditional healthcare professional-led questionnaire, demonstrating strong concordance between doctor- and patient-derived results. We will use this in outpatient clinics and general practice to increase our capture rate of at-risk patients, making valuable use of otherwise wasted patient waiting times.

INTRODUCTION

Outpatient clinics offer an opportunity to collect valuable health information from a captive population. We have previously developed a modified fracture risk assessment (FRAX®) tool, enabling patients to self-assess their osteoporotic fracture risk in a touch-screen computer format and demonstrated its acceptability with patients. We aim to validate the accuracy of our tool against the traditional questionnaire.

METHODS

Fifty patients over 50 years of age within the fracture clinic independently completed a paper equivalent of our touch-screen-modified FRAX® questionnaire. Responses were analysed against the traditional healthcare professional (HCP)-led questionnaire which was carried out afterwards. Correlation was assessed by sensitivity, specificity, Cohen's kappa statistic and Fisher's exact test for each potential FRAX® outcome of "treat", "measure BMD" and "lifestyle advice".

RESULTS

Age range was 51-98 years. The FRAX® tool was completed by 88 % of patients; six patients lacked confidence in estimating either their height or weight. Following question adjustment according to patient response and feedback, our tool achieved >95 % sensitivity and specificity for the "treat" and "lifestyle advice" groups, and 79 % sensitivity and 100 % specificity in the "measure BMD" group. Cohen's kappa value ranged from 0.823 to 0.995 across all groups, demonstrating "very good" agreement for all. Fisher's exact test demonstrated significant concordance between doctor and patient decisions.

DISCUSSION

Our modified tool provides a simple, accurate and reliable method for patients to self-report their own FRAX® score outside the clinical contact period, thus releasing the HCP from the time required to complete the questionnaire and potentially increasing our capture rate of at-risk patients.

Patient-reported outcome assessment after total joint replacement: comparison of questionnaire completion times on paper and tablet computer

INTRODUCTION

Patient-reported outcome (PRO) assessment is becoming increasingly important after joint replacement surgery. However, PRO data collection, questionnaire handling, and data processing are time consuming and costly process. The aim of our study was to evaluate the efficiency of PRO assessment using tablet computers compared with traditional paper questionnaires in a total hip or knee arthroplasty (THR or TKR) population.

MATERIALS AND METHODS

We recruited 100 patients from outpatient clinics attending for routine follow-up 2 months, 1 year, or 5 years after THR or TKR. Fifty patients completed the Western Ontario and McMaster Universities (WOMAC) osteoarthritis score and Forgotten Joint Score-12 (FJS-12) questionnaires on paper, and 50 patients completed these on a tablet computer. Questionnaire completion was timed for each PRO assessment and for manual data entry of the paper questionnaires into the database. The t test, Mann-Whitney U test, Fisher's exact test, and Wilcoxon test were used for statistical analysis.

RESULTS

The mean age of the patients was 67.0 years (standard deviation 10.3 years), with no significant difference between the two groups. Median time for WOMAC questionnaire completion (including data entry for the paper questionnaires) was 197 s for the paper version and 117 s for the tablet version (p < 0.001). Median times for completion of FJS-12 were comparable for paper and tablet versions (32 vs. 37 s). We did not find a significant correlation between age and time for questionnaire completion.

CONCLUSION

Electronic PRO data collection can substantially decrease time, logistics, and effort associated with questionnaire completion in daily clinical practice. It is also acceptable for use in an older arthroplasty population.

The role of technical advances in the adoption and integration of patient-reported outcomes in clinical care

BACKGROUND

Patient-reported outcomes (PROs) are gaining recognition as key measures for improving the quality of patient care in clinical care settings. Three factors have made the implementation of PROs in clinical care more feasible: increased use of modern measurement methods in PRO design and validation, rapid progression of technology (eg, touchscreen tablets, Internet accessibility, and electronic health records), and greater demand for measurement and monitoring of PROs by regulators, payers, accreditors, and professional organizations. As electronic PRO collection and reporting capabilities have improved, the challenges of collecting PRO data have changed.

OBJECTIVES

To update information on PRO adoption considerations in clinical care, highlighting electronic and technical advances with respect to measure selection, clinical workflow, data infrastructure, and outcomes reporting.

METHODS

Five practical case studies across diverse health care settings and patient populations are used to explore how implementation barriers were addressed to promote the successful integration of PRO collection into the clinical workflow. The case studies address selecting and reporting of relevant content, workflow integration, previsit screening, effective evaluation, and electronic health record integration.

CONCLUSIONS

These case studies exemplify elements of well-designed electronic systems, including response automation, tailoring of item selection and reporting algorithms, flexibility of collection location, and integration with patient health care data elements. They also highlight emerging logistical barriers in this area, such as the need for specialized technological and methodological expertise, and design limitations of current electronic data capture systems.

Method of administration of PROMIS scales did not significantly impact score level, reliability, or validity

OBJECTIVES

To test the impact of the method of administration (MOA) on score level, reliability, and validity of scales developed in the Patient Reported Outcomes Measurement Information System (PROMIS).

STUDY DESIGN AND SETTING

Two nonoverlapping parallel forms each containing eight items from each of three PROMIS item banks (Physical Function, Fatigue, and Depression) were completed by 923 adults with chronic obstructive pulmonary disease, depression, or rheumatoid arthritis. In a randomized crossover design, subjects answered one form by interactive voice response (IVR) technology, paper questionnaire (PQ), personal digital assistant (PDA), or personal computer (PC) and a second form by PC, in the same administration. Method equivalence was evaluated through analyses of difference scores, intraclass correlations (ICCs), and convergent/discriminant validity.

RESULTS

In difference score analyses, no significant mode differences were found and all confidence intervals were within the prespecified minimal important difference of 0.2 standard deviation. Parallel-forms reliabilities were very high (ICC = 0.85-0.93). Only one across-mode ICC was significantly lower than the same-mode ICC. Tests of validity showed no differential effect by MOA. Participants preferred screen interface over PQ and IVR.

CONCLUSION

We found no statistically or clinically significant differences in score levels or psychometric properties of IVR, PQ, or PDA administration compared with PC.

Measurement equivalence of touch-screen computerized and paper-based diabetes-specific quality-of-life questionnaires

Current advances in technology have enabled the development of a computer-based questionnaire that provides advantages over the paper-based mode of administration, such as automatic data entry, storage and calculations. However, before implementing a computer-based questionnaire, its equivalence with the original paper-based questionnaire must first be demonstrated. The purpose of this study was to evaluate the measurement equivalence of the computerized Diabetes-Specific Quality-of-Life questionnaire (cD-QOL) with its original paper-based counterpart. A two-period crossover design was used in this study. The measurement equivalence was evaluated using quadratic weighted kappa coefficients, intraclass correlations and Cronbach's alpha comparisons. The cD-QOL was equivalent to its original paper-based counterpart. Participants preferred the cD-QOL over the paper-based questionnaire and reported that it was easy to use.

Understanding women's experiences of electronic interviewing during the clinical episode in urogynaecology: a qualitative study

INTRODUCTION AND HYPOTHESIS

Questionnaires for assessing health and related quality of life are increasingly advocated but little is known about women's views on them. The aim of the study was to understand women's experiences of using an electronic personal assessment questionnaire for pelvic floor disorders (ePAQ-PF) during the clinical episode.

METHODS

A qualitative study was performed in a tertiary referral centre for urogynaecology. Women who completed the electronic questionnaire (ePAQ-PF) before and after intervention for pelvic floor disorders were recruited. Semi-structured interviews were conducted in 20 women and the transcripts were analysed using a thematic approach to identify themes and categories. The main outcome measures were: (1) women's feelings about their experience of using the questionnaire and the impact it had on their clinical episode, (2) exploration of ways in which the questionnaire influenced communication, (3) influence of the questionnaire on anxiety and expectations relating to clinical care and (4) women's feelings about how the use of the questionnaire has affected their health and well-being.

RESULTS

Qualitative analysis identified eight themes relating to the burden and the benefit of questionnaire use with 'benefit' being the dominant theme. Women felt that the questionnaire improved their understanding of their condition, improved communication with clinicians and helped prepare them for clinical consultations, generally finding it relevant, easy and enjoyable to complete. Some women commented on the burden of questionnaire use and expressed concerns about its length and that it's closed multiple choice format was restrictive.

CONCLUSIONS

The identified principal themes of enhanced communication and preparedness for clinical consultation provided by the questionnaire appeared to support improved focus and insight, which in turn contributed to the setting of realistic expectations.

Autonomous online health assessment questionnaire registry in daily clinical practice

OBJECTIVE

Tight control in RA necessitates frequent disease monitoring; patients might participate by self-assessment of their functional status. Therefore, we assessed the feasibility and acceptability of autonomous online registry of physical functioning.

METHODS

In two tertiary-care centres (in The Netherlands and France), consecutive RA patients were approached to perform autonomous registry of the HAQ in an electronic medical record. Feasibility and acceptability of autonomous HAQ registry was assessed through: (i) the percentage of acceptances; (ii) the time needed to register the HAQ (the Netherlands); (iii) patient satisfaction with autonomous registry; and (iv) willingness for future home-based HAQ completion, either self-declared (The Netherlands) or actual file access from home within 6 months (France).

RESULTS

In all, 214 patients were approached; 163 agreed to participate; 137 (64% of 214) had complete data that were analysed. Median age was 56 years (range 20-78 years), 80% were female, median disease duration was 9 years. The median time needed to fill in the HAQ in the waiting room was 5.8 min; patient satisfaction was high (mean score 4.1 out of 5), self-declared willingness for autonomous registry at home was 73%. In the 6-month follow-up period, 46% of patients accessed their medical file from home at least once.

CONCLUSION

Many RA patients reported willingness to self-monitor their disease online, but fewer than half of the patients actually did. To enhance patient autonomous monitoring, progress is needed in terms of Internet access, continuous patient support and, importantly, convincing patients that they will benefit from autonomous monitoring.

Using patient-reported outcomes in clinical oncology practice: benefits, challenges and next steps

Measuring patient outcomes such as health-related quality-of-life in clinical practice can provide opportunities for patient monitoring and management. Well-validated instruments are available and studies have shown that such information is acceptable to - even valued by - patients and their clinicians. However, despite such general acceptance of the idea and, as demonstrated in feasibility studies, such systematic reporting occurs rarely in oncology practice in the USA and many challenges to widespread adoption exist. These challenges include limitations in knowledge about how best to interpret individual patient-reported outcomes and clinician, patient-related and health system issues. The way forward does not lie simply in urging clinicians to add patient-reported measurement to other tasks that are part of everyday practice. Rather, new information infrastructures and technologies, combined with redesign of care, are more likely to embed the routine use of patient-reported outcomes. In addition to taking vital signs and performing laboratory tests, such information can better provide a timely response to patient needs.

Improvements in measuring the health-related quality of life of cancer patients

There have been considerable improvements in the collection of health-related quality of life (HRQOL) data in oncology over the past 20 years. The facility with which HRQOL information can now be collected from patients has also been associated with an improved understanding of the meaning of HRQOL and the association between HRQOL and patients' treatment and care plans. Therefore the role that HRQOL data can play in routine clinical practice is increasingly being recognized. The appearance of computer-adaptive tests will herald a new era in HRQOL where questionnaires will be individually tailored to each patient utilizing details unique to that person and linked to clinical management systems to allow a comprehensive assessment of HRQOL status.

Personal digital assistant data capture: the future of quality of life measurement in prostate cancer treatment

PURPOSE

This article examines the potential use of personal digital assistant (PDA) data capture systems for real-time linear monitoring of health-related quality of life (HRQOL) in prostate cancer research and clinical care.

METHODS

We discuss the benefits and potential issues of using PDA data capture in the clinical health care setting. In addition, we describe the development and potential use of a PDA data capture system specific to managing HRQOL in prostate cancer treatment.

CONCLUSION

Follow-up health care clinics require a practical and systematic process of HRQOL data capture and analysis. Traditional paper questionnaire data capture is problematic. Data manipulation required for clinical decision-making is impractical for patient feedback on same-day clinic visits. Furthermore, the process of transforming paper questionnaire data to analysis-quality data can compromise data integrity. In contrast, research findings confirm the acceptability, ease of use, and reliability of PDAs in capturing data across health care settings, including the collection of serial HRQOL data. The main concern for PDA capture systems is the ability to compare respondent's answers between the paper and PDA questionnaire. Other challenges included patients reporting a lack of computer literacy and/or poor eyesight, as well as initial start-up costs. If issues are successfully addressed, the use of a PDA data capture system, such as the PDA HRQOL system at Princess Margaret Hospital's Prostate Centre, allows for valid and economical data collection with the possibility of linear real-time measurement of changes in HRQOL. Accordingly, there appears to be significant potential for PDA data collection of serial HRQOL in prostate cancer clinic settings.

Validity of a computer touch-screen questionnaire system in back patients

STUDY DESIGN

Validation study.

OBJECTIVE

A system for patient self-recording on a computer touch-screen was developed. The validity of this method compared with the use of regular paper-and-pen questionnaires was studied.

SUMMARY OF BACKGROUND DATA

Systematic evaluation of health problems often involves the use of self-reporting questionnaires in order to collect data on different variables. Recording of such data for subsequent analysis requires several steps including filling out of paper forms and secretarial work. Missing values and misrecordings are frequent problems.

METHODS

Seventy-nine patients with back problems visiting our outpatient clinic for surgical evaluation were invited to take part in the study by answering a mailed questionnaire concerning background data, pain, function, quality of life, and depressive symptoms approximately 3 weeks before their visit. At the day of the visit they were asked to again answer the same questions with a replicate response option format displayed on a computer touch-screen.

RESULTS

The agreement concerning background history questions, measured by kappa values was generally good (0.71-1.0). For visual analogue scale recordings (0-100) of back and leg pain, the mean of the differences were 1.1 and 2.1, respectively, and the correlations (Pearson) 0.72 and 0.87. The Euro-Qol 5 Dimension Score, the General Function Score, the Zung Depression Scale and the physical dimensions of the Short Form-36 showed a high degree of agreement between paper and screen recordings with difference means close to 0 and reliabilities comparing well to published methodologic errors for paper form versions. There were, however, differences concerning the mental components of the SF-36 with somewhat higher ratings on screen recordings. Missing values were 0% for screen recordings and for paper forms, 2.3% on individual questions and 12% on composite scores.

CONCLUSION

Computerized touch-screen questionnaires virtually eliminates missing values and show good validity and reliability compared to paper forms. The SF-36 tended to produce slightly higher values on touch-screen recordings in questions concerning mental health.

Implementation of computer-based quality-of-life monitoring in brain tumor outpatients in routine clinical practice

CONTEXT

Computerized assessment of quality of life (QOL) in patients with brain tumors can be an essential part of quality assurance with regard to evidence-based medicine in neuro-oncology.

OBJECTIVES

The aim of this project was the implementation of a computer-based QOL monitoring tool in a neurooncology outpatient unit. A further aim was to derive reference values for QOL scores from the collected data to improve interpretability.

METHODS

Since August 2005, patients with brain tumors treated at the neuro-oncology outpatient unit of the Innsbruck Medical University were consecutively included in the study. QOL assessment (European Organisation for Research and Treatment of Cancer [EORTC] Quality of Life Questionnaire [QLQ-C30] plus the EORTC QLQ-brain cancer module [BN20]) was computer-based, using a software tool called the Computer-based Health Evaluation System.

RESULTS

A total of 110 patients with primary brain tumors (49% female; mean [standard deviation] age 47.9 [12.6] years; main diagnoses: 30.9% astrocytoma, 17.3% oligodendroglioma, 17.3% glioblastoma, 13.6% meningioma) was included in the study. On average, QOL was assessed 4.74 times per patient, 521 times in total. The user-friendly software was successfully implemented and tested. The routine QOL assessment was found to be feasible and was well accepted by both physicians and patients.

CONCLUSION

The software-generated graphic QOL profiles were found to be an important tool for screening patients for clinically relevant problems. Thus, computer-based QOL monitoring can contribute to an optimization of treatment (e.g., symptom management, psychosocial interventions) and facilitate data collection for research purposes.

Health-related quality of life following haematopoietic cell transplantation: patient education, evaluation and intervention

Health-related quality of life (QOL) is a vital concern in the pre-treatment consent process and post-treatment care of recipients of haematopoietic cell transplantation (HCT). We propose that comprehensive care of such patients requires an integration of knowledge of the impact of HCT on QOL, assessment of QOL, as well as resources available for intervention. This knowledge may significantly improve patient care when incorporated into daily clinical practice in the transplant setting. As a framework for this approach, this article reviews the literature on QOL after allogeneic and autologous HCT for adults with haematological malignancies. We then discuss evidence in support of the beneficial impact of clinical QOL assessment, and finally evaluate behavioural interventions that show promise to maintain or improve QOL after HCT.

Towards the Implementation of Quality of Life Monitoring in Daily Clinical Routine: Methodological Issues and Clinical Implication

Quality of life (QOL) has become a widely used outcome parameter in the evaluation of treatment modalities in clinical oncology research. By now, many of the practical problems associated with measuring QOL in clinical practice can be overcome by the use of computer-based assessment methods. QOL assessment in oncology is dominated by two measurement systems, the FACT scales and the EORTC QLQ-C30 with its modules. The amount of human resources required to implement routine data collection has been reduced significantly by advanced computer technology allowing data collection in busy clinical practice. Monitoring of QOL can contribute to oncologic care by facilitating detection of physical and psychological problems and tracking the course of disease and treatment over time. Furthermore, the integration of screening for psychosocial problems into QOL monitoring contributes to the identification of patients who are in need of psychooncologic interventions. Computer-based QOL monitoring does not replace the direct physician-patient communication but enables to identify specific impairments and symptoms including psychological problems. Beyond clinical practice, QOL data can be used for research purposes and may help health care planners to determine those patient services that should be maintained or ones that should be developed.

Quality of life and outcomes research in head and neck cancer: a review of the state of the discipline and likely future directions

Quality of life (QOL) is by definition a multi-dimensional global construct that has become an increasingly important outcome measure in cancer treatment. The impact of a head and neck cancer (HNC) diagnosis on the person and the consequences of its treatment cross multiple functional domains that have a clear and direct influence on one's post-treatment well-being and associated QOL. The evaluation of QOL and performance outcome in cancer is critical to optimal patient care, comprehensive evaluation of treatment alternatives, and the development of informed rehabilitation and patient education services. Despite the difficulties of going from concept to quantification of patient perceptions, the number of instruments available to measure QOL psychometrically has increased rapidly. Assessments can now be made in a variety of distinctive ways using both specific and generic measures. There is no gold-standard questionnaire and the choice is based on psychometric properties, research objectives and study design. QOL assessment has evolved over the years into an organised scientific discipline, such that useful insights can be obtained by a review of the current literature. However, more work needs to be done to improve the applicability and clinical utility of QOL assessment. Most importantly, QOL studies should be reported in such a way as to provide clinically meaningful data to physicians and surgeons, in order to link research to clinical practice. Further attention should be paid to the development of newer theoretical models, minimalist approaches, development of more sensitive and specific instruments and the effective use of modern technology to achieve this objective.

Logistic feasibility of health related quality of life measurement in clinical practice: results of a prospective study in a large population of chronic liver patients

BACKGROUND

The objective of the present study was to provide a complete and detailed report of technical and logistical feasibility problems with the implementation of routine computerized HRQoL measurement at a busy outpatient department of Hepatology that can serve as a tool for future researchers interested in the procedure.

METHODS

Practical feasibility was assessed by observing problems encountered during the development of the computer program, observing patients' ability to complete the HRQoL questionnaires, monitoring the number of times that patients completed the HRQoL questionnaires and observing logistics at the outpatient department. Patients' reasons for not completing the HRQoL questionnaires were assessed retrospectively by means of a mailed questionnaire. Physicians' attitudes towards the availability of computerized HRQoL information about their patients were assessed by means semi-structured interviews and by means of checklists administered after each consultation with s study participant.

RESULTS

All physicians (n = 11) and 587 patients agreed to participate in the study. Practical feasibility problems concerned complicated technical aspects of developing a user-friendly computer program and safe data transmission over the Internet, patients' lack of basic computer skills and patients' lack of compliance (completion of questionnaires on only 43% of the occasions). The main reason given for non-compliance was simply forgetting, which seemed to be related to reception employees' passive attitude towards sending patients to the computer. Physicians were generally positive about the instant computerized availability of HRQoL information. They requested the information in 92% of the consultations and found the information useful in 45% of the consultations, especially when it provided them with new information.

CONCLUSION

This study was among the first to implement the complete procedure of routine computerized HRQoL measurements in clinical practice and to subsequently describe the feasibility issues encountered. It was shown that the attitudes of physicians were generally positive. Several barriers towards successful implementation of such a procedure were encountered, and subsequently solutions were provided. Most importantly, when implementing routine computerized HRQoL measurements in clinical practice, assistance of an IT professional for the development of a tailor-made computer program, availability of questionnaires in multiple languages and the use of touch-screen computers to optimise patient participation are essential. Also, all staff of the department concerned should approve of the intervention and consider it as part of standard clinical routine if successful implementation is to be obtained.

Taking PROs and patient-centered care seriously: incremental and disruptive ideas for incorporating PROs in oncology practice

Using patient-reported outcomes (PROs) in clinical practice poses challenges for health care teams and organizations to respond to individual patient needs in a timely fashion. Well-validated tools and feasibility studies are available, but successful spread will require knowledge of effective technology dissemination in complex health delivery systems. Given what has been learned about effective implementation, it is reasonable to ask whether the broad adoption of PROs can occur incrementally using current models of care to apply PRO technology. Another approach is to start with patient needs and focus on how to meet those needs most effectively using PROs in new ways of organizing health care.

Outcome scores collected by touchscreen: medical audit as it should be in the 21st century?

INTRODUCTION

Collecting outcome scores in paper form is fraught with difficulty. We have assessed the feasibility of, and patient's attitude towards, entering scores using a touchscreen.

PATIENTS AND METHODS

A touchscreen was installed in the orthopaedic out-patient clinic. If relevant, patients were asked to complete either an Oswestry Disability Index (ODI) or Oxford Shoulder Score (OSS) using the screen. Patients were given written instructions and their hospital number by the receptionist who had no further input. Scores were completed with two identifiers. A paper questionnaire was used to assess computer experience and attitude towards the touchscreen.

RESULTS

A total of 1348 patients, average age 50 years, successfully completed a score in the first 12 months. One-third were over 60 years. Overall, 91% correctly entered their hospital number and date of birth, falling to 84% in patients over 70 years. All patients were identifiable. The average time to complete the scores was 4.7 min rising with age. Of 170 patients completing the paper assessment of the touchscreen, one-third had little or no experience of computers and a third were over 60 years. Of patients, 93% were willing to repeat the score using the touchscreen to monitor progress. Two-thirds found it easier to use than expected. Only 10% would prefer a paper score. These results were maintained among patients over 60 years. Only two were unable to complete the score and 80% of those potentially eligible did so. The remainder were called to clinic before the touchscreen was free.

CONCLUSIONS

Orthopaedic outcome scores can be collected in very large volumes using a touchscreen. Data are then in an immediately usable form. The method is acceptable to patients, independent of age and computer experience. Even in the oldest patients, the accuracy is higher than for paper versions of the score. Combined with operative data, this simple method has the potential to provide a very powerful audit tool indeed.

Applying quality-of-life data formally and systematically into clinical practice

The systematic integration of quality-of-life (QOL) assessment into the clinical setting, although deemed important, infrequently occurs. Barriers include the need for a practical approach perceived as useful and efficient by patients and clinicians and the inability of clinicians to readily identify the value of integrating QOL assessments into the clinical setting. We discuss the use of QOL data in patient care and review approaches used to integrate QOL assessment into the clinical setting. Additionally, we highlight select QOL measures that have been successfully applied in the clinical setting. These measures have been shown to identify key QOL issues, improve patient-clinician communications, and improve and enhance patient care. However, the work done to date requires continued development. Continued research is needed that provides information about benefits and addresses limitations of current approaches.

Use of Patient-Reported Outcomes in Clinical Oncology Practice

The Institute of Medicine report, Crossing the Quality Chasm, suggested some new ways of thinking about organizing care. This article describes how practices might create continuous healing relationships using methods that are independent of patient visits to monitor and address problems that may occur during cancer care. Such a system would be based on patient report, timely and useful, sensitive to change, and low burden for patients, clinicians, and administrative staff. Furthermore, it would be built into the delivery of care and be integrated with other data systems such as patient records, decision support, and community or other resources. Using reports for patients that are presented in a format that is easily understandable, patients should be able to monitor their own progress.

Palliative Care Consultation, Quality-of-Life Measurements, and Bereavement for End-of-Life Care in Patients With Lung Cancer

OBJECTIVE

To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer.

METHODS

To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients.

RESULTS

Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death.

CONCLUSION

Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Conducting routine fatigue assessments for use in clinical oncology practice: patient and provider perspectives

GOALS OF WORK

Fatigue is the most common symptom associated with cancer and its treatment. The present study measured patient and provider perceptions of the feasibility and acceptability of conducting computerized fatigue assessments during routine follow-up outpatient clinic visits.

MATERIALS AND METHODS

A subset of 64 patients from a larger study, testing items for inclusion in a fatigue item bank, completed two computerized fatigue assessments at 2- to 3-month intervals. After the second assessment, patients completed a questionnaire about the usefulness of the assessments and the understandability of graphic reports depicting the fatigue scores. They were also asked about the optimal frequency for conducting fatigue assessments. Providers were asked similar feasibility questions.

MAIN RESULTS

Providers thought displays of fatigue scores would be more useful than patients did. Patients and providers also differed on the frequency with which fatigue assessments should be conducted. Interestingly, of the 37% of patients who reported that assessments should be conducted at a different frequency than the choices that were offered, 50% reported that the assessments should be conducted according to their treatment schedule. The majority of providers thought fatigue assessments should be administered at each MD visit.

CONCLUSION

Patients and providers differed about the perceived usefulness of displaying fatigue scores and the frequency with which routine assessments should be conducted. However, both patients and providers appeared to endorse the notion that routine assessments would be beneficial. Integration of routine assessments of commonly experienced symptoms such as fatigue may have important implications for improving symptom management in the future, ultimately resulting in better overall patient care.

Electronic and computer-generated patient questionnaires in standard care

Patient-derived measures of disease activity have been proven to be reliable, valid, sensitive to change, and less susceptible to placebo effects in the assessment of many rheumatic diseases. Traditionally, paper forms have been used to capture this information but with advances in technology and a growing number of computer users, computerized versions have been developed. The computerized patient-derived questionnaires have been shown to be valid and reliable in many studies. Despite a concern for the usability and acceptability among inexperienced computer users and certain subgroups, such as older persons, a majority of patients queried preferred the electronic versions and found them easy to use. In addition, these computerized versions offer several advantages over the paper format, including improved data capture with less ambiguity, less long-term cost, immediate scoring and availability of the results, and--most importantly--the ability for more frequent disease activity, efficacy, and safety assessments.

Quality of life assessment in women with breast cancer: benefits, acceptability and utilization

In 2006, breast cancer was the third leading cause of death in American women; however, more women survive breast cancer than any other type of cancer. As the disease progresses, it is important to know how one's health-related quality of life (QOL) is affected for those who receive treatment, those who survive, and those who remain disease-free. The purpose of this study was to summarize the benefits, challenges, and barriers of QOL measurement for female breast cancer patients. A PubMed literature search was conducted using the terms "quality of life" and "breast cancer." The search was then refined with terms related to QOL assessment instruments. The research team reviewed over 100 of the 2,090 articles identified. From the results, a detailed outline of QOL instruments is presented, and the effectiveness of QOL instruments is discussed. In the current literature review, both generic and breast cancer specific QOL instruments, examining computerized and paper-and-pencil versions, are explained as well as the advantages, acceptability, and problems of these assessments. Potential barriers to implementation are also discussed. The implementation of QOL assessment tools in breast cancer clinical practice is discussed, with evidence detailing how such tools would benefit patients.

Daily health status registration (patient diary) in patients with rheumatoid arthritis: a comparison between personal digital assistant and paper-pencil format

OBJECTIVE

The patient perspective workshops at the Outcome Measures in Rheumatology Clinical Trials have included daily measures of health status (patient diary) and use of electronic tools for data collection in the research agenda. The objective of this study was to compare daily and weekly registrations of self-reported health status measures between personal digital assistant (PDA) and paper-pencil (PP) format regarding scores, variation, and feasibility.

METHODS

Thirty-eight patients with stable rheumatoid arthritis recorded their health status during 84 days in a repeated crossover design, using PDA or PP format during four 21-day periods. Visual analog scales (VAS) for pain, fatigue, and global disease and the Rheumatoid Arthritis Disease Activity Index were scored daily; the Short Form 36 and Modified Health Assessment Questionnaire were scored weekly.

RESULTS

The average scores and measures of variation of the 4 daily health status measures over 21 days did not differ significantly between PDA and PP formats in either of the 2 crossover periods. The values for the average range between the maximum and minimum values for daily measures were similar between the 2 formats, but showed considerable variation (e.g., range for pain VAS was 19-28 mm over each 21-day period). The time to complete the instruments was similar between the 2 formats. Missing daily data entries were generally low for both periods and somewhat higher for PDA. The majority of patients (82.9%) preferred using PDA.

CONCLUSION

Daily assessments with PDA may be efficiently used for frequent data collection because this format performs similarly to the traditional PP format.

The future of outcomes measurement: item banking, tailored short-forms, and computerized adaptive assessment

The use of item banks and computerized adaptive testing (CAT) begins with clear definitions of important outcomes, and references those definitions to specific questions gathered into large and well-studied pools, or "banks" of items. Items can be selected from the bank to form customized short scales, or can be administered in a sequence and length determined by a computer programmed for precision and clinical relevance. Although far from perfect, such item banks can form a common definition and understanding of human symptoms and functional problems such as fatigue, pain, depression, mobility, social function, sensory function, and many other health concepts that we can only measure by asking people directly. The support of the National Institutes of Health (NIH), as witnessed by its cooperative agreement with measurement experts through the NIH Roadmap Initiative known as PROMIS (www.nihpromis.org), is a big step in that direction. Our approach to item banking and CAT is practical; as focused on application as it is on science or theory. From a practical perspective, we frequently must decide whether to re-write and retest an item, add more items to fill gaps (often at the ceiling of the measure), re-test a bank after some modifications, or split up a bank into units that are more unidimensional, yet less clinically relevant or complete. These decisions are not easy, and yet they are rarely unforgiving. We encourage people to build practical tools that are capable of producing multiple short form measures and CAT administrations from common banks, and to further our understanding of these banks with various clinical populations and ages, so that with time the scores that emerge from these many activities begin to have not only a common metric and range, but a shared meaning and understanding across users. In this paper, we provide an overview of item banking and CAT, discuss our approach to item banking and its byproducts, describe testing options, discuss an example of CAT for fatigue, and discuss models for long term sustainability of an entity such as PROMIS. Some barriers to success include limitations in the methods themselves, controversies and disagreements across approaches, and end-user reluctance to move away from the familiar.

Asking the right questions: investigating needs assessments and health-related quality-of-life questionnaires for use in oncology clinical practice

GOALS OF WORK

Questionnaires used in oncology practice for individual patient management need to address issues patients find important and want help with and issues cancer center health professionals can address. We investigated the item content from two health-related quality-of-life (HRQOL) questionnaires and two needs assessments for this purpose.

PATIENTS AND METHODS

In this preliminary study, 61 cancer patients and 19 cancer center health professionals rated the item content from the EORTC-QLQ-C30, FACT-G, Supportive Care Needs Survey-34 (SCNS), and Kingston Needs Assessment--Cancer. Patients rated each item's importance and whether they wanted help with it; health professionals rated each item's importance and whether they felt able to help patients address it. Patients and health professionals also reported their overall questionnaire preference.

MAIN RESULTS

Patients rated information about treatments (options, benefits, side effects) and care coordination as the most important issues and those for which they most wanted help from their health professionals. Health professionals rated pain and other symptom/side effect items as most important to patients and those for which they were most able to help. Findings were consistent across tumor type and treatment status. Patients had an overall preference for the SCNS. Health professionals had no clear questionnaire preference.

CONCLUSIONS

This preliminary study suggests that the issues patients most want help with may not be the issues that health professionals feel most able to address. If these findings are confirmed in more representative samples, interventions may be needed to assist health professionals in managing cancer patients' HRQOL issues and needs.

Is the use of QOL data really any different than other medical testing?

QOL data and routine clinical data such as laboratory data, whether used in clinical practice or research, can be viewed by clinicians in the same way. Both provide important patient-related information using instruments which are reliable and valid. Both require that the clinician or researcher understand how to utilize and interpret the data and gain comfort with doing so through experience. It is through this repeated usage of QOL data that clinicians will, hopefully, come to accept QOL data as a routine and invaluable part of their practice and view it just as they view other clinical data. Whether it is a clinician looking at QOL data or laboratory data for the first time, or a clinical researcher including QOL data in a clinical trial for the first time, training, repetitive use, and experience is necessary to feel comfortable with integrating the data to recommend an appropriate clinical action or to capture the meaningful effect.

Integrating QOL assessments for clinical and research purposes

QOL questionnaires can be a useful tool for patients, clinicians, and researchers. Although each has a different goal and investment in the data, each of these perspectives can contribute to truly collaborative care in which the needs of the patient are met.

Computerised assessment of quality of life in oncology patients and carers

OBJECTIVES

To examine the feasibility of a computerised assessment and to compare resulting quality of life scores among oncology carers and patients.

METHODS

Six hundred and twenty-two subjects (carers n = 234, patients n = 388) attending an oncology or haematology clinic completed the WHO-Quality of Life-BREF (WHOQOL-BREF) and demographics on a personal computer. Age- and gender-standardised scores for carers and patients were compared to community norms. Carers were compared with patients using six three-way ANOVAs.

RESULTS

In total, 60.3% (234/388) of the patients had an accompanying carer attempt the survey and 93.6% (219 of 234) completed all items. The four domains of the WHOQOL-BREF had acceptable internal consistency (Cronbach alpha coefficients). Carers had lower quality of life on three domains (physical, psychological and environmental), and patients on two domains (physical and psychological), compared with the general community. Carers had higher overall satisfaction with their health than patients (standardised difference of 0.52 units-moderate effect).

CONCLUSION

A computerised system for assessing quality of life was feasible and found that carers and patients had significant impairments in quality of life. Clinicians and services interested in quality of life for carers and patients may use computerised assessments to identify those with poorer quality of life.

Development of a Smiling Touchscreen multimedia program for HRQoL assessment in subjects with varying levels of literacy

OBJECTIVE

As low literacy affects the assessment of health-related quality of life (HRQoL) in several ways (e.g., subject eligibility and cost of administration), better approaches to HRQoL assessment in subjects with varying literacy levels are needed.

METHODS

We developed a multimedia touchscreen program (the Smiling Touchscreen, ST) to administer HRQoL instruments to subjects with varying levels of Chinese language and computer literacy, using an iterative process where patients' input on design, clarity of instructions, and user-friendliness were repeatedly gathered and incorporated in development. The ST thus has several user-friendly features for low-literacy subjects (e.g., presentation of individual items using visual and auditory stimuli, voice-text synchronization, and visual analog scale with a touch and drag function), which we evaluated using qualitative and quantitative methods.

RESULTS

The ST was well accepted by subjects (n = 66, 76% female, median [interquartile] age: 49.0 [40.0, 56.0]) with high (n = 43) or low (n = 23) literacy, 98% of whom found it easy or very easy to use, and 85% found the voice-text synchronization feature useful. In low-literacy subjects without computer experience (30%), none reported any difficulties using the ST. The median (interquartile) time spent to complete the ST (four Instruction and Practice screens, 24 questions, one visual analog scale) for high- and low-literacy groups was 13.9 (9.6, 23.9) and 23.2 (15.8, 26.5) minutes, respectively. Among subjects expressing a preference (n = 47), 21 (47%) favored the ST over interviewer- or self-administration.

CONCLUSION

The ST is well accepted by subjects with varying literacy levels, including those without computer experience. It is thus a promising new approach for HRQoL assessment among subjects with varying literacy levels.

Chiropractic manipulation in adolescent idiopathic scoliosis: a pilot study

BACKGROUND

Adolescent idiopathic scoliosis (AIS) remains the most common deforming orthopedic condition in children. Increasingly, both adults and children are seeking complementary and alternative therapy, including chiropractic treatment, for a wide variety of health concerns. The scientific evidence supporting the use chiropractic intervention is inadequate. The purpose of this study was to conduct a pilot study and explore issues of safety, patient recruitment and compliance, treatment standardization, sham treatment refinement, inter-professional cooperation, quality assurance, and outcome measure selection.

METHODS

Six patients participated in this 6-month study, 5 of whom were female. One female was braced. The mean age of these patients was 14 years, and the mean Cobb angle was 22.2 degrees. The study design was a randomized controlled clinical trial with two independent and blinded observers. Three patients were treated by standard medical care (observation or brace treatment), two were treated with standard medical care plus chiropractic manipulation, and one was treated with standard medical care plus sham manipulation. The primary outcome measure was Cobb, and the psychosocial measure was Scoliosis Quality of Life Index.

RESULTS

Orthopedic surgeons and chiropractors were easily recruited and worked cooperatively throughout the trial. Patient recruitment and compliance was good. Chiropractic treatments were safely employed, and research protocols were successful.

CONCLUSION

Overall, our pilot study showed the viability for a larger randomized trial. This pilot confirms the strength of existing protocols with amendments for use in a full randomized controlled trial.

TRIAL REGISTRATION

This trial has been assigned an international standard randomized controlled trial number by Current Controlled Trials, Ltd. http://www.controlled-trials.com/isrctn/. The number is ISRCTN41221647.

Touch‐screen versus paper‐and‐pen questionnaires

PURPOSE

The aim of the paper is to compare the computer administration method (touch-screen) with the original paper-and-pen approach when measuring patients' perceptions of care quality.

DESIGN/METHODOLOGY/APPROACH

The study group consisted of 199 patients who responded to touch-screen and 219 who responded to paper-and-pen questionnaires, receiving care between January and March 2003 at two out-patient clinics in one county in Sweden. The response rate was 75 per cent. A modified version of the quality from the patient's perspective questionnaire was used.

FINDINGS

Two main findings emerged: first, both methods yielded almost identical results in quality of care ratings, and second, the touch-screen method was perceived to be easier to use and to take less time to complete.

ORIGINALITY/VALUE

The paper shows that both methods are acceptable, but the touch-screen method appears to be preferred by patients.

Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care

OBJECTIVE

To develop and evaluate a Web-based, electronic pelvic floor symptoms assessment questionnaire (e-PAQ)1 for women.

DESIGN

A cross-sectional study in primary and secondary care.

SETTING

Two general practices, two community health clinics and a secondary care urogynaecology clinic.

SAMPLE

A total of 432 women (204 in primary care and 228 in secondary care) were recruited between June 2003 and January 2004.

METHODS

The e-PAQ was located on a workstation (computer, touchscreen and printer). Women completed the e-PAQ prior to their appointment. Untreated women in primary care were asked to return seven days later to complete the e-PAQ a second time (test-retest).

MAIN OUTCOME MEASURES

Factor analysis, reliability, validity, patient satisfaction, completion times and system costs.

RESULTS

In secondary care, factor analysis identified 14 domains within the four dimensions (urinary, bowel, vaginal and sexual symptoms) with internal consistency (Cronbach's alpha)>or=0.7 in 11 of these. In primary care, alpha values were all>or=0.7 and test-retest analysis found acceptable intraclass correlations of 0.50-0.95 (P<0.001) for all domains. A measure of face validity and utility was gained using a nine-item questionnaire, which yielded strongly positive patient views on relevance and acceptability.

CONCLUSIONS

The e-PAQ offers a user-friendly clinical tool, which provides valid and reliable data. The system offers comprehensive symptoms and quality of life evaluation and may enhance the clinical episode as well as the quality of care for women with pelvic floor disorders.