Participation and consultation engagement strategies have complementary roles: A case study of patient and public involvement in clinical practice guideline development

Health professional involvement in the formulation of research questions: findings from the Italian guideline on palliative care in adults with glioma

BACKGROUND

In 2017, the European Association of Neuro-Oncology (EANO) published the guideline for palliative care in adults with glioma. The Italian Society of Neurology (SIN), the Italian Society for Palliative Care (SICP), and the Italian Association for Neuro-Oncology (AINO) joined forces to update the guideline, and adapt it to the Italian context.

AIM

We involved patients, caregivers, and (herein presented) healthcare professionals (HPs) in the formulation of the guideline clinical questions.

DESIGN AND PARTICIPANTS

Online survey of Italian HPs experienced in the care of patients with glioma. Participants rated the importance of 14 pre-specified intervention topics on a 0/10 scale and gave their free comments.

RESULTS

Of 244 participants, 149 (61%) were palliative medicine (PM) HPs and 95 Neuro HPs. Their mean age was 48.9 years, 63% were women, and 48% had over 12 years of experience in the care of glioma patients. Physicians were 68%, followed by nurses (28%), psychologists (7%), therapists (3%), and social workers (2%). Most HPs rated the pre-specified topics as important (score ≥ 7) or critical (score ≥ 9), with some differences between PM and Neuro HP groups. There were 58 free comments: 46 (78%) on nine pre-specified topics, and 13 on four new topics, three of which were guideline-pertinent ("caregiver's support and education"; "family physician's training in neuro-oncology"; and "PM HPs' training in neuro-oncology").

CONCLUSIONS

Participation in the survey was high and information-rich, between-group rating differences reflecting HP background. Participants endorsed the 14 intervention topics devised by the guideline panel and identified three additional topics.

Patient and public involvement in the development of clinical practice guidelines: a scoping review

OBJECTIVES

Organisations that develop clinical practice guidelines (CPGs) encourage involvement of patients and the publics in their development, however, there are no standard methodologies for doing so. To examine how CPGs report patient and public involvement (PPI), we conducted a scoping review of the evidence addressing the following four questions: (1) who are the patients and publics involved in developing the CPG?; (2) from where and how are the patients and publics recruited?; (3) at what stage in the CPG development process are the patients and publics involved? and (4) how do the patients and publics contribute their views? We also extracted data on the use of PPI reporting checklists by the included studies.

DESIGN

We used the methodology developed by Arksey and O'Malley and refined by the Joanna Briggs Institute. We searched PubMed, Embase, CINAHL and PsycINFO, websites of national guideline bodies from the UK, Canada, Australia and the USA, and conducted a forward citation search. No language, date or participant demographics restrictions were applied. Data were synthesised narratively.

RESULTS

We included 47 studies addressing 1 or more of the 4 questions. All included studies reported who the patient and publics involved (PPI members) were, and several studies reported PPI members from different groups. Patients were reported in 43/47 studies, advocates were reported in 22/47 studies, patients and advocates reported in 17/47 studies, and general public reported in 2/47 studies. Thirty-four studies reported from where the patients and publics were recruited, with patient groups being the most common (20/34). Stage of involvement was reported by 42/47 studies, most commonly at question identification (26/42) and draft review (18/42) stages. Forty-two studies reported how the patients contributed, most commonly via group meetings (18/42) or individual interviews. Ten studies cited or used a reporting checklist to report findings.

CONCLUSIONS

Our scoping review has revealed knowledge gaps to inform future research in several ways: replication, terminology and inclusion. First, no standard approach to PPI in CPG development could be inferred from the research. Second, inconsistent terminology to describe patients and publics reduces clarity around which patients and publics have been involved in developing CPGs. Finally, the under-representation of research describing PPI in the development of screening, as opposed to treatment, CPGs warrants further attention.

Does patient and public involvement influence the development of competency frameworks for the health professions? A systematic review

Competency frameworks typically describe the perceived knowledge, skills, attitudes and other characteristics required for a health professional to practice safely and effectively. Patient and public involvement in the development of competency frameworks is uncommon despite delivery of person-centered care being a defining feature of a competent health professional. This systematic review aimed to determine how patients and the public are involved in the development of competency frameworks for health professions, and whether their involvement influenced the outcome of the competency frameworks. Studies were identified from six electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, Web of Science and ERIC). The database search yielded a total of 8,222 citations, and 43 articles were included for data extraction. Most studies were from the United Kingdom (27%) and developed through multidisciplinary collaborations involving two or more professions (40%). There was a large variation in the number of patients and members of the public recruited (range 1–1,398); recruitment sources included patients and carers with the clinical condition of interest (30%) or established consumer representative groups (22%). Common stages for involving patients and the public were in generation of competency statements (57%) or reviewing the draft competency framework (57%). Only ten studies (27%) took a collaborative approach to the engagement of patients and public in competency framework development. The main ways in which involvement influenced the competency framework were validation of health professional-derived competency statements, provision of desirable behaviors and attitudes and generation of additional competency statements. Overall, there was a lack of reporting regarding the details and outcome of patient and public involvement. Further research is required to optimize approaches to patient and public involvement in competency framework development including guidance regarding who, how, when and for what purposes they should be engaged and the requirements for reporting.

Multiple stakeholders' perspectives on patient and public involvement in community mental health services research: A qualitative analysis

Background

Patient and public involvement (PPI) has become essential in health research. However, little is known about multiple stakeholders' perspectives on the implementation of PPI in community mental health research settings. The present study aimed to qualitatively analyse multiple stakeholders' views on PPI, including potential concerns, barriers and approaches.

Methods

This study involved conducting focus group interviews and collecting qualitative data from 37 participants in multiple stakeholder groups (patients = 6, caregivers = 5, service providers = 7, government staff = 5 and researchers = 14) in the community mental health field. The data were qualitatively analysed using a data‐driven approach that derived domains, themes and subthemes related to perspectives on PPI and to specific challenges and approaches for implementing PPI.

Results

The qualitative analysis identified four domains. The ‘Positive views and expectations regarding PPI’ domain consisted of themes related to supportive views of PPI in a mental health service research setting and improvements in the quality of research and service. The ‘General concerns about PPI’ domain included themes concerning the need for non‐PPI research and tokenism, excessive expectations concerning social changes and use of evidence from PPI research, and heavy burdens resulting from PPI. The ‘Specific issues regarding the implementation of PPI’ domain consisted of four themes, including academic systems, selection methods (e.g., representativeness and conflict of interest issues), relationship building, and ambiguous PPI criteria. In particular, all stakeholder groups expressed concerns about relational equality during PPI implementation in Japan. The ‘Approaches to PPI implementation’ domain included themes such as facilitating mutual understanding, creating a tolerant atmosphere, establishing PPI support systems (e.g., training, ethics and human resource matching) and empowering patient organizations.

Conclusion

The study replicated most of the barriers and approaches to PPI reported by qualitative research in Western counties. However, utilization of evidence produced by PPI research and partnership in the PPI process may be particularly serious issues in Japan. Future PPI studies should carefully address solutions that fit each culture.

Patient or Public Contribution

A patient‐researcher was involved in all stages of this project, from development of the research topic and the protocol to manuscript preparation.

Identifying current driver rehabilitation practices for clients with physical impairments

Introduction

Driving is an important occupation that influences a person’s ability to access community resources and participate in meaningful activities. Occupational therapists and other clinicians who are trained as driver rehabilitation specialists provide interventions to improve function and independence in driving. The objective of this study was to examine consistency of adaptive driving equipment prescription and driver retraining recommendations for clients with physical impairment and identify factors that influence driver rehabilitation recommendations.

Methods

Clinicians practicing in Canada and the United States were surveyed electronically. Data were analyzed using descriptive statistics and content analysis.

Results

Out of 36 respondents, the majority (97.2%) were occupational therapists. Completion of in-clinic (97.0%) and on-road (84.4%) evaluations were consistent among the majority of respondents, yet components comprising evaluations varied. Fewer respondents were in agreement in equipment recommendations for secondary controls. Respondents emphasized the importance of clinical reasoning skills when making equipment and intervention recommendations.

Conclusion

Further development of clinical guidelines and advanced training in driver rehabilitation may be beneficial to facilitate clinical reasoning and improve consistency of practice.

Evaluating the Acceptability, Feasibility, and Outcomes of Two Methods Involving Patients With Disability in Developing Clinical Guidelines: Crossover Pilot Study

Background

Engaging patients and the public in clinical practice guideline (CPG) development is believed to contribute significantly to guideline quality, but the advantages of the various co-design strategies have not been empirically compared, making it difficult to choose one strategy over another.

Objective

This pilot study aims to document the acceptability, feasibility, and outcomes of 2 methods of involving patients in outlining CPG.

Methods

A single-blind crossover pragmatic study was performed with patients with traumatic brain injury. The patients experimented with 2 alternative methods of producing clinical practice recommendations (ie, a discussion group and a wiki). The participants rated the acceptability of the 2 methods, and feasibility was assessed using indicators, such as the number of participants who completed the 2 methods and the number of support interventions required. Experts, blinded to the method, independently rated the participants' outcome recommendations for clarity, accuracy, appropriateness, and usefulness.

Results

We recruited 20 participants, and 16 completed the study. The acceptability of the 2 methods showed little variation, with qualitative comments expressing a slight preference for the social nature of focus groups. Thus, both methods of involving patients in CPG development appeared feasible, and the experts’ opinions of the adapted recommendations were both positive, although the recommendations produced through focus groups were deemed more relevant to support clinical practice.

Conclusions

Our results confirm the acceptability and feasibility of focus groups and wikis to allow patients with traumatic brain injury to participate in clinical practice guideline production. This study contributes to the scientific literature by suggesting that the 2 methods were acceptable, feasible, and produced positive outcomes.

Trial Registration

ClinicalTrials.gov NCT02023138; https://clinicaltrials.gov/ct2/show/NCT02023138

Conceptualizing patient participation in psychiatry: A survey describing the voice of patients in outpatient care

BACKGROUND

While increasingly discussed in somatic care, the concept of patient participation remains unsettled in psychiatric care, potentially impeding person-centred experiences.

OBJECTIVE

To describe outpatient psychiatric care patients' conceptualization of patient participation.

DESIGN

An exploratory survey.

SETTING AND PARTICIPANTS

Patients in four psychiatric outpatient care units.

VARIABLES

Patients conceptualized patient participation by completing a semi-structured questionnaire, including optional attributes and free text. Data were analysed using statistics for ordinal data and content analysis for free text.

RESULTS

In total, 137 patients (69% of potential respondents) completed the questionnaire. The discrete items were favoured for conceptualizing patient participation, indicating a primary connotation that participation means being listened to, being in a reciprocal dialogue, learning about one's health care and managing one's symptoms. Additional free-text responses acknowledged the attributes previously recognized, and provided supplementary notions, including that patient participation is about mutual respect and shared trust.

DISCUSSION

What patient participation is and how it can be facilitated needs to be agreed in order to enable preference-based patient participation. Patients in outpatient psychiatric care conceptualize participation in terms of both sharing of and sharing in, including taking part in joint and solo activities, such as a reciprocal dialogue and managing symptoms by yourself.

CONCLUSION

While being a patient in psychiatric care has been associated with a lack of voice, an increased understanding of patient participation enables person-centred care, with the benefits of collaboration, co-production and enhanced quality of care.

PATIENT CONTRIBUTION

Patients provided their conceptualization of patient participation in accordance with their lived experience.

'It takes a village': a qualitative study on malnutrition and oral nutritional supplements with older adults in Ireland

BACKGROUND

Malnutrition affects approximately 20% of older adult populations in Europe, yet their views on the condition are rarely explored. This qualitative study aimed to explore the experiences of older adults living with malnutrition and prescribed oral nutritional supplements in the community setting.

METHODS

Semi-structured individual interviews were used to collect data from 13 community-dwelling individuals aged ≥60 years with a current or previous prescription for oral nutritional supplements. Self-perceived health status was measured using the EuroQol EQ-5D-5L, a short questionnaire and visual analogue scale. Interviews were audio-recorded and transcribed verbatim. Interview data were organized using NVivo 12 and analyzed using inductive thematic analysis.

RESULTS

Median age was 80.0 (interquartile range 19.5) years, seven were male and six were female. Median health score was 60.0 (interquartile range 35.0) out of 100. Almost one-third reported severe or extreme problems with usual activities, and pain or discomfort. One main theme was identified from the interviews: 'It takes a village', with four subthemes (i) 'I get by with a little help from my friends', (ii) 'The obvious diagnosis', (iii) 'The missing T in MDT' and (iv) 'Confusion'. Participants with malnutrition reported relying on friends, family and carers with poor multidisciplinary team communication and lack of dietetic support.

CONCLUSIONS

Participants in this study experienced poor management of malnutrition with missing links between the hospital and community healthcare settings, and lack of dietetic services. Patient views should be used to inform public health guidelines and guide future interventions in the community to improve the health status of older adults with malnutrition.

Clinical practice guidelines for the nutritional risk screening and assessment of cancer patients: a systematic quality appraisal using the AGREE II instrument

PURPOSE

To evaluate the quality of published clinical practice guidelines (CPGs) regarding the nutritional risk screening and assessment of cancer patients and to identify high-quality CPGs for clinical healthcare professionals.

METHODS

Guidelines for the nutritional risk screening and assessment of cancer patients were comprehensively searched in eight electronic databases, including The Lancet, PubMed, Cochrane Library, Excerpta Medica dataBASE (EMBASE), Web of Science, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBMdisc), and Wan Fang Data, through August 2020. Six relevant guideline databases, including the National Comprehensive Cancer Network (NCCN), the National Guideline Clearinghouse (NGC), the Guideline International Network (GIN), the New Zealand Guidelines Group (NZGG), the China Guideline Clearinghouse (CGC), and Medlive, and relevant nutrition society websites, were also searched through August 2020. The methodological quality of the included CPGs was appraised independently by three assessors using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) tool.

RESULTS

Seven CPGs were located, and the domain with the highest percentage was "clarity of presentation" (85.44%), while the domain with the lowest percentage was "applicability" (40.26%). From the AGREE II results, two guidelines were rated as "strongly recommended," three were assessed as "recommended with modifications," and two were deemed as "not recommended."

CONCLUSION

Considering that the two "strongly recommended" guidelines were developed within the American and European contexts, translation, validation, and cultural adaptation are recommended prior to implementing these guidelines in other countries or healthcare contexts to improve their effectiveness and sensitivity for local cancer patients.

TRIAL REGISTRATION

PROSPERO registration of the study protocol: CRD42020177390 (July 5, 2020).

Research priorities of caregivers and individuals with dementia with Lewy bodies: An interview study

BACKGROUND

Funding bodies are placing increased emphasis on patient and public involvement in research, but the research priorities of individuals and caregivers living with dementia with Lewy bodies (DLB) are unknown.

METHOD

Investigators conducted telephone interviews with individuals living with DLB and caregivers. Participants were recruited from a Lewy Body Dementia Association Research Center of Excellence. Interviews employed a semi-structured questionnaire querying research needs in different categories and then asking participants to select their top priorities. Investigators used a qualitative descriptive approach to analyze transcripts and identify themes.

RESULTS

Twenty individuals with DLB and 25 caregivers participated. Seventeen from each group participated as part of a patient-caregiver dyad. Twenty-three of the caregivers were spouses, two were daughters. Individuals with DLB and caregivers identified research needs relating to focusing on awareness, determining the cause of DLB, improving diagnosis, and investigating what to expect/disease stages. Participants also highlighted DLB symptoms needing additional research, therapies to prevent, cure, or slow the progression of DLB, and research targeting daily function and quality of life, caregiving, and improving education.

CONCLUSIONS

These findings support the research priorities defined in the National Institutes of Health dementia care summits in addition to ADRD priority-setting summits. Research is needed across all domains of DLB. Funding should be informed by the priorities of all relevant stakeholders and support research investigating causes, natural history, biomarkers, and treatment in addition to research targeting themes regarding living with disease (e.g. independence, quality of life, caregiving, and education).

Patient and Family Participation in Clinical Guidelines Development: The Cystic Fibrosis Foundation Experience

Patient and family participation in guideline development is neither standardized nor uniformly accepted in the guideline development community, despite the 2011 Institute of Medicine’s Guidelines We Can Trust and the Guideline International Network’s GIN-Public Toolkit recommendations. The Cystic Fibrosis Foundation has included patients and/or family members directly in guideline development since 2004. Over time, various strategies for increasing patient and family member participation have been implemented. Surveys of recent patient/family and clinical guidelines committee members have shown that inclusion of individuals with cystic fibrosis and their family members on guidelines committees has provided insight otherwise invisible to clinicians.

Participation and consultation engagement strategies have complementary roles: A case study of patient and public involvement in clinical practice guideline development

Background

Patient and public involvement (PPI) is recommended when developing high‐quality clinical practice guidelines, but the effects of different PPI strategies are largely unstudied.

Objective

To assess the impact of participation and consultation strategies on guideline question development.

Design

Instrumental case study design.

Setting and participants

This study used a clinical practice guideline in development by the American Academy of Neurology. A patient, two caregivers and a dementia advocate participated in the guideline development group alongside clinicians. The guideline protocol was posted for public consultation for 30 days.

Interventions studied

Participation (patient representatives on the guideline development group) and consultation (public comment, survey) PPI strategies.

Main outcome measures

Public comment responses and guideline development group meeting transcripts were analysed descriptively. Transcript quotes were compared to the conceptual model of PPI in guideline development. The effects of participation and consultation strategies within the guideline case were compared.

Results

Participation strategies shaped discussions, set a patient‐centred scope, highlighted personal aspects of disease, affected how professionals viewed PPI, identified issues overlooked by medical professionals, and contributed to selecting patient‐relevant guideline populations and outcomes. Professionals responded to public comment more than patient representatives. Patient survey participants confirmed the priorities voiced by patient representatives on the guideline development group. Final guideline questions included populations and outcomes promoted by patient representatives despite negative feedback from professional public commenters.

Discussion and conclusions

Participation and consultation PPI strategies have different advantages. Congruence between strategies increases the strength of the patient voice. Guideline developers should prioritize using both strategies for successful PPI.