Patient reported outcome measures (PROMs) in primary care: an observational pilot study of seven generic instruments

Reliability, Measurement Error, Responsiveness, and Minimal Important Change of the Patient-Specific Functional Scale 2.0 for Patients With Nonspecific Neck Pain

OBJECTIVE

The Patient-Specific Functional Scale (PSFS) is a patient-reported outcome measure used to assess functional limitations. Recently, the PSFS 2.0 was proposed; this instrument includes an inverse numeric rating scale and an additional list of activities that patients can choose. The aim of this study was to assess the test-retest reliability, measurement error, responsiveness, and minimal important change of the PSFS 2.0 when used by patients with nonspecific neck pain.

METHODS

Patients with nonspecific neck pain completed a numeric rating scale, the PSFS 2.0, and the Neck Disability Index at baseline and again after 12 weeks. The Global Perceived Effect (GPE) was also collected at 12 weeks and used as an anchor. Test-retest measurement was assessed by completion of a second PSFS 2.0 after 1 week. Measurement error was calculated using a Bland-Altman plot. The receiver operating characteristic method with the anchor (GPE) functions as the reference standard was used for calculating the minimal important change.

RESULTS

One hundred patients were included, with 5 lost at follow-up. No floor and ceiling effects were reported. In the test-retest analysis, the mean difference was 0.15 (4.70 at first test and 4.50 at second test). The ICC (mixed models) was 0.95, indicating high agreement (95% CI = 0.92-0.97). For measurement error, the upper and lower limits of agreement were 0.95 and -1.25 points, respectively, with a smallest detectable change of 1.10. The minimal important change was determined to be 2.67 points. The PSFS 2.0 showed satisfactory responsiveness, with an area under the curve of 0.82 (95% CI = 0.70-0.93). There were substantial to high correlations between the change scores of the PSFS 2.0 and the Neck Disability Index and GPE (0.60 and 0.52, respectively; P < .001).

CONCLUSION

The PSFS 2.0 is a reliable and responsive patient-reported outcome measure for use by patients with neck pain.

Measurement properties of a computer adaptive device, the Senscoordination 3D Cervical Trainer, to assess cervical range of motion in people with neck pain

INTRODUCTION

Clinicians commonly assess cervical range of motion (ROM) in patients with neck pain. Recently, a new instrument has been developed, the Senscoordination 3D Cervical Trainer (SCT), designed to measure neck ROM in addition to joint position error, static and dynamic balance performance, and performance on a 'neuro muscular control test'. This study aims to assess the interrater reliability, concurrent validity, and responsiveness of the SCT using the CROM device as a comparator.

METHODS

One hundred patients with non-specific neck pain were included and their active cervical ROM was measured in a random order by two raters in succession using both devices simultaneously at baseline and after personalised physiotherapy management, at 12 week follow up. Convergent validity and responsiveness were quantified by a Pearson correlation coefficient. The intraclass correlation coefficient (ICC) was used to calculate the test-retest reliability of the SCT. The smallest detectable change (SDC) was calculated per movement direction and for the total range of motion.

RESULTS

The correlation between the measures obtained with the CROM device and the SCT was high (0.97 or 0.98 depending on direction of movement). Interrater reliability was high for all directions (ICC ranging from 0.81 to 0.97). The SDC ranged from 6.9 for left cervical rotation to 12.2 for right cervical rotation. At the follow up, correlation between the change score on the CROM device and the SCT was high (0.86-0.94 depending on the direction of movement).

CONCLUSION

The SCT is a valid, reliable and responsive instrument for measuring cervical ROM.

Patient-Reported Outcomes and Surgical Quality

Delivering high-quality surgical care requires knowing how best to define and measure quality in surgery. Patient-reported outcomes (PROs) enable surgeons, health care systems, and payers to understand meaningful health outcomes from the patient's perspective and can be measured using patient-reported outcome measures (PROMs). As a result, there is much interest in using PROMs in routine surgical care, to guide quality improvement and to inform reimbursement pay structures. This chapter defines PROs and PROMs, differentiates PROMs from other quality measures such as patient-reported experience measures, describes PROMs in the context of routine clinical care, and provides an overview of interpreting PROM data. This chapter also describes how PROMs may be applied to quality improvement and value-based reimbursement in surgery.

Systematic surveillance of patient-reported symptoms of viral respiratory tract infectious Syndromes in diverse populations

BACKGROUND

Patient reported outcome measures (PROM) can improve patient care and be crucial for symptom tracking especially during disease outbreaks. FLU-PRO Plus is a validated PROM used to track viral respiratory symptoms. Our study aimed to evaluate the feasibility of using FLU-PRO© Plus, to track symptoms across three healthcare systems.

METHODS

The prospective, longitudinal study recruited adults between February-May 2021 from HealthPartners Institute (HP), Kaiser Permanente Georgia (KPGA), and Kaiser Permanente Mid-Atlantic States (KPMAS). Adult members were eligible if they had a positive lab or diagnosis for either COVID-19 or influenza-like illness (ILI) or exhibited 2 + viral respiratory symptoms. Descriptive statistics were calculated to describe the patient characteristics for participants that were eligible for FLU-PRO Plus, successfully contacted, attempted to log in to the FLU-PRO Plus website, and participants who completed FLU-PRO Plus Day 1. Bivariable and multivariable logistic regression using PROC GLIMMIXX investigated the patient characteristics associated with (1) successful contact and (2) FLU-PRO Plus Day 1 completion.

RESULTS

We identified a total of 15,650 eligible participants during the enrollment period: 9,582 from HP, 1,740 from KPGA, and 4,328 from KPMAS. Among the total of 409 eligible adults who attempted to participate in FLU-PRO Plus, 317 completed FLU-PRO Plus Day 1. Among the 317 individuals that completed FLU-PRO Plus Day 1, 205 (67.5%) were diagnosed with COVID-19; 112 adults diagnosed with COVID-19 completed FLU-PRO Plus Day 14. Among adults successfully contacted, adults aged 35-64 (OR = 1.40, 95% CI 1.05, 1.87), females (OR = 1.77, 95% CI 1.38, 2.27), and adults diagnosed with COVID-19 (OR = 1.66, 95% CI 1.27, 2.17) had higher odds of completing FLU-PRO Plus Day 1; Asian adults (OR = 0.38, 95% CI 0.19, 0.76) and Black and African American adults (OR = 0.33, 95% CI 0.19, 0.76) had lower odds compared to White adults.

CONCLUSION

Our study reports on the feasibility of patients across three integrated healthcare systems utilizing FLU-PRO Plus to monitor their respiratory symptoms. Patient reported outcome measures (PROM) can improve patient care, quality of life, and reduce the strain of limited resources on healthcare systems. Future FLU-PRO Plus studies should develop an implementation strategy to fully integrate FLU-PRO Plus within clinical care and patient management.

Psychometric qualities of the patient rated Wrist/Hand evaluation (PRWHE) in dutch primary care patients with wrist complaints

Background

Knowledge on the course, disability and functionality of wrist complaints is still compendious in primary care guidelines, despite the high prevalence in primary care. Valid questionnaires can facilitate the monitoring of patients in primary care and research initiatives. In this study, we aimed to study the psychometric qualities of the Dutch version of the Patient Rated Wrist/Hand Evaluation (PRWHE-DLV) among adults with (sub)acute wrist complaints in primary care.

Methods

An observational cohort of 35 adults with (sub)acute wrist complaints in Dutch primary care was established. The content validity of the PRWHE-DLV was validated by assessing the floor and ceiling effects at baseline (T0). Reproducibility was assessed by the test-retest reliability between T0 and T1 (2–5 days after T0), using the Intra-class Correlation Coefficient. The construct validity was assessed based on the correlation between the PRWHE-DLV and the Quick-DASH, Physical Component Score (SF-12), VAS-function, Physical Functioning (SF-12), VAS-pain and Bodily Pain (SF-12) at T0. Responsiveness was defined as the ability of the PRWHE-DLV to measure change 3 weeks after T0 (internal) and the relation of these changes to clinically important outcomes (external).

Results

Psychometric qualities of the PRWHE-DLV demonstrated high content validity with no floor or ceiling effects, excellent reliability (Intra-class correlation coefficient = 0.90; 95% CI 0.80–0.95), high construct validity with the validated Quick-DASH and VAS score (r = 0.85 with Quick-DASH, r = 0.75 with VAS-function and r = 0.78 with VAS-pain) and high responsiveness.

Conclusion

The PRWHE-DLV provided reliable and adequate information for primary care clinical practice.

Examining utility and feasibility of implementing patient-reported outcome measures in occupational therapy primary care practice

Introduction

Occupational therapists are increasingly part of interprofessional primary care teams, helping to expand primary care to meet client needs. Effectiveness of occupational therapy services is difficult to determine with currently collected data, and little is known about the best tools to use or how to integrate tools into practice. We explored the utility and feasibility of implementing patient-reported outcome measures (PROMs) within occupational therapy primary care practice.

Method

We integrated pre-test/post-test and exploratory qualitative designs. Over 7 months, nine occupational therapists administered two PROMs to clients receiving falls prevention services, addressing falls efficacy and participation in daily occupations. Subsequent interviews with therapists explored the utility and feasibility of using the tools. We assessed pre-to-post change in PROM scores and thematically analyzed interview data.

Results

The occupational therapists valued measuring function and participation in daily occupations to inform practice, communicate with team members, and demonstrate effectiveness. The falls efficacy scale appeared to capture change over time and was feasible to implement at pre-test.

Conclusion

PROMs appear useful within occupational therapy primary care falls prevention services and can be feasible with attention to administration processes. Further development and testing of PROMs is needed to support occupational therapy primary care practice.

The use of patient-reported outcome measures in primary care: applications, benefits and challenges

PROMs use in primary care has expanded from simply describing patient populations to contributing to decision-making, in response to the increasingly complex, ever-changing healthcare environment. In Alberta, primary care is organized into primary care networks (PCNs), where family physicians are grouped geographically and supported by allied health professionals. PCNs implement programs and services in response to local population health needs with frequent evaluation, often incorporating PROMs for this purpose. As PCN programs and services vary greatly across Alberta, so do their use of PROMs. An area of commonality is the use of the EQ-5D-5L instrument; 29 out of 41 PCNs are registered and licensed to use the instrument. It is often administrated by paper, pre- and post-program, and in combination with other specific measures, depending on the program or target population. Some PCNs share programming and therefore outcome measurement, but often the selection, implementation (including training and administration procedures) and evaluation/reporting of PROMs are unique to the PCN. As well, data analysis is largely dependent on the size and capacity of the PCN. Using PROMs for PCN program evaluation supports clinical understanding and complements clinical outcomes. PROMs describe the population attending a program, as well as provide an element of consistency when examining trends across multiple programs or timepoints. This contributes to inquiries and decisions around program development, components, administrative features, resource allocation and delivery. Challenges of PROMs use in primary care include the absence of cohesive data capture technology. This limits data capabilities and presents difficulties with data fidelity, storage, export, and analysis. Additionally, this real-world application lacks a control arm and presents methodological challenges for comparative research purposes. Furthermore, capturing long term patient outcomes poses administrative challenges of multiple follow ups. More research is required into best reporting mechanisms to ensure the data is used to its full potential. To overcome these challenges, leadership and clinician engagement are key. As well, determining consistent PCN PROM reporting requirements will ensure data are comparable across PCNs and contribute to provincial level evaluations, further supporting the movement towards overall health system quality improvement.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Adverse events reporting in stage III NSCLC trials investigating surgery and radiotherapy

Background

Current treatment options for stage III non-small cell lung cancer (NSCLC) consist of different combinations of chemotherapy, surgery, radiotherapy and immunotherapy. Treatment choices are highly individual decisions, in which adverse events (AEs) are relevant for decision-making. This study aims to analyse reporting of AEs in prospective stage III NSCLC trials, focussing on trials including radiotherapy and/or surgery.

Methods

PubMed was searched for prospective studies dealing with stage III NSCLC from January 1987 to April 2019. Meta-analyses were screened as a positive control. Pearson's Chi-squared test and smooth kernel distribution were used to estimate distributions. Data was resampled using bootstrapping.

Results

Out of 1193 initially identified studies, 119 met the inclusion criteria. Of these, 31 had a surgical procedure in any study arm. Grade 3 and 4 AEs were reported in 94.12% and 92.44% of the included studies, respectively. Reporting of grade 5 AEs was provided in 87.39% of cases. Grade 1 and 2 AEs were less commonly reported at 53.78% and 63.03%, respectively. One study did not mention any AEs. Of the 31 treatment arms including any form of surgery, AEs were not reported in 10. Overall, 231 different AE items were reported, only 18 of them were included in at least 20% of the analysed studies.

Conclusion

Overall, AE reporting in stage III NSCLC was inconsistent and inhomogeneous. Studies including surgical study arms often reported only treatment-related deaths in regards of surgical AEs. Underreporting of AEs prohibits the extraction of patient-relevant information for decision-making and represents a suboptimal use of invested resources.

Adverse event reporting for stage III NSCLC is inconsistent and inhomogeneous. Surgical studies tend to underreport lower grade adverse effects. Patient-relevant information for decision-making is lost and invested resources are used suboptimally.https://bit.ly/3gLNIYy

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients

BACKGROUND

Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

OBJECTIVE

To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

DESIGN

We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

SETTING AND PARTICIPANTS

A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

RESULTS

In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

DISCUSSION AND CONCLUSIONS

There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version)

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

A socio-technical systems approach to the use of health IT for patient reported outcomes: Patient and healthcare provider perspectives

BACKGROUND

Patient-Reported Outcomes (PROs) can be used to inform the clinical management of individuals, including patient self-management, care planning, and goal setting. Despite a rapid proliferation of technology to collect and integrate PROs in clinical care, uptake by patients and healthcare providers remains sub optimal. A consideration of systems factors to understand these challenges is needed.

OBJECTIVES

To apply the socio-technical systems (STS) model as a framework for understanding the usability and functional requirements of patients collecting PRO data using applications (apps), and of healthcare providers using these data at the point of care in ambulatory settings.

METHODS

With questions guided by the STS model, semi-structured interviews were conducted with eighteen patients and nine healthcare providers to elicit feedback about facilitators and barriers to successful use of PRO apps and PRO data in ambulatory settings. Patient participants were selected to fit into two categories: older, low utilizers of technology with less than a bachelor's degree, and younger higher utilizers of technology with at least a bachelor's degree. Participants were from primary and specialty care practices. Data were analyzed inductively to identify emergent themes.

RESULTS

Younger patients were only interested in using a PRO app if they had an active health issue to track. The nine older patients preferred passive means of data collection if they were to track a health issue, and preferred direct contact with their healthcare provider and using office visits to share information. All patients desired optimal usability and emphasized bidirectional communication in an app that is transparent about privacy. All nine healthcare providers agreed that PRO data would be most useful and relevant if key patient populations were targeted based on the specific measure. In this case the healthcare providers noted potentially optimal utility of collecting physical function PRO data for patients 65 and older. Access to the data was highlighted by each healthcare provider stating that these data would be most useful if they were seamlessly integrated into the electronic health record.

DISCUSSION

Several emergent themes were identified under the five selected dimensions of the STS model (clinical content, human computer interface, hardware and software computing infrastructure, people, and workflow and communication). Findings highlighted the continued need for innovative methods to obtain more rapid cycle, continuous feedback to identify system factors impacting use of these technologies.

CONCLUSION

The STS model provides a comprehensive framework that can be applied to collect patient and healthcare provider feedback to better guide the design and implementation of new health information technology.

Connected Health Services: Framework for an Impact Assessment

Background

Connected health (CH), as a new paradigm, manages individual and community health in a holistic manner by leveraging a variety of technologies and has the potential for the incorporation of telehealth and integrated care services, covering the whole spectrum of health-related services addressing healthy subjects and chronic patients. The reorganization of services around the person or citizen has been expected to bring high impact in the health care domain. There are a series of concerns (eg, contextual factors influencing the impact of care models, the cost savings associated with CH solutions, and the sustainability of the CH ecosystem) that should be better addressed for CH technologies to reach stakeholders more successfully. Overall, there is a need to effectively establish an understanding of the concepts of CH impact. As services based on CH technologies go beyond standard clinical interventions and assessments of medical devices or medical treatments, the need for standardization and for new ways of measurements and assessments emerges when studying CH impact.

Objective

This study aimed to introduce the CH impact framework (CHIF) that serves as an approach to assess the impact of CH services.

Methods

This study focused on the subset of CH comprising services that directly address patients and citizens on the management of disease or health and wellness. The CHIF was developed through a multistep procedure and various activities. These included, as initial steps, a literature review and workshop focusing on knowledge elicitation around CH concepts. Then followed the development of the initial version of the framework, refining of the framework with the experts as a result of the second workshop, and, finally, composition and deployment of a questionnaire for preliminary feedback from early-stage researchers in the relevant domains.

Results

The framework contributes to a better understanding of what is CH impact and analyzes the factors toward achieving it. CHIF elaborates on how to assess impact in CH services. These aspects can contribute to an impact-aware design of CH services. It can also contribute to a comparison of CH services and further knowledge of the domain. The CHIF is based on 4 concepts, including CH system and service outline, CH system end users, CH outcomes, and factors toward achieving CH impact. The framework is visualized as an ontological model.

Conclusions

The CHIF is an initial step toward identifying methodologies to objectively measure CH impact while recognizing its multiple dimensions and scales.

Understanding patient-reported outcome measures in colorectal cancer

Quality of life has become increasingly regarded as a key outcome measurement for cancer patients. Patient-reported outcome measures (PROMs) represent the tools used to ascertain self-reported quality of life. This review provides a summary of the literature regarding the use of PROMs in colorectal cancer and evaluates the advantages and limitations of generic and disease specific questionnaires that can be utilized in clinical practice. Factors that influence PROMs are outlined, including cancer characteristics, patient factors and treatment methods. Finally, future directions for the use of PROMs in colorectal cancer to inform healthcare delivery at an individual- and systems-based level are discussed.

Measuring patient and family perceptions of team processes and outcomes in healthcare teams: questionnaire development and psychometric evaluation

BACKGROUND

There is a lack of validated instruments examining dimensions of team functioning from the perspective of patients and families consistent with a conceptual framework. The study aimed to develop and assess the psychometric properties of the Patient-Perceptions of Team Effectiveness (PTE) questionnaire.

METHODS

A cross-sectional survey was undertaken in three studies. Data were collected from May-October 2016 for Study 1, April 2018-ongoing for Study 2, and October 2016 to June 2017 for Study 3. Online and paper versions of the self-administered questionnaire were available in English and in French. The initial questionnaire included 41 items. Study 1 included 320 respondents. Reliability was assessed using Cronbach alpha. Face validity (n = 250) was assessed using a structured questionnaire. Content validity was examined using subject matter experts and Spearman's item-total correlations. Construct validity was examined using known group comparisons (i.e., clinical specialty, education, length of follow-up, reason of consultation). Content analysis was used for open-ended questions.

RESULTS

The questionnaire took 10 to 15 min to complete. Positive assessments were noted for instructions, formatting, font size and logical ordering of questions. In Study 1, reliability indices for the PTE-Overall, Team Processes and Outcomes subscales ranged from 0.72 to 0.84. Item-total correlations ranged from 0.551 to 0.794 (p <  0.001). Differences were noted between clinical specialties, education, length of follow-up, reason of consultation, low and high functioning teams. No differences were noted between English and French language respondents. Psychometric properties were re-assessed in Study 2 and 3 after unclear questions were reworked. Reliability indices for the subscales ranged from 0.76 to 0.94 and differences remained significant between low and high functioning teams.

CONCLUSION

The final 43-item instrument is easy to administer to patients and families. The studies provide evidence of validity to support the propositions in the conceptual framework. The patient-level measures can be aggregated to the team, organizational or system level. The information can be used to assess healthcare team functioning in acute and primary care and determine the role patients and families are playing in teams. Further testing is needed with patients and families who are hospitalized or receiving care from teams in rural areas.

Use and Effects of Patient Access to Medical Records in General Practice Through a Personal Health Record in the Netherlands: Protocol for a Mixed-Methods Study

Background

In the Dutch health care system, general practitioners hold a central position. They store information from all health care providers who are involved with their patients in their electronic health records. Web-based access to the summary record in general practice through a personal health record (PHR) may increase patients’ insight into their medical conditions and help them to be involved in their care.

Objective

We describe the protocol that we will use to investigate the utilization of patients’ digital access to the summary of their medical records in general practice through a PHR and its effects on the involvement of patients in their care.

Methods

We will conduct a multilevel mixed-methods study in which the PHR and Web-based access to the summary record will be offered for 6 months to a random sample of 500 polypharmacy patients, 500 parents of children aged <4 years, and 500 adults who do not belong to the former two groups. At the patient level, a controlled before-after study will be conducted using surveys, and concurrently, qualitative data will be collected from focus group discussions, think-aloud observations, and semistructured interviews. At the general practice staff (GP staff) level, focus group discussions will be conducted at baseline and Q-methodology inquiries at the end of the study period. The primary outcomes at the patient level are barriers and facilitators for using the PHR and summary records and changes in taking an active role in decision making and care management and medication adherence. Outcomes at the GP staff level are attitudes before and opinions after the implementation of the intervention. Patient characteristics and changes in outcomes related to patient involvement during the study period will be compared between the users and nonusers of the intervention using chi-square tests and t tests. A thematic content analysis of the qualitative data will be performed, and the results will be used to interpret quantitative findings.

Results

Enrollment was completed in May 2017 and the possibility to view GP records through the PHR was implemented in December 2017. Data analysis is currently underway and the first results are expected to be submitted for publication in autumn 2019.

Conclusions

We expect that the findings of this study will be useful to health care providers and health care organizations that consider introducing the use of PHR and Web-based access to records and to those who have recently started using these.

Trial Registration

Netherlands Trial Registry NTR6395; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6395 (Archived by WebCite at http://www.webcitation.org/71nc8jzwM)

Registered Report Identifier

RR1-10.2196/10193

Coping better with health problems after a visit to the family physician: associations with patients and physicians characteristics

BACKGROUND

Good patient experience is recognized as an important component of a strong primary care system. Among the dimensions related to experience in family medicine, the ability to cope better with health problems is considered to be a measure of the quality of a consultation with a family physician (FP). The objective is to identify factors related to patients, physicians and practice, associated with patients' ability to cope better with their health problems after a family medicine consultation.

METHODS

The data stemmed from the Swiss part of the Quality and Costs of Primary Care (QUALICOPC) study, an international cross sectional survey aiming to compare quality, cost and equity in primary care. In Switzerland, a random sample of 199 FPs and 1791 patients participated. The negative answer to the question: "After this visit, I feel I can cope better with my health problems" was modeled using multilevel logistic regressions.

RESULTS

Difficulty to cope better with health problems was positively associated with the following: younger age (OR: 1.58, 95% CI [1.03-2.41]), cultural aspects related to the Swiss area of language (French speaking people declared higher inability than German and Italian ones), presence of chronic disease (OR: 1.54 95% CI [1.00-2.39]). Conversely an intermediate number (1-4) of visits during the last 6 months (OR: 0.37 95% CI [0.23-0.62]) and the satisfaction with the physician (OR: 0.18 95% CI [0.08-0.44]) are negative predictors of the patient inability to cope better with his health problems. A self-reported effort-reward imbalance at work (OR: 0.64 95% CI [0.41-1.00]) was the only predictive FP characteristic (negatively associated).

CONCLUSIONS

Although the design of the study does not allow causal inference, this study showed that the predictors of patient difficulties to cope better with health problem are mainly centered on the patients' characteristics. The patient-physician relationship both in terms of quality and frequency of visits is probably also important. Organizational practice characteristics do not seem to play a major role but stress at work among physicians should be further investigated.

[Patient reported outcome measures in geriatric care: first experiences]

BACKGROUND

There are difficulties in expressing the value of geriatric care in outcome measures such as recovery or mortality rates. Rather, the goal of geriatric care is to maintain quality of life and functionality. As such, patient reported outcome measures (PROMs) may be more effective in measuring the value healthcare creates in geriatric patients. In 2015 the Dutch Geriatrics Society asked their Committee Quality of Care Measurement to select a suitable PROM for the purpose of measuring the outcomes of geriatric hospital care.

METHODS/RESULTS

The goal of this PROM is to measure outcomes of an hospital admission in the perspective of the elderly patient who was admitted to a geriatric ward. A group of caregivers in geriatric care identified four possible PROMs in the literature and based on selection criteria the TOPICS-MDS was chosen as most suitable. To increase the feasibility of implementation in daily practice, an item reduction study was performed and this resulted in a short form: TOPICS-SF. Two pilot studies in three hospitals took place on a geriatric ward. A response of 62% was observed during the first pilot with TOPICS-MDS and a response of 37% was observed during the second pilot with TOPICS-SF. The Katz-15 improved during hospital stay and during one month at home after discharge.

CONCLUSION

The TOPICS-SF has been selected as PROM for the older patient receiving geriatric care and is feasible in practice. More research in different settings and with different moments of measurements is needed to evaluate the responsiveness of TOPICS-SF and the conditions for feasible implementation in daily practice.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

One question might be capable of replacing the Shoulder Pain and Disability Index (SPADI) when measuring disability: a prospective cohort study

Questions

Is it possible to replace the Shoulder Pain and Disability Index (SPADI) with a single substitute question for people with shoulder pain, when measuring disability and how well does this substitute question perform as a predictor for recovery.

Design

A prospective cohort study.

Participants

A total of 356 patients with shoulder pain in primary care.

Analyses

Convergent, divergent, and “known” groups validity were assessed by using hypotheses testing. Responsiveness was assessed using the Receiver Operating Curve and hypothesis testing. In addition, we performed multivariate regression to assess if the substitute question showed similar properties as the SPADI and if it affected the model itself, using recovery as an outcome.

Results

The Spearman correlation coefficient between the total SPADI score and the substitute question was high, and moderate with the Shoulder Disability Questionnaire. The correlation between the substitute question and the EQ-5D-3L was low and the responsiveness was acceptable. The substitute question did not significantly contribute to both prognostic prediction models as opposed to the SPADI. Regardless all models showed poor to fair discrimination.

Conclusion

The single question is a reasonable substitute for the SPADI and can be used as a screening instrument for shoulder disability in primary clinical practice. It has slightly poorer predictive power and should therefore not be used for prognosis.

Raising the profile of pilot and feasibility studies in relation to the development, evaluation and implementation of patient-reported outcome measures

This editorial introduces a new special series on the pilot and feasibility testing of patient-reported outcome measures (PROMs) in the on-line open access journal Pilot and Feasibility Studies. Pilot and feasibility studies are typically implemented to address issues of uncertainty before undertaking a larger definitive study such as a randomised controlled trial or large scale survey. This editorial considers the role that such pilot and feasibility testing plays in relation to the development, evaluation and implementation of PROMs. This is often an essential element of PROM research but is typically overlooked-especially within current methodological guidance, reporting space and also debate. This editorial aims to open up a dialogue about the role of pilot and feasibility testing in relation to PROMs. It highlights some of the areas in PROMs research where these types of studies have been carried out and discusses the ways in which the PROM community may be better supported and encouraged to integrate this element of the research process into their PROM-based work.

The Responsiveness and Interpretability of the Shoulder Pain and Disability Index

Study Design Clinical measurement study, prospective cohort design. Background Shoulder pain is a common disorder, and treatment is most often focused on a reduction of pain and functional disabilities. Several reviews have encouraged the use of the Shoulder Pain and Disability Index (SPADI) to objectify functional disability. It is important to assess the responsiveness and interpretability of the SPADI in patients seeking physical therapy treatment for their shoulder pain in a primary care setting. Objective To assess the responsiveness and interpretability of the SPADI in patients with shoulder pain visiting a physical therapist in primary care. Methods The target population consisted of patients who consulted a physical therapist for their shoulder pain. The patients received physical therapy treatment and completed the Dutch-language version of the SPADI at baseline and at 26-week follow-up. The interpretability floor and ceiling effects and the minimal important change (MIC) were assessed using the receiver operating characteristic method, and a visual anchor-based MIC distribution method was used to assess several Global Perceived Effect scale (GPE)-based anchors. The measurement error was calculated using the smallest detectable change. For the responsiveness, the area under the receiver operating characteristic curve was used, and correlations with the GPE and the change score of the Shoulder Disability Questionnaire (as this questionnaire measures the same construct) were assessed. Results A total of 356 patients participated at baseline and 237 (67%) returned the SPADI after 26 weeks. The mean score on the SPADI at baseline was 46.7 points (on a 0-100 scale). The SPADI showed no signs of floor and ceiling effects. The smallest detectable change was 19.7 points. The MIC was 20 (43% of baseline value), and therefore a change of 43% or more in an individual patient was considered to be clinically relevant. The area under the receiver operating characteristic curve (AUC) was 0.81, the Spearman correlation between the SPADI change score and the GPE was 0.53, and the Pearson correlation between the Shoulder Disability Questionnaire and the SPADI change score was 0.71. Conclusion The results of this study confirm the responsiveness of the SPADI, making it a useful instrument to assess functional disability in longitudinal studies; however, the measurement error should be taken into account when making decisions in individual patients. J Orthop Sports Phys Ther 2017;47(4):278-286. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7079.

Control of Allergic Rhinitis and Asthma Test for Children (CARATKids): Validation in Brazil and cutoff values

BACKGROUND

The Control of Allergic Rhinitis and Asthma Test for Children (CARATKids) assesses asthma and allergic rhinitis control in children younger than 12 years.

OBJECTIVE

To validate the Brazilian Portuguese version of the CARATKids and to define the cutoff values for identifying uncontrolled disease.

METHODS

Children aged 6 to 12 years with asthma and allergic rhinitis were studied (n = 102). CARATKids, childhood Asthma Control Test (cACT), total nasal symptom score (TNSS), and visual analog scale (VAS) scores were obtained at baseline and after 4 to 6 weeks. Internal consistency, test-retest reliability, responsiveness, and validity of the Brazilian CARATKids were assessed according to the Consensus-based Standards for the Selection of Health Measurements Instruments checklist. The minimal clinically important difference (MCID) was evaluated using distribution and anchor methods. Spearman correlations were used to compare CARATKids scores with external measures of control. Receiver operating characteristic curve analysis was performed to establish cutoff values.

RESULTS

Fifty children completed both visits. The Cronbach α and intraclass correlation coefficient of CARATKids were 0.81 and 0.85, respectively. The Guyatt responsiveness index was -1.34, and within-patient change in clinically unstable patients (n = 31) was significant (P = .02). As for cross-sectional and longitudinal validity, correlation coefficients ranged from 0.58 to 0.77 (P < .001) and 0.30 to 0.57 (P < .05), respectively. The estimated MCID for CARATKids was 3. The optimal cutoffs (sensitivity and specificity) to exclude uncontrolled and controlled disease were 3 or less (97% and 67%) and 6 or greater (56% and 96%), respectively.

CONCLUSION

CARATKids is a reliable and valid tool to assess asthma and allergic rhinitis control in Brazilian children. A score of 6 or higher on CARATKids identifies uncontrolled disease, and a score of 3 or lower excludes poor disease control.

Patient-Centered Outcome Measures in Lung Cancer Trials

BACKGROUND

Scientific communities focusing on cancer research have urged for the development of trials that address patient-centered outcome measures instead of solely focusing on cancer as a disease-centered process. This is important for a patient with lung cancer because of the rapid course of disease and generally poor prognosis. We set out to determine the characteristics and study objectives of the current clinical trials in pulmonary malignancies.

METHODS

The United States National Institutes of Health clinical trial registry was searched on April 23rd 2015, for currently recruiting phase I, II, or III clinical trials in lung cancer. Trial characteristics and study objectives were extracted from the registry website.

RESULTS

Of the 419 clinical trials included in this review, patient-centered outcome measures are investigated in a minority of the trials. Outcome measures as quality of life, functional capacity, and health care utilization are included in a small number of trials (20, 4, and 2 % respectively). Treatment completion is included in 1 % of the trials. Research goals are most frequently toxicity (78 %) and progression-free survival (76 %).

CONCLUSION

Patient-centered outcome measures are included in a minority of the currently recruiting clinical trials in pulmonary malignancies. If we do not investigate these outcome measures, it is not possible to increase our knowledge of the optimal treatment, as this should aim to optimize the patient's wellbeing as well as the course of disease. One option could be to incorporate combinations of patient- and disease-centered endpoints, for instance by using overall treatment utility or quality-adjusted outcome measures.

Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys

BACKGROUND

Previous studies have indicated increased risk of mental disorder symptoms, suicide and substance misuse in lesbian, gay and bisexual (LGB) adults, compared to heterosexual adults. Our aims were to determine an estimate of the association between sexual orientation identity and poor mental health and wellbeing among adults from 12 population surveys in the UK, and to consider whether effects differed for specific subgroups of the population.

METHODS

Individual data were pooled from the British Cohort Study 2012, Health Survey for England 2011, 2012 and 2013, Scottish Health Survey 2008 to 2013, Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12. Individual participant meta-analysis was used to pool estimates from each study, allowing for between-study variation.

RESULTS

Of 94,818 participants, 1.1 % identified as lesbian/gay, 0.9 % as bisexual, 0.8 % as 'other' and 97.2 % as heterosexual. Adjusting for a range of covariates, adults who identified as lesbian/gay had higher prevalence of common mental disorder when compared to heterosexuals, but the association was different in different age groups: apparent for those under 35 (OR = 1.78, 95 % CI 1.40, 2.26), weaker at age 35-54.9 (OR = 1.42, 95 % CI 1.10, 1.84), but strongest at age 55+ (OR = 2.06, 95 % CI 1.29, 3.31). These effects were stronger for bisexual adults, similar for those identifying as 'other', and similar for 'low wellbeing'.

CONCLUSIONS

In the UK, LGB adults have higher prevalence of poor mental health and low wellbeing when compared to heterosexuals, particularly younger and older LGB adults. Sexual orientation identity should be measured routinely in all health studies and in administrative data in the UK in order to influence national and local policy development and service delivery. These results reiterate the need for local government, NHS providers and public health policy makers to consider how to address inequalities in mental health among these minority groups.

Evaluating the implementation fidelity of New Medicines Service for asthma patients in community pharmacies in Belgium

BACKGROUND

In October 2013, a New Medicines Service (NMS) was introduced in community pharmacies in Belgium to support asthma patients who are novice users of inhaler devices with corticosteroids. The protocol-based intervention used the Asthma Control Test (ACT) and the Medication Adherence Report Scale (MARS) to assess asthma control and medication adherence. The NMS is the first initiative that puts advanced pharmaceutical care into practice in Belgium. The present study evaluated the degree to which the NMS program is delivered as intended, drawing on the concept of implementation fidelity (IF).

METHODS

The main dimensions of IF and potential moderating and facilitating factors for the implementation of NMS in community pharmacies were evaluated using telephone interviews with pharmacists (n = 497), semi-structured interviews with patients eligible for NMS (n = 30), focus groups among general practitioners (n = 72) and lung specialists (n = 5), and a work system analysis in community pharmacies (n = 19).

RESULTS

The uptake of NMS in Belgian community pharmacies remains low. In addition to practical barriers, pharmacists found it difficult to identify new asthmatic patients when they were not informed about the diagnosis. A lack of commitment from physicians, patients and pharmacists was noted in the early start-up phase of the program. Many pharmacists did not see how NMS differed from existing pharmaceutical care. Physicians considered this service as part of their own tasks and discouraged ACT for asthma follow-up in the community pharmacy.

CONCLUSIONS

The introduction of the NMS program was not sufficiently embedded in the Belgian health care organization, causing low uptake and resistance to its implementation by pharmacists, patients, and other health care professionals. To increase the uptake of this type of service and its possible extension to other patient groups, more collaboration among the different health care professionals during design and implementation is necessary, as well as systematic data collection to monitor the quality of the service, better training of pharmacists, and more information for patients and physicians.

A novel method for expediting the development of patient-reported outcome measures and an evaluation of its performance via simulation

BACKGROUND

Developing valid and reliable patient-reported outcome measures (PROMs) is a critical step in promoting patient-centered health care, a national priority in the U.S. Small populations or rare diseases often pose difficulties in developing PROMs using traditional methods due to small samples.

METHODS

To overcome the small sample size challenge while maintaining psychometric soundness, we propose an innovative Ordinal Bayesian Instrument Development (OBID) method that seamlessly integrates expert and participant data in a Bayesian item response theory (IRT) with a probit link model framework. Prior distributions obtained from expert data are imposed on the IRT model parameters and are updated with participants' data. The efficiency of OBID is evaluated by comparing its performance to classical instrument development performance using actual and simulation data. RESULTS AND DISCUSSION : The overall performance of OBID (i.e., more reliable parameter estimates, smaller mean squared errors (MSEs) and higher predictive validity) is superior to that of classical approaches when the sample size is small (e.g. less than 100 subjects). Although OBID may exhibit larger bias, it reduces the MSEs by decreasing variances. Results also closely align with recommendations in the current literature that six subject experts will be sufficient for establishing content validity evidence. However, in the presence of highly biased experts, three experts will be adequate.

CONCLUSIONS

This study successfully demonstrated that the OBID approach is more efficient than the classical approach when the sample size is small. OBID promises an efficient and reliable method for researchers and clinicians in future PROMs development for small populations or rare diseases.

An Integrative Review of Enablement in Primary Health Care

OBJECTIVES

To review how enablement is conceptualized and practiced in primary health care and to explore the factors that influence patient enablement in this setting.

METHOD

A narrative integrative literature review was undertaken.

RESULTS

Twenty-four articles specifically relating to enablement in primary health care were identified. Three literature reviews, 4 qualitative studies, and 17 quantitative studies were included in the analysis.

CONCLUSIONS

In the primary health care setting, the concept of enablement is well defined as an outcome measure of quality. The literature exploring the practice of enablement is sparse, but 2 randomized controlled trials suggest enablement is linked to better outcomes for patients with asthma and diabetes. Primary factors influencing enablement included the practitioners' open communication style, the degree to which the practitioner is patient centered, and longer consultations. Other factors found to be associated with enablement were the presenting health issue, general state of health, ethnicity, the patient's own coping strategies and degree of independence, and socioeconomic status. The association between enablement and patients' expectations and satisfaction is less clear. The majority of research on enablement was carried out among general practitioners. Further research into the degree to which patients are enabled by a wider range of health care providers is needed. Additional qualitative research would provide a deeper understanding of the attributes of enablement in the primary health care setting.