Patient reports of the outcomes of treatment: a structured review of approaches

Content validity of patient-reported measures evaluating experiences of the quality of transitions in healthcare settings-a scoping review

No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients' experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs' content validity. The method was guided by the Joanna Briggs Institutes' guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults' experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.

Calculation of the minimum clinically important difference (MCID) using different methodologies: case study and practical guide

INTRODUCTION

Establishing thresholds of change that are actually meaningful for the patient in an outcome measurement instrument is paramount. This concept is called the minimum clinically important difference (MCID). We summarize available MCID calculation methods relevant to spine surgery, and outline key considerations, followed by a step-by-step working example of how MCID can be calculated, using publicly available data, to enable the readers to follow the calculations themselves.

METHODS

Thirteen MCID calculations methods were summarized, including anchor-based methods, distribution-based methods, Reliable Change Index, 30% Reduction from Baseline, Social Comparison Approach and the Delphi method. All methods, except the latter two, were used to calculate MCID for improvement of Zurich Claudication Questionnaire (ZCQ) Symptom Severity of patients with lumbar spinal stenosis. Numeric Rating Scale for Leg Pain and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire Walking Ability domain were used as anchors.

RESULTS

The MCID for improvement of ZCQ Symptom Severity ranged from 0.8 to 5.1. On average, distribution-based methods yielded lower MCID values, than anchor-based methods. The percentage of patients who achieved the calculated MCID threshold ranged from 9.5% to 61.9%.

CONCLUSIONS

MCID calculations are encouraged in spinal research to evaluate treatment success. Anchor-based methods, relying on scales assessing patient preferences, continue to be the "gold-standard" with receiver operating characteristic curve approach being optimal. In their absence, the minimum detectable change approach is acceptable. The provided explanation and step-by-step example of MCID calculations with statistical code and publicly available data can act as guidance in planning future MCID calculation studies.

Assessing Internalizing Symptoms and Their Relation with Levels of Impairment: Evidence-Based Cutoffs for Interpreting Inventory of Depression and Anxiety Symptoms (IDAS-II) Scores

Tests and scales measuring psychological disorders should provide information about how scores relate to other constructs such as quality of life or functional impairment. Such information is necessary to allow that their scores contribute to clinical decision making. The current study analyzes the clinical utility of the Spanish version of the Inventory for Depression and Anxiety Symptoms (IDAS-II) to discriminate between different levels of functional impairment and identify the IDAS-II scales that contribute most to explaining impairment. The total sample (N = 1390) consists of two subsamples: a community sample of the general population (n = 1072) selected by random sampling; and a sample of patients (n = 318) from public and private mental health services. The Spanish IDAS-II for measuring internalizing symptoms and WHODAS 2.0 for measuring impairment were administered to all participants. All scales show statistically significant higher scores in the patient sample, with Cohen's d effect sizes values greater than 0.30, except for well-being (d = 0.19). The cutoff values and their confidence intervals do not overlap with the means of either the community or patient sample. AUC values for most of the scales are above .70, except for appetite gain, ordering, euphoria, cleaning, and well-being. Multiple linear regression model using IDAS-II scales explain 57.1% of the variance of the WHODAS 2.0 (F _12.1377 = 155.305; p < .001). Cutoff values provided allow us to reliably differentiate between the patients and community samples. Spanish IDAS-II scores show greater sensitivity and specificity in detecting those with greater impairment. General Depression, Lassitude, Panic and Claustrophobia contribute to impairment in a greater extent. Knowledge of which symptoms are most related with impairment, allows healthcare providers to improve treatment planning based on empirical evidence.

Patient-reported experiences and outcomes following two different approaches for non-surgical periodontal treatment: a randomized field study

Context

The current report is part of a prospective, multi-center, two-arm, quasi-randomized field study focusing on the effectiveness in general praxis of evidence-based procedures in the non-surgical treatment of patients with periodontitis.

Objective

The specific aims were to (i) evaluate patient-reported experience and outcome measures of treatment following a guided approach to periodontal infection control (GPIC) compared to conventional non-surgical therapy (CNST) and to (ii) identify potential predictors of subjective treatment outcomes and patient’s adherence to self-performed infection control, i.e. adequate oral hygiene.

Methods

The study sample consisted of 494 patients treated per protocol with questionnaire- and clinical data at baseline and 6-months. The GPIC approach (test) comprised patient education for adequate oral hygiene prior to a single session of full-mouth ultra-sonic instrumentation, while the CNST approach (control) comprised education and instrumentation (scaling and root planing) integrated at required number of consecutive appointments. Clinical examinations and treatment were performed by Dental Hygienists, i.e. not blinded. Data were processed with bivariate statistics for comparison between treatment groups and with multiple regression models to identify potential predictors of subjective and clinical outcomes. The primary clinical outcome was gingival bleeding scores.

Results

No substantial differences were found between the two treatment approaches regarding patient-reported experiences or outcomes of therapy. Patients’ experiences of definitely being involved in therapy decisions was a significant predictor for a desirable subjective and clinical outcome in terms of; (i) that oral health was considered as much improved after therapy compared to how it was before, (ii) that the treatment definitively had been worth the cost and efforts, and (iii) adherence to self-performed periodontal infection control. In addition, to be a current smoker counteracted patients’ satisfaction with oral health outcome, while gingival bleeding scores at baseline predicted clinical outcome in terms of bleeding scores at 6-months.

Conclusions

The results suggest that there are no differences with regard to patient-reported experiences and outcomes of therapy following a GPIC approach to periodontal infection control versus CNST. Patients’ experiences of being involved in therapy decisions seem to be an important factor for satisfaction with care and for adherence to self-performed periodontal infection control.

Registered at: ClinicalTrials.gov (NCT02168621).

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Cochlear implants in adults with partial deafness: subjective benefits but associated psychological distress

PURPOSE

The present study investigated adults with partial deafness (PD) and asked them to rate the benefits of their cochlear implant (CI), their general level of satisfaction with it, and their level of psychological distress. Of particular interest was the role of gender.

METHODS

The study comprised 71 participants (41 females) with PD who had been provided with a CI. The Nijmegen Cochlear Implant Questionnaire (NCIQ) was used to assess the benefits of their CI. Satisfaction with their CI was measured using a visual analog scale. The severity of mental distress was assessed with the General Health Questionnaire (GHQ-28).

RESULTS

On various NCIQ scales, the average benefits of a CI were rated at 66%. Females gave a lower rating than males. The mental distress experienced by the group was significantly higher than in the general population. Females had more severe symptoms of anxiety and insomnia than males. There was a significant relationship between psychological distress and CI benefit, but only in females. Besides general distress, the most affected spheres were related to psychosocial functioning-"self-esteem", "activity limitation", and "social interaction". Contrary to expectations, there was no relationship between mental distress and CI satisfaction.

CONCLUSIONS

The perceived benefits of a CI in subjects with PD relate mostly to the level of mental distress, although gender is an important factor. For females, their emotional state affects how beneficial their CI is perceived. Due to the higher levels of mental distress, females tend to need more psychological intervention and support.

Benralizumab improves patient reported outcomes and functional parameters in difficult-to-treat patients with severe asthma: Data from a real-life cohort

In the last decade, an increasing number of randomized controlled trials (RCTs) on biologic therapy in patients with severe asthma have included patient-reported outcomes (PROs) as secondary efficacy measures. The majority of these RCTs showed a benefit in symptoms and quality of life. However, the magnitude of this benefit remains uncertain, because it rarely exceeded the minimal important difference (MID), owing to a significant improvement in the control group (placebo effect). Real-life studies on biologic therapies assessing PRO are scarce. They may support and integrate RCT results through their different experimental design. This real-life retrospective study provides data on 15 patients with difficult-to-treat severe eosinophilic asthma treated with benralizumab up to 6 months. Asthma quality of life questionnaire (AQLQ) and asthma control test (ACT) were assessed and administered at each visit to minimize the Hawthorne effect. Changes in general accepted efficacy measures, such as forced expiratory volume in 1 s (FEV₁), peak expiratory flux (PEF), exacerbation rate and blood eosinophils, from baseline were also assessed. AQLQ and ACT improved from 3.9 ± 0.4 to 5.2 ± 0.4 and from 15.6 ± 5.7 to 18.1 ± 5.6, respectively. FEV₁ increased of about 250 ml (+14%). PEF increased from 288 ± 107 to 333 ± 133 l/min. The number of exacerbations requiring OCS courses decreased from 2.8 ± 2.2 to 0.5 ± 0.8. Eosinophil counts dropped to 25.6 ± 15 cells/microliter. In conclusion, most patients reported improvements in AQLQ and ACT greater than MID, suggesting that these outcome represent a sensitive tool in real-life effectiveness studies. Our approach reduced the limitations of transition questions and the Hawthorne effect, increasing findings reliability.

Recall Bias in Retrospective Assessment of Preoperative Patient-Reported American Shoulder and Elbow Surgeons Scores in Arthroscopic Rotator Cuff Repair Surgery

BACKGROUND

The gold-standard method for collecting patient-reported outcomes (PROs) is the prospective assessment of preoperative to postoperative change. However, this method is not always feasible because of unforeseen cases or emergencies, logistical and infrastructure barriers, and cost issues. In such cases, a retrospective approach serves as a potential alternative, but there are conflicting conclusions regarding the reliability of the recalled preoperative PROs after orthopaedic procedures.

PURPOSE

To assess the agreement between prospectively and retrospectively collected PROs for a common, low-risk procedure.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Patients who underwent arthroscopic rotator cuff repair between May 2012 and September 2017 at the study institution were identified. All of the patients completed the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form preoperatively at their preassessment appointment. Patients were then contacted in the postoperative period and asked to recall their preoperative condition while completing another ASES form.

RESULTS

A total of 84 patients completed the telephone survey and were included in this analysis (mean age, 57.40 ± 9.96 years). The mean duration of time from onset of shoulder symptoms to surgery was 9.13 ± 9.08 months. The mean duration of time between surgery and recall ASES administration was 39.12 ± 17.37 months. The mean recall ASES score was significantly lower than the preoperative ASES score (30.69 ± 16.93 vs 51.42 ± 19.14; P < .001). There was poor test-retest reliability between preoperative ASES and recall ASES (intraclass correlation coefficient, 0.292; 95% CI, -0.07, 0.57; P = .068). Greater age at the time of recall, a shorter symptomatic period before surgery, and less severe preoperative shoulder dysfunction were associated with a greater difference between preoperative ASES and recall ASES.

CONCLUSION

Retrospectively reported PROs are subject to significant recall bias. Recalled PROs were almost always lower than their prospectively recorded counterparts. Recalled PROs are more likely to be accurate when reported by younger patients, those with a longer duration of symptoms, and those with more severe preoperative conditions.

The Patient Needs in Asthma Treatment (NEAT) questionnaire: Further evidence on its psychometric properties

BACKGROUND

Building on previous psychometric work, we sought to assess the Patient Needs in Asthma Treatment (NEAT) questionnaire's validity, responsiveness to change, and the minimal important change (MIC) over a 3-year period (Study 1) and its reliability and the smallest detectable change (SDC) in a test-retest study (Study 2) among patients self-reporting physician-diagnosed asthma.

METHODS

In Study 1, a total of 207 patients completed a survey which included the NEAT, the Asthma Control Test (ACT), the Asthma Quality of Life Questionnaire-Sydney (AQLQ-S), and a question on treatment satisfaction in 2014 and 2017. In Study 2, a total of 78 patients completed NEAT twice on average four weeks apart in 2018.

RESULTS

Concurrent validity: In linear regressions, unmet patient needs were cross-sectionally associated with poorer asthma control (β = -0.21; P = 0.01), asthma-related quality of life (QoL) (β = 0.31; P < 0.01), and treatment satisfaction (β = -0.59; P < 0.01). Predictive Validity: Higher unmet needs at baseline predicted worse treatment satisfaction at follow-up (β = -0.28; P < 0.01), but neither asthma control nor asthma-related QoL. Responsiveness to change was demonstrated by linear regressions of changes in the total NEAT score and changes in AQLQ-S (β = 0.21; P < 0.01) and treatment satisfaction (β = -0.36; P < 0.01). MIC: Patients whose NEAT score increased between baseline and follow-up by the identified MIC (0.301) reported lower treatment satisfaction at follow-up (β = -0.17; P = 0.01). Test-retest reliability was demonstrated by correlations between NEAT baseline and follow-up scores (eg, intra-class correlation coefficients for total score = 0.78). The SDC (0.384) was slightly larger than MIC.

CONCLUSION

NEAT is a promising tool for assessing asthma treatment needs.

What is the correlation between patient-reported outcome measure (PROM) scores and patient satisfaction following elective reverse total shoulder replacement?

BACKGROUND

Outcomes of reverse total shoulder arthroplasty (RTSA) have typically been assessed using the same instruments as anatomical shoulder arthroplasties. However, to date, there has been a lack of investigation with respect to the correlation of such scores and patient satisfaction in the RTSA population.

METHODS

The Oxford Shoulder Score (OSS) and Quick Disabilities of the Arm, Shoulder and Hand (QD) score were prospectively collected in 38 RTSA patients (41 shoulders) postoperatively. Scores were then evaluated to establish whether or not they correlated with patient satisfaction at a minimum of 1 year postoperatively.

RESULTS

The correlation coefficient for the OSS and patient satisfaction was found to be 0.313 (p = 0.011) and the correlation coefficient for the QD score and patient satisfaction was -0.292 (p = 0.017), showing a statistically significant but moderately weak relationship between the OSS and QD scores with patient satisfaction (p < 0.05).

CONCLUSIONS

The present study showed no strongly significant relationship between patient-reported outcome measure (PROM) scores and patient satisfaction following elective RTSA. These findings emphasise the need to question the appropriateness of standard PROM scores for the assessment of outcome and success following elective RTSA.

Can practitioners use patient reported measures to enhance person centred coordinated care in practice? A qualitative study

BACKGROUND

To ascertain whether person centred coordinated care (P3C) is being delivered in healthcare services, components relating to the construct need to be measured. Patient reported measures (PRMs) can be used to provide a measurement of patients' experiences of P3C. Traditionally, they have been used to assess whether interventions are delivering P3C. Recently there has been an increased interest in using them to directly enhance P3C in clinical practice by, for example, improving practitioner-patient communication. However, there is limited research available on how P3C can be implemented in practice. This study aimed to extend this literature base by exploring how professionals use PRMs to enhance P3C.

METHODS

Cross sectional thematic analysis of 26 semi-structured interviews with a variety of professionals who have experience of how PRMs can be used to make improvements to P3C. Inductive themes were mapped onto components of P3C care that fell under five established domains of P3C (Information and Communication; My Goals/Outcomes; Decision making; Care Planning and Transitions) to explore whether and how individual components of P3C were being improved through PRMs. Barriers and facilitators that affected the delivery and the results of the PRMs were also identified.

RESULTS

Three P3C domains (Information and Communication, My Goals/Outcomes and Care Planning) were mapped frequently onto themes generated by the participants' interviews about PRM use. However, the domain 'Decision Making' was only mapped onto one theme and 'Transitions' was not mapped at all. Participant reports suggested that PRM use by practitioners enhanced patients' ability to self-manage, communicate, engage and reflect during consultations. Barriers to PRM use were related to a lack of a whole service approach to implementation.

CONCLUSIONS

Practitioners use both PROMs and PREMs in various ways to improve different aspects of patient care. By sharing experiences professionals can benefit from each other's learning and work together to extend the potential value that PRMs can offer to P3C delivery.

Validity and reliability of the measure yourself medical outcome profile 2 (MYMOP2) questionnaire among Turkish patients having anorectal disorders

BACKGROUND/AIMS

Measure Yourself Medical Outcome Profile 2 (MYMOP2) is a patient-generated outcome measure allowing patients to select the problems that are the most important to them and that they want to address, and it measures the effects of the problem from a wide range of health care interventions. This study aimed to translate the questionnaire into Turkish language (Turkish MYMOP-TMYMOP) and add this clinically useful measure to Turkish medical practice by assessing its validity and reliability.

MATERIALS AND METHODS

Fifty volunteers with anorectal disorders were prospectively included into the study. Each patient was enrolled into a pelvic floor training biofeedback program, specific to their anorectal symptomatology. The subjects were administered both the Nottingham Health Profile and the TMYMOP2 questionnaires before the treatment session (initial visit) and at the control follow-up visits (the first and second months, via e-mail or telephone calls).

RESULTS

The TMYMOP2 questionnaire was shown to be moderately valid (the Pearson correlation coefficient score between the total scores of the subgroups of the two questionnaires were 0.335 and 0.642, respectively, p<0.05) and highly reliable (the Cronbach's alfa coefficient score between the total scores of the subgroups of the two questionnaires were 0.77, 0.82, and 0.88 in the beginning and at the first and second month follow-up visits, respectively).

CONCLUSION

The TMYMOP2 was shown to be a low-to-moderately valid and a highly reliable scale. Because it is brief and short to complete, it might be an important and free-to-use tool to measure the diseases, and it can enhance the patient-centered care within the Turkish health care context.

The Development of a Conceptual Framework and Preliminary Item Bank for Childbirth-Specific Patient-Reported Outcome Measures

OBJECTIVE

To develop a conceptual framework and preliminary item bank for childbirth-specific patient-reported outcome (PRO) domains.

DATA SOURCES

Women, who were U.S. residents, ≥18 years old, and ≥20 weeks pregnant, were surveyed regarding their childbirth values and preferences (V&P) using online panels.

STUDY DESIGN

Using community-based research techniques and Patient-Reported Outcomes Management Information System (PROMIS® ) methodology, we conducted a comprehensive literature review to identify self-reported survey items regarding patient-reported V&P and childbirth experiences and outcomes (PROs). The V&P/PRO domains were validated by focus groups. We conducted a cross-sectional observational study and fitted a multivariable logistic regression model to each V&P item to describe "who" wanted each item.

PRINCIPAL FINDINGS

We identified 5,880 V&P/PRO items that mapped to 19 domains and 58 subdomains. We present results for the 2,250 survey respondents who anticipated a vaginal delivery in a hospital. Wide variation existed regarding each V&P item, and personal characteristics, such as maternal confidence and ability to cope well with pain, were frequent predictors in the models. The resulting preliminary item bank consisted of 60 key personal characteristics and 63 V&P/PROs.

CONCLUSIONS

The conceptual framework and preliminary (PROMIS® ) item bank presented here provide a foundation for the development of childbirth-specific V&P/PROs.

Codesigning a Measure of Person-Centred Coordinated Care to Capture the Experience of the Patient: The Development of the P3CEQ

BACKGROUND

Person-centred coordinated care (P3C) is a priority for stakeholders (ie, patients, carers, professionals, policy makers). As a part of the development of an evaluation framework for P3C, we set out to identify patient-reported experience measures (PREMs) suitable for routine measurement and feedback during the development of services.

METHODS

A rapid review of the literature was undertaken to identity existing PREMs suitable for the probing person-centred and/or coordinated care. Of 74 measures identified, 7 met our inclusion criteria. We critically examined these against core domains and subdomains of P3C. Measures were then presented to stakeholders in codesign workshops to explore acceptability, utility, and their strengths/weaknesses.

RESULTS

The Long-Term Condition 6 questionnaire was preferred for its short length, utility, and tone. However, it lacked key questions in each core domain, and in response to requests from our codesign group, new questions were added to cover consideration as a whole person, coordination, care plans, carer involvement, and a single coordinator. Cognitive interviews, on-going codesign, and mapping to core P3C domains resulted in the refinement of the questionnaire to 11 items with 1 trigger question. The 11-item modified version was renamed the P3C Experiences Questionnaire.

CONCLUSIONS

Due to a dearth of brief measures available to capture people's experience of P3C for routine practice, an existing measure was modified using an iterative process of adaption and validation through codesign workshops. Next steps include psychometric validation and modification for people with dementia and learning difficulties.

Identification, description and appraisal of generic PROMs for primary care: a systematic review

Background

Patients attend primary care with many types of problems and to achieve a range of possible outcomes. There is currently a lack of patient-reported outcome measures (PROMs) designed to capture these diverse outcomes. The objective of this systematic review was to identify, describe and appraise generic PROMs suitable for measuring outcomes from primary care.

Methods

We carried out a systematic Medline search, supplemented by other online and hand-searches. All potentially relevant PROMs were itemised in a long-list. Each PROM in the long-list which met inclusion criteria was included in a short-list. Short-listed PROMs were then described in terms of their measurement properties and construct, based on a previously published description of primary care outcome as three constructs: health status, health empowerment and health perceptions. PROMs were appraised in terms of extent of psychometric testing (extensive, moderate, low) and level of responsiveness (high, medium, low, unknown).

Results

More than 5000 abstracts were identified and screened to identify PROMs potentially suitable for measuring outcomes from primary care. 321 PROMs were long-listed, and twenty PROMs were catalogued in detail. There were five PROMs which measured change directly, without need for a baseline. Although these had less strong psychometric properties, they may be more responsive to change than PROMs which capture status at a point in time. No instruments provided coverage of all three constructs. Of the health status questionnaires, the most extensively tested was the SF-36. Of the health empowerment instruments, the PEI, PAM and heiQ provided the best combination of responsiveness and psychometric testing. The health perceptions instruments were all less responsive to change, and may measure a form of health perception which is difficult to shift in primary care.

Conclusions

This systematic review is the first of its kind to identify papers describing the development and validation of generic PROMs suitable for measuring outcomes from primary care. It identified that: 1) to date, there is no instrument which comprehensively covers the outcomes commonly sought in primary care, and 2) there are different benefits both to PROMs which measure status at a point in time, and PROMs which measure change directly.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0722-9) contains supplementary material, which is available to authorized users.

Patient-Reported Measures for Person-Centered Coordinated Care: A Comparative Domain Map and Web-Based Compendium for Supporting Policy Development and Implementation

BACKGROUND

Patient-reported measure (PRM) questionnaires were originally used in research to measure outcomes of intervention studies. They have now evolved into a diverse family of tools measuring a range of constructs including quality of life and experiences of care. Current health and social care policy increasingly advocates their use for embedding the patient voice into service redesign through new models of care such as person-centered coordinated care (P3C). If chosen carefully and used efficiently, these tools can help improve care delivery through a variety of novel ways, including system-level feedback for health care management and commissioning. Support and guidance on how to use these tools would be critical to achieve these goals.

OBJECTIVE

The objective of this study was to develop evidence-based guidance and support for the use of P3C-PRMs in health and social care policy through identification of PRMs that can be used to enhance the development of P3C, mapping P3C-PRMs against an existing model of domains of P3C, and integration and organization of the information in a user-friendly Web-based database.

METHODS

A pragmatic approach was used for the systematic identification of candidate P3C-PRMs, which aimed at balancing comprehensiveness and feasibility. This utilized a number of resources, including existing compendiums, peer-reviewed and gray literature (using a flexible search strategy), and stakeholder engagement (which included guidance for relevant clinical areas). A subset of those candidate measures (meeting prespecified eligibility criteria) was then mapped against a theoretical model of P3C, facilitating classification of the construct being measured and the subsequent generation of shortlists for generic P3C measures, specific aspects of P3C (eg, communication or decision making), and condition-specific measures (eg, diabetes, cancer) in priority areas, as highlighted by stakeholders.

RESULTS

In total, 328 P3C-PRMs were identified, which were used to populate a freely available Web-based database. Of these, 63 P3C-PRMs met the eligibility criteria for shortlisting and were classified according to their measurement constructs and mapped against the theoretical P3C model. We identified tools with the best coverage of P3C, thereby providing evidence of their content validity as outcome measures for new models of care. Transitions and medications were 2 areas currently poorly covered by existing measures. All the information is currently available at a user-friendly web-based portal (p3c.org.uk), which includes all relevant information on each measure, such as the constructs targeted and links to relevant literature, in addition to shortlists according to relevant constructs.

CONCLUSIONS

A detailed compendium of P3C-PRMs has been developed using a pragmatic systematic approach supported by stakeholder engagement. Our user-friendly suite of tools is designed to act as a portal to the world of PRMs for P3C, and have utility for a broad audience, including (but not limited to) health care commissioners, managers, and researchers.

Can Patients With Low Back Pain Be Satisfied With Less Than Expected?

STUDY DESIGN

A prospective cohort study within care as usual.

OBJECTIVE

(1) To explore the psychometric properties of a baseline disability questionnaire designed to collect patients' expectation. (2) To analyze relations between satisfaction with care and treatment success in patients with chronic low back pain (CLBP). (3) To determine the chances of being satisfied with the received care in absence of treatment success.

SUMMARY OF BACKGROUND DATA

There is a lack of evidence on determinants of treatment satisfaction in patients with CLBP, specifically the role of patient's expectation of disability reduction after treatment.

METHODS

Treatment expectation was measured with questions inspired by the Pain Disability Index (PDI) at baseline. Treatment success was considered if disability at the end of therapy was lower than, or equal to pretreatment expectation. An exploratory factor analysis was performed on the new questionnaire. Binary logistic regression models were used to analyze how much variance of satisfaction with care was explained by treatment success, pain disability at baseline, sex, age, duration of complaints, and pain intensity. The odds ratio of being satisfied when treatment was successful was calculated.

RESULTS

Six hundred nine patients were included. The factor structure of the PDI-expectancy had optimal fit with a one factor structure. There were low correlations between the expected and baseline disability, pain intensity, and duration of pain. Correlation between treatment success and satisfaction with care was low (χ = 0.13; P < 0.01). Treatment success had a low contribution to satisfaction with care. Of all participating patients, 51.4% were satisfied with care even when treatment was not successful. The odds ratio for being satisfied was 2.42 when treatment was successful compared to when treatment was not successful.

CONCLUSION

The PDI-expectancy is internally consistent. Pretreatment expectation contributes uniquely but slightly to satisfaction with care; patients whose treatment was considered successful have 1.38 to 4.24 times higher chance of being satisfied at the end of treatment. Even when treatment was not successful, 51.4% of the patients with CLBP are satisfied with care.

LEVEL OF EVIDENCE

2.

Impact of clinical leadership in teams' course on quality, efficiency, responsiveness and trust in the emergency department: study protocol of a trailing research study

INTRODUCTION

Clinical leadership has long been recognised as critical for optimising patient safety, quality of care and interprofessional teamwork in busy and stressful healthcare settings. There is a need to compensate for the absence of the conventional mentor-to-apprentice transfer of clinical leadership knowledge and skills. While young doctors and nurses are increasingly proficient in medical, surgical and technical skills, their training in, and knowledge of clinical leadership skills, is not adequate to meet the demands for these non-technical skills in the emergency department. Thus, the purpose of the paper is to present and discuss the study protocol of clinical leadership in a course for teams that aims to improve quality, efficiency, responsiveness of healthcare services and collegial trust in the emergency department.

METHODS AND ANALYSIS

The study employs a trailing research design using multiple quantitative and qualitative methods in the summative (pretest and post-test) and formative evaluation. Quantitative data have been collected from a patient questionnaire, the emergency departments' database and by the observation of team performance. Qualitative data have been collected by shadowing healthcare professionals and through focus group interviews. To ensure trustworthiness in the data analysis, we will apply member checks and analyst triangulation, in addition to providing contextual and sample description to allow for evaluation of transferability of our results to other contexts and groups.

ETHICS AND DISSEMINATION

The study is approved by the ethics committee of the western part of Norway and the hospital. The study is based on voluntary participation and informed written consent. Informants can withdraw at any point in time. The results will be disseminated at research conferences, peer review journals and through public presentations to people outside the scientific community.

Triage in an adult emergency service: patient satisfaction

Abstract OBJECTIVE Assess the degree of patient satisfaction with triage in the adult emergency service of a public hospital. METHOD Exploratory, descriptive, cross-sectional study with a quantitative approach. Three hundred patients were interviewed and the data were analyzed using descriptive statistics based on sociodemographic variables and those related to patient satisfaction. RESULTS There was a predominance of women, with elementary education and a mean age of 41 years. Most of the interviewees reported being satisfied in regard to the following items: timely service, embracement, trust, environment (comfort, cleanliness and signage), humanization (courtesy, respect, and interest), timely referral/scheduling of appointments and care expectations. CONCLUSION There was a high level of patient satisfaction, evidenced by the strong association of user satisfaction with the items investigated.

Relationship of the adherence to the Mediterranean diet with health-related quality of life and treatment satisfaction in patients with type 2 diabetes mellitus: a post-hoc analysis of a cross-sectional study

OBJECTIVE

The main aim of this study was to assess the association between adherence to the traditional Mediterranean diet (MedDiet) and health-related quality of life (HRQoL) and treatment satisfaction in patients with type 2 diabetes mellitus (T2DM).

METHODS

This cross-sectional study included 294 patients with T2DM (146 with diabetic retinopathy and 148 without retinopathy). HRQoL and treatment satisfaction were assessed with the Audit Diabetes-Dependent Quality of Life and Diabetes Treatment Satisfaction Questionnaires, respectively. Adherence to the MedDiet was evaluated with the relative Mediterranean Diet Score (rMED). The rMED was added to multivariate linear regression models to assess its relative contribution as a quantitative as well as a qualitative variable after recoding to maximize each of the model's coefficients of determination to explain quality of life as well as treatment satisfaction dimensions.

RESULTS

The adherence to the Mediterranean diet showed no significant association with the overall quality of life score. However, rMED was associated with some HRQoL dimensions: travels, self-confidence and freedom to eat and drink (p = 0.020, p = 0.015, p = 0.037 and p = 0.015, respectively). Concerning treatment satisfaction, rMED was positively associated with its overall score (p = 0.046), and especially with the understanding of diabetes (p = 0.0004) and treatment recommendation (p = 0.036), as well as with the perceived frequency of hyperglycaemias (p = 0.039).

CONCLUSION

Adherence to the Mediterranean diet was associated with greater treatment satisfaction in patients with T2DM. Although we found no association with overall HRQoL, adherence to this dietary pattern was associated with some quality of life dimensions.

Challenges, solutions and future directions in the evaluation of service innovations in health care and public health

Evaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.

Patient-reported outcomes in the Swedish National Quality Registers

Patient-reported outcomes (PROs) are important in the healthcare system to gain understanding of patients' views on the effects of a treatment. There is an abundance of available patient-reported outcome measures (PROMs), both disease specific and generic. In the Swedish healthcare system, the national quality registers are obliged to incorporate PROs for certification at a high level. A review of the latest annual applications for funding (n = 108) shows that at present, 93 national quality registers include some form of PROM or patient-reported experience measure (PREM). Half of the registers include some type of generic measure, more than half include disease/symptom-specific measures, and around 40% include PREMs. Several different measures and combinations of measures are used, the most common of which are the EQ-5D, followed by the SF-36/RAND-36. About one-fifth of the registers report examples of how patient-reported data are used for local quality improvement. These examples include enhancing shared decision-making in clinical encounters (most common), as a basis for care plans, clinical decision aids and treatment guidelines, to improve the precision of indications for surgery (patient and healthcare professional assessments may differ), to monitor complications after the patient has left hospital and to improve patient information. In addition, funding applications reveal that most registers plan to extend their array of PROMs and PREMs in future, and to increase their use of patient-reported data as a basis for quality improvement.

Patients' needs in asthma treatment: development and initial validation of the NEAT questionnaire

OBJECTIVE

We aimed to develop and tentatively validate an instrument assessing patients' needs related to asthma treatment.

METHODS

Patients were recruited through various approaches (e.g. physicians, pharmacies and patient organizations). Utilizing a mixed methods design, we first conducted five focus groups to explore needs among patients. Next, we devised an item pool which was revised, reduced and evaluated by patients. Finally, data from a survey (n = 362) were used to further reduce the item pool and to examine the questionnaire's psychometric properties and validity.

RESULTS

Four broad needs categories emerged from the focus groups: (1) information needs; (2) consideration of patient views in diagnosis; (3) consideration of patient views in treatment planning; and (4) addressing patients' fears. We devised 45 items, which were reduced to 22 items based on patient feedback. The survey data suggested a 13-item scale with four subscales ("patient expertise", "drug effects", "handling drugs" and "exacerbations"). Cronbach's alpha was acceptable for those subscales (>0.7) and for the total score (0.9). Increasing scores on subscales and the total score (implying more unmet needs) showed close and consistent associations with poor asthma control, reduced quality of life and low treatment satisfaction.

CONCLUSIONS

The development process of the Needs in Asthma Treatment (NEAT) questionnaire ensured that needs of asthma patient are captured with high validity. The NEAT questionnaire has been shown to be valid, thereby representing a promising tool for research and delivery of patient-centered care.

Application of the new GOLD COPD staging system to a US primary care cohort, with comparison to physician and patient impressions of severity

Background

In 2011, the traditional Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD spirometry-based severity classification system was revised to also include exacerbation history and COPD Assessment Test (CAT) and modified Medical Research Council Dyspnea Scale (mMRC) scores. This study examined how COPD patients treated in primary care are reclassified by the new GOLD system compared to the traditional system, and each system’s level of agreement with patient’s or physician’s severity assessments.

Methods

In this US multicenter cross-sectional study, COPD patients were recruited by 83 primary care practitioners (PCPs) to complete spirometry testing and a survey. Patients were classified by the traditional spirometry-based system (stages 1–4) and under the new system (grades A, B, C, D) using spirometry, exacerbation history, mMRC, and/or CAT results. Concordance between physician and patient-reported severity, spirometry stage, and ABCD grade based on either mMRC or CAT scores was examined.

Results

Data from 445 patients with spirometry-confirmed COPD were used. As compared to the traditional system, the GOLD mMRC system reclassifies 47% of patients, and GOLD CAT system reclassifies 41%, but the distributions are very different. The GOLD mMRC system resulted in relatively equal distributions by ABCD grade (33%, 22%, 19%, 26%, respectively), but the GOLD CAT system put most into either B or D groups (9%, 45%, 4%, and 42%). The addition of exacerbation history reclassified only 19 additional patients. Agreement between PCPs’ severity rating or their patients’ self-assessment and the new ABCD grade was very poor (κ=0.17 or less).

Conclusion

As compared to the traditional system, the GOLD 2011 multidimensional system reclassified nearly half of patients, but how they were reclassified varied greatly by whether the mMRC or CAT questionnaire was chosen. Either way, the new system had little correlation with the PCPs or their patients’ impressions about the COPD severity.

The Outcomes and Experiences Questionnaire: development and validation

BACKGROUND

This report presents evidence regarding the development and validation of a new questionnaire, the Outcomes and Experiences Questionnaire (OEQ). The rationale for the questionnaire is to bring together into one short instrument questions about two distinct domains - patients' reports of the outcomes of their care and how they experience care.

METHODS

The OEQ was developed from literature reviews, iterative drafting and discussion within the research group and cognitive testing with a sample of patients who had a hospital experience. Two validation studies were carried out with an eleven item OEQ. The goals of the studies were to examine response rates and to test specific hypotheses of how OEQ should relate to other variables normally collected in the two studies. In the first study, the OEQ was added to the follow-up questionnaires for patients (n=490) receiving surgery for hip or knee replacement or varicose vein procedures participating in the national Patient Reported Outcome Measures (PROMs) program permitting the analysis of the OEQ against change scores for the measures obtained before and after surgery. In the second study the OEQ was included in a sample of patients (n=586) who had been selected to receive the National Health Service (NHS) inpatient survey from three contrasting hospital trusts.

RESULTS

Results from study one provided consistent and substantial evidence of construct validity of OEQ particularly for those receiving hip or knee replacement. The OEQ sub-scales behaved differently and as predicted against other PROMs variables. Again hypotheses of how the two sub-scales regarding outcomes and experiences would relate to the existing domains of patient experience in the inpatient survey were broadly confirmed in study two.

CONCLUSION

The report provides encouraging evidence of the OEQ's capacity to assess distinct reports from patients about outcomes and experiences of care within a single short questionnaire.

A brief patient-reported outcome instrument for primary care: German translation and validation of the Measure Yourself Medical Outcome Profile (MYMOP)

BACKGROUND

Measure Yourself Medical Outcome Profile (MYMOP) is a patient-generated outcome instrument capable of measuring effects from a wide range of health care interventions. This paper reports the translation of this instrument into German (MYMOP-D) and the assessment of validity and sensitivity to change for the MYMOP-D. The instrument was piloted in a German primary care context.

METHODS

The translation process was conducted according to international guidelines. Recruited patients of both general practitioners and non-medical Complementary and Alternative Medicine (CAM) practitioners ("Heilpraktiker") in the German state of Baden-Wuerttemberg completed a questionnaire comprised of the MYMOP-D and the EQ-5D. Responses were analysed to assess construct validity. For assessing the instrument's sensitivity to change, patients received the MYMOP-D again after four weeks at which point they were also asked for their subjective views on change of symptoms. Correlation between MYMOP-D and EQ-5D and sensitivity to change as gradient in score change and as standardized response mean (SRM) were calculated.

RESULTS

476 patients from general practices and 91 patients of CAM practitioners were included. Construct validity of the MYMOP-D was given with a correlation of r = .47 with the EQ-5D. Sensitivity to change for subjective change of symptoms could only be analysed for improvement or no change of symptoms, as only 12 patients reported deterioration of symptoms. Results showed the expected smooth gradient with 2.2, 1.3, and 0.5 points of change for large, little improvement and no change, respectively. SRM for MYMOP-D Profile Score was 0.88.

CONCLUSIONS

The MYMOP-D shows excellent construct validity. It is able to detect changes when symptoms in patients improve or remain unchanged. Deterioration of symptoms could not be evaluated due to too few data. With its brevity and simplicity, it might be an important tool for enhancing patient-centred care in the German health care context.