Clinicians' knowledge and attitudes towards patient reported outcomes in colorectal cancer care - insights from qualitative interviews

Functional Results After Nerve-Sparing, Sphincter Preserving Rectal Cancer Surgery: Patient-Reported Outcomes of Sexual and Urinary Dysfunction

There is an ongoing unmet need of early identification and discussion regarding the sexual and urinary dysfunction in the peri-operative period to improve the quality of life (QoL), particularly in young rectal cancer survivors. Retrospective analysis of prospectively maintained database was done. Male patients less than 60 years who underwent nerve preserving, sphincter sparing rectal cancer surgery between January 2013 and December 2019, were screened. International Index of Erectile Function (IIEF-5) questionnaire was given to assess erectile dysfunction (ED). Patients were asked questions regarding their sexual and urinary function from the EORTC-QL CRC 38 questionnaire, and responses were recorded. Patients were also asked to report any retrograde ejaculation in post-operative period. Sixty-two patients were included in the study. Fifty-four patients (87.1%) received a diversion stoma. Sixteen patients (29.6%) felt stoma was interfering with their sexual function. Six patients (9.7%) reported retrograde ejaculation. Only 5 patients (8.06%) had moderate to severe ED, and the rest had none to mild ED. On univariate and multivariate analysis, only age predicted the development of clinically significant ED. Ten patients (16.1%) had significantly reduced sexual urges, and 23 patients (37.1%) had significant decrease in sexual satisfaction after surgery. Five patients (8.06%) reported having minor urinary complaints. No patient reported having major complaint pertaining to urinary health. While long-term urinary complaints are infrequent, almost half the patient suffered from erectile dysfunction in some form. There is a weak but significant association of age and ED. Follow-up clinic visits provide an ideal opportunity to counsel patients and provide any medical intervention, when necessary.

Patient-Reported Outcomes in Colorectal Surgery

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

An implementation study of electronic assessment of patient-reported outcomes in inpatient radiation oncology

Purpose

Despite evidence for clinical benefits, recommendations in guidelines, and options for electronic data collection, routine assessment of patient-reported outcomes (PROs) is mostly not implemented in clinical practice. This study aimed to plan, conduct and evaluate the implementation of electronic PRO (e-PRO) assessment in the clinical routine of an inpatient radiation oncology clinic.

Methods

The guideline- and evidence-based, stepwise approach of this single-center implementation study comprised preparatory analyses of current practice, selection of assessment instruments and times, development of staff training, and evidence-based recommendations regarding the use of the e-PRO assessment, as well as on-site support of the implementation. Process evaluation focused on potential clinical benefit (number of documented symptoms and supportive measures), feasibility and acceptance (patient contacts resulting in completion/non-completion of the e-PRO assessment, reasons for non-completion, preconditions, facilitators and barriers of implementation), and required resources (duration of patient contacts to explain/support the completion).

Results

Selection of instruments and assessment times resulted in initial assessment at admission (EORTC QLQ-C30, QSR 10), daily symptom monitoring (EORTC single items), and assessment at discharge (EORTC QLQ-C30). Recommendations for PRO-based clinical action and self-management advice for patients concerning nine core symptoms were developed. Staff training comprised group and face-to-face meetings and an additional e-learning course was developed. Analyses of clinical records showed that e-PRO assessment identified more symptoms followed by a higher number of supportive measures compared to records of patients without e-PRO assessment. Analysis of n = 1597 patient contacts resulted in n = 1355 (84.9%) completed e-PROs (initial assessment: n = 355, monitoring: n = 967, final assessment: n = 44) and n = 242 (15.2%) non-completions. Instructions or support to complete e-PROs took on average 5.5 ± 5.3 min per patient contact. The most challenging issue was the integration of the results in clinical practice.

Conclusion

E-PRO assessment in oncologic inpatient settings is acceptable for patients and can support symptom identification and the initiation of supportive measures. The challenge of making the “data actionable” within the clinical workflow and motivating clinical staff to use the results became evident.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00478-3.

Cancer patients’ perceptions regarding their symptoms and functioning are important as they can differ from a professional assessment. Patients’ perceptions and self-assessment can be collected via electronic devices. Thus, the clinical staff can see a graphic overview of individual disease-related burden. Despite studies indicating the benefit of this assessment for care and symptom management, it is not integrated into routine care so far. The aim of our study was, to plan, conduct and evaluate the implementation of electronic patient-reported assessment in a radio-oncology inpatient clinic under “real-life” clinical conditions instead of study conditions. Patients could complete an electronic assessment at the beginning/end and during their treatment. Results indicate that electronic self-assessment can identify more symptoms than the assessment of physicians and nurses. Patients completing a self-assessment are more likely to receive supportive measures. The majority of 80–90% of patients were willing to complete a self-assessment. On average 5–6 min were needed to explain or support the completion. While the intervention was feasible and acceptable for patients, motivating clinical staff using its results was most challenging. The importance of technical support became evident.

Collection and Utilization of Patient-Reported Outcome Measures in a Colorectal Surgery Clinic

INTRODUCTION

The routine collection of patient-reported outcome measures (PROMs) promises to improve patient care. However, in colorectal surgery, PROMs are uncommonly collected outside of clinical research studies and rarely used in clinical care. We designed and implemented a quality improvement project with the goals of routinely collecting PROMs and increasing the frequency that PROMs are utilized by colorectal surgeons in clinical practice.

METHODS

This mixed-methods, quality improvement project was conducted in the colorectal surgery clinic of a tertiary academic medical center. Patients were administered up to five PROMs before each appointment. PROM completion rates were measured. Additionally, we performed two educational interventions to increase utilization of our electronic health record's PROM dashboard by colorectal surgeons. Utilization rates and attitudes toward the PROM dashboard were measured.

RESULTS

Overall, patients completed 3600 of 3977 (90.9%) administered PROMs during the study period. At baseline, colorectal surgeons reviewed 6.7% of completed PROMs. After two educational interventions, this increased to 39.3% (P = 0.004). Colorectal surgeons also felt that the PROM dashboard was easier to use. Barriers to greater PROM dashboard utilization included poor user interface/user experience and a perceived lack of knowledge, time, and relevance.

CONCLUSIONS

The collection of PROMs in colorectal surgery clinics is feasible and can result in high PROM completion rates. Educational interventions can improve the utilization of PROMs by colorectal surgeons in clinical practice. Our experience collecting PROMs through this quality improvement initiative can serve as a template for other colorectal surgery clinics interested in collecting and utilizing data from PROMs.

Different Approaches for Case-Mix Adjustment of Patient-Reported Outcomes to Compare Healthcare Providers-Methodological Results of a Systematic Review

Simple Summary

Patient-reported outcomes need to be reported with case-mix adjustment in order to allow fair comparison between healthcare providers. This systematic review identified different approaches to case-mix adjustment, with wide variation between the various approaches.

Abstract

Patient-reported outcomes (PROs) are increasingly being used to compare the quality of outcomes between different healthcare providers (medical practices, hospitals, rehabilitation facilities). However, such comparisons can only be fair if differences in the case-mix between different types of provider are taken into account. This can be achieved with adequate statistical case-mix adjustment (CMA). To date, there is a lack of overview studies on current CMA methods for PROs. The aim of this study was to investigate which approaches are currently used to report and examine PROs for case-mix-adjusted comparison between providers. A systematic MEDLINE literature search was conducted (February 2021). The results were examined by two reviewers. Articles were included if they compared (a) different healthcare providers using (b) case-mix-adjusted (c) patient-reported outcomes (all AND conditions). From 640 hits obtained, 11 articles were included in the analysis. A wide variety of patient characteristics were used as adjustors, and baseline PRO scores and basic sociodemographic and clinical information were included in all models. Overall, the adjustment models used vary considerably. This evaluation is an initial attempt to systematically investigate different CMA approaches for PROs. As a standardized approach has not yet been established, we suggest creating a consensus-based methodological guideline for case-mix adjustment of PROs.

Exploring the use of health and wellbeing measures during pregnancy and the first year following birth in women living with pre-existing long-term conditions: qualitative interviews with women and healthcare professionals

BACKGROUND

One way in which care for pregnant and postpartum women living with long-term health conditions (LTCs) may be improved is through the adoption of standardised measures to provide evidence of health outcomes and wellbeing from the woman's perspective.

AIM

The study explores the views of pregnant and postpartum women living with LTCs, and healthcare professionals to better understand the potential value of using standardised health and wellbeing measures within this patient population.

METHODS

Qualitative semi-structured telephone interviews were conducted to explore the perceived value of using measures with pregnant and postpartum women living with LTCs within maternity services. Participants were asked to provide feedback on three exemplar measures: the Long Term Conditions Questionnaire, the Wellbeing in Pregnancy Questionnaire and the EuroQol EQ-5D-5L instrument. Thematic analysis was used in the analysis of the transcripts.

RESULTS

Eleven women and 11 healthcare professionals took part in semi-structured interviews. Analysis identified five themes as relevant to the use of measures within maternity services: 1) Improving care, 2) Assessing outcomes, 3) Interpretation and application of data, 4) Engagement challenges and implementation and, 5) Women and healthcare professionals alignment.

CONCLUSIONS

Despite varying prior experience and expressing some questions about implementation, respondents were cautiously positive about the use of standardised health and wellbeing measures. Their use offers the opportunity for both affected women and healthcare professionals caring for them to collectively identify and assess important areas of unmet needs and improve outcomes. Incorporating the perspectives of women with LTC's will help bring awareness to elements of women centred care which health services may seek to address.

Could existing infrastructure for using patient-reported outcomes as quality measures also be used for individual care in patients with colorectal cancer?

Background

There has been increasing interest in integrating patient-reported outcomes (PROs) into routine oncological practice. To date, however, PROs have rarely been implemented in Germany. Currently, PROs are being used as performance measures in colorectal cancer centers in Germany. This content analysis identified factors that may inhibit or facilitate the additional use of PROMs for individual patient management.

Methods

The analysis follows an exploratory approach. Out of 103 centers that participated in a multicentric PRO quality management and benchmarking program in Germany, twelve oncological health-care providers from eight certified colorectal cancer centers were interviewed using a semi-structured interview guide. The interviewees were clinicians (physicians, nurses, psycho-oncologist and physician assistant) who care for colorectal cancer patients. This analysis evaluated whether and how PROs that are primarily collected for quality management/benchmarking reasons could also be used for the management of individual patients. The data was analyzed using a content-analysis approach.

Results

The interviewees were not using PRO in their routine clinical work, but they recognized its added value and pointed out potential example uses. Identified inhibiting factors for the use of PROs in clinical routine work were effortful access to PRO reports, lacking coordinating structures, time delays and time points of measurements as well as redundancy with other instruments. Facilitating factors for the use of PROs in clinical routine work that were identified included access via electronic patient records, implementation of coordinating structures for PRO processes in the center, clear PRO reports that are easy to interpret, and measurements at relevant time points.

Discussion

Clinicians had quite a positive attitude toward PROs and recognized their added value. Inhibiting and facilitating factors of an organizational and technical nature were identified.

Conclusions

These findings indicate how PROs used for quality management purposes may also be used for the management of individual patients. Therefore, existing structures and processes in the certified colorectal cancer centers, as well as lessons learned from the literature on the implementation of PROs monitoring individual patients need to be taken into account.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06457-6.