Using Outcome Measures in Daily Practice: Development and Evaluation of an Implementation Strategy for Physiotherapists in the Netherlands

Current use of patient-reported outcome measures by musculoskeletal physiotherapists in Portugal

BACKGROUND

Musculoskeletal conditions are the leading cause of disability, requiring continuous outcome measurement, including the utilization of patient-reported outcome measures (PROMs).

OBJECTIVE

The aims of the study were a) to characterize the use PROMs by Portuguese physiotherapists in patients with musculoskeletal conditions; b) to analyze the associated factors of their use and; c) to identify the barriers and facilitators to their implementation.

METHODS

A cross-sectional online survey was carried out with musculoskeletal physiotherapists working in Portugal. Closed questions were used to describe the use of PROMs. The factors associated with the non-use of PROMs were analysed through logistic regression models (p= 0.05). Barriers and facilitators were assessed through open questions and analyzed using thematic analysis.

RESULTS

One hundred and fifty-six physiotherapists answered the online survey. Most physiotherapists do not use outcome measures consistently and physical tests are often chosen (70.5%) over PROMs (17.3%). The work sector (p= 0.01; p= 0.015; p= 0.009). the workplace stimulus (p= 0.001) and the physiotherapists' knowledge about PROMs (p= 0.017) were identified as factors associated with the non-use of PROMs. Barriers and facilitators to the use of PROMs are related to physiotherapists' skills, the patients' characteristics, the workplace conditions, and the instruments' characteristics.

CONCLUSION

This study showed the poor use of PROMs by musculoskeletal physiotherapists and identified the associated factors, barriers, and facilitators that should be considered to increase its future use by musculoskeletal physiotherapists in Portugal.

Physical and occupational therapists' perceptions of sustainability of a knowledge translation intervention to improve the use of outcome measures in inpatient rehabilitation: a qualitative study

PURPOSE

To assess the perceptions, barriers, and facilitators of sustaining the use of outcome measures of physical and occupational therapists following a three-year knowledge translation intervention.

METHODS

A phenomenological qualitative study was conducted at an inpatient rehabilitation hospital on 13 clinicians (6 physical therapists and 7 occupational therapists) participating in the knowledge translation intervention. Data collection used semi-structured interviewing during three focus groups to understand the lived experience of clinicians participating in the knowledge translation project. Data were analyzed using the Consolidated Framework for Implementation Research (CFIR) codebook.

RESULTS

Two investigators coded twelve CFIR constructs into barriers and facilitators for outcome measure use. Four key themes emerged as determinants for outcome measures use: (1) Organizational support and clinician engagement; (2) the knowledge translation intervention; (3) the outcome measures themselves; and (4) the patients. Clinicians reported using outcome measures for patient education, treatment planning, and goal setting, while they found other outcome measures lacked functional significance. Facilitators included organizational support, access to knowledge, ongoing training, and clinician engagement. Ongoing barriers included the need for more training and the need to select different tests.

CONCLUSIONS

This study found proper selection of outcomes measures is important and attributed the sustainability of the knowledge translation intervention to organizational support, clinician engagement and ongoing training. The clinicians wanted continued training to overcome new barriers. Barriers identified in this study were unique to the typical barriers identified for outcome measure use. Ongoing barrier assessments are needed for continued refinement of knowledge translation interventions to enhance sustainability.

Patient-reported outcome measurements (PROMs): Use during the physical therapy practice and associated factors

OBJECTIVE

To assess the current level of routine use of psychosocial-related patient-reported outcome measurements (PROMs) in physical therapy practice and which physical therapist-level factors are associated with the use of these measurement instruments.

METHODS

We conducted an online survey study among Spanish physical therapists involved in the treatment of LBP patients in Public Health Service, Mutual Insurance Companies, and private practice during 2020. Descriptive analyses were conducted for reporting the number and instruments utilized. Thus, sociodemographic and professional features differences between PTs using and not using PROM were analyzed.

RESULTS

From 485 physiotherapists completing the questionnaire nationwide, 484 were included. A minority of therapists routinely used psychosocial-related PROMs (13.8%) in LBP patients and only 6.8% did so through standardized measurements instruments. The Tampa Scale for Kinesiophobia (28.8%) and the Pain Catastrophizing Scale (15.1%) were used most frequently. Physiotherapists working in Andalucía and País Vasco regions, in private practice environments, educated in psychosocial factors evaluation and management, considering psychosocial factors during the clinical practice and expecting patients' collaborative attitudes demonstrated significantly greater use of PROMS (p < 0.05).

CONCLUSIONS

This study showed that the majority of physiotherapists in Spain do not use PROMs for evaluating LBP (86.2%). From those physiotherapists using PROMs, approximately the half use validated instruments such as the Tampa Scale for Kinesiophobia or the Pain Catastrophizing Scale while the other half limit their evaluation to anamnesis and non-validated questionnaires. Therefore, developing effective strategies to implement and facilitate the use of psychosocial-related PROMs would enhance the evaluation during the clinical practice.

Clinicians' perceived value and demographic factors that predict the utilisation of patient reported outcome measures for low back pain amongst chiropractors in Australia

Background

Factors that influence utilisation rates of patient reported outcome measures (PROMs) for low back pain (LBP) within the chiropractic profession of Australia are currently unknown. This study aimed to examine whether factors, including age, sex, experience level, clinical title (principal vs associate), or a clinicians’ perceived value of PROMs, are predictive of the frequency and/or type of PROMs used by chiropractors in the management of LBP.

Methods

A cross sectional online survey was distributed to members of the Chiropractic Association of Australia (CAA now known as Australian Chiropractors Association-ACA) and Chiropractic Australia (CA). 3,014 CAA members and 930 CA members were invited to participate totaling 3,944, only respondents that were using PROMs were included in the analysis (n = 370). Ordinal logistic regression was used to examine associations between clinician demographics and perceived value of PROMs, and the frequency of pain, health, and functional patient reported outcome measure (PROM) usage by chiropractors.

Results

Principal chiropractors were more likely (Wald = 4.101, p = 0.04, OR = 1.4 (1.0–2.1)) than associate chiropractors to frequently use pain-related PROMs for the management of patients with LBP. The remaining demographic factors (age, sex, and experience level) were not associated with the frequency of PROM usage; nor were the perceived value clinicians place on PROMs in clinical practice.

Conclusion

Principal chiropractors were more likely to frequently use pain-related PROMs for the management of patients with LBP when compared to associate chiropractors. Demographic factors, appear to have little influence on PROM usage. While chiropractors place high value on PROMs, these beliefs are not associated with increased frequency of PROM usage for the management of LBP.

A meta-analysis of the global prevalence of methicillin-resistant Staphylococcus aureus (MRSA) isolated from clinical and subclinical bovine mastitis

AIMS

This meta-analysis aims to assess the point prevalence of methicillin-resistant Staphylococcus aureus (MRSA) isolated from bovine mastitis cases at the global level.

METHODS AND RESULTS

Several electronic databases were searched for relevant publications (PubMed, EMBASE, Web of Knowledge and Cochrane Library). Heterogeneity between studies was assessed using the Cochrane Q test and I² test statistics based on the random-effect model. The potential sources of between-study heterogeneity were evaluated using subgroup analysis and meta-regression. Sensitivity and publication bias analyses were performed. Sixty-six studies with a total of 77,644 mastitis cases were eligible and included in the analysis. The overall pooled prevalence of MRSA was 4·30% (95% CI: 3·24-5·50) with a significant heterogeneity (I²  = 97·48%, p < 0·001). In the subgroup analysis by region, the highest prevalence was found in Asia (6·47%, 95% CI: 4·33-8·97), and the lowest prevalence was reported in Europe (1·18%, 95% CI: 0·18-2·83). The pooled prevalence was significantly higher in clinical mastitis and cases published during 2016-2020.

CONCLUSIONS

The results of this study suggest that there is a lower prevalence of MRSA in bovine mastitis. However, its prevalence increased in the past 4 years. Therefore, continuous surveillance is urgently required for monitoring the dissemination of these clinically important bacteria.

SIGNIFICANCE OF THE STUDY

To our knowledge, this is the first meta-analysis to estimate the global prevalence of MRSA isolated from bovine mastitis cases.

Knowledge Translation Research to Promote Behavior Changes in Rehabilitation: Use of Theoretical Frameworks and Tailored Interventions: A Scoping Review

OBJECTIVE

To describe knowledge translation (KT) research as a means of changing practice behaviors in rehabilitation. We specifically aimed to explore how theories, models, and frameworks (TMFs) are used to guide KT, guide methods to tailor KT interventions, and evaluate outcomes. We hypothesized these methods would have increased over the past 10 years.

DATA SOURCES

We identified articles through searches conducted using databases Cumulative Index to Nursing and Allied Health, MEDLINE, PubMed, Academic Search Premier, and previous reviews from January 2000 to April 2020. Search terms included physical therapy, occupational therapy, speech-language pathology, knowledge translation, and knowledge-to-action (KTA).

STUDY SELECTION

Two authors interpedently screened titles, abstracts, and full-text articles. Studies were included if behavior change of rehabilitation practitioners was measured. Systematic reviews, protocols, and capacity-building interventions were excluded.

DATA EXTRACTION

Three authors extracted information on study design, theoretical frameworks, intervention strategies, and outcome evaluation.

DATA SYNTHESIS

Fifty-six studies were included in the review. Sixteen (29%) reported the use of a theoretical framework to guide the KT process. Since 2013, the KTA framework was used 35% of the time. Twenty-two studies (39%) reported barrier assessments to tailor interventions, and 82% were published after 2013. However, barrier assessment in the local context was only conducted 64% of the time. Outcomes of tailored interventions were most frequently measured using chart audits (50%) and questionnaires (41%). Further, the link between KT theory, specific barriers, and selection of intervention strategies was not consistently described.

CONCLUSIONS

Over the past 7 years, there has been an increase in the use of KT TMFs and tailored interventions. Recommendations for future research include the use of TMFs to guide local barrier assessment, KT strategy selection, intervention development, and overall KT process and mapping barriers to selected intervention strategies.

Which Factors Influence the Use of Patient-Reported Outcome Measures in Dutch Physiotherapy Practice? A Cross-Sectional Study

Purpose: Patient-reported outcome measures (PROMs) have the potential to enhance the quality of health care but, as a result of suboptimal implementation, it is unclear whether they fulfil this role in physiotherapy practice. This cross-sectional study aimed to identify the factors influencing PROM use in Dutch private physiotherapy practices. Method: A total of 444 physiotherapists completed a self-assessment questionnaire and uploaded the data from their electronic health record (EHR) systems to the national registry of outcome data. Univariate and multivariate ordinal logistic and linear regression analysis were used to identify the factors associated with self-reported PROM use and PROM use registered in the EHR systems, which were derived from the self-assessment questionnaire and from the data in the national registry, respectively. Five categories with nine independent variables were selected as potential factors for regression analysis. The similarity between self-reported and registered PROM use was verified. Results: On the basis of self-report and EHR report, we found that 21.6% and 29.8% of participants, respectively, used PROMs with more than 80% of their patients, and we identified the factors associated with PROM use. Conclusions: The factors associated with PROM use are EHR systems that support PROM use and more knowledge about PROM use. These findings can guide future strategies to enhance the use of PROMs in physiotherapy practice.

Person-Centered Care and Physical Therapy: A "People-Like-Me" Approach

In health care, "person centeredness" is a valued (though nebulous) concept. In physical therapy, clinical interactions often strive to be person-centered, for example, by focusing on participation and valuing patient empowerment. However, the available evidence has mostly been constructed around populations (or study samples) rather than individuals. In this perspective, an alternative evidence framework is described, constructed around measurements in routine practice. Specifically, the authors propose developing "people-like-me" reference charts, generated with historical outcomes data, to provide real-time information on an individual's status relative to similar people. The authors present an example of how this could work using their experience with people rehabilitating after total knee arthroplasty. They also describe several challenges that must be addressed to bring this innovation into practice. First, the most important outcome measures for stakeholders (eg, patients, clinicians) need to be identified and monitored longitudinally to ensure that "people-like-me" estimates are useful and support the goals of person-centered care. Statistical methods for selecting "people-like-me" need to be examined and refined. Finally, the "people-like-me" information needs to be packaged in such a way that it is accessible, intuitive, and helpful at the point of care. Ideally, the entire process should recognize from the outset that practice patterns evolve, so databases, statistical models, and decision tools should be dynamic by design. Ultimately, the authors propose this framework as a practical mechanism to advance person-centered decisions in physical therapy according to the ideals of evidence-based practice.

Current use of PROMs and factors associated with their use in patients with nonspecific low back pain

OBJECTIVE

Patient-related outcome measures (PROMs) can guide clinicians in providing evidence-based treatment and have the potential to empower patients, support clinical decision making, and improve quality of care. In order to make the information coming from PROMs useful, it is important to know to what extent the use of PROMs is biased in any way. Therefore, we assessed (a) the current level of use of PROMs among primary care physiotherapists and (b) which factors on the patient level, therapist level, and primary care practice level are associated with the use of PROMs in patients with nonspecific low back pain (LBP).

DESIGN

An observational study based on electronic health record data recorded routinely in Nivel Primary Care Database.

PARTICIPANTS

A total of 2916 patients aged 18 years or older with nonspecific LBP consulting a primary care physiotherapist.

METHODS

Multilevel logistic regression analyses were used to identify factors at the level of the patient, physiotherapist, and primary care practice, which may affect the use of PROMs.

RESULTS

PROMs were used in 46% of the patients, by 72% of the physiotherapists, and in 71% of the physiotherapy practices. None of the included independent variables were associated with the use of PROMs. Only 1% of the variance was explained by the final model.

CONCLUSION

This study shows that the use of PROMs is mostly dependent on characteristics of patients. However, we did not succeed in identifying characteristics of patients that are responsible for that. This could mean that therapists randomly choose patients for PROMs or that there is some other unmeasured patient characteristic determining the use of PROMs. The former explanation implies no systematic bias in the information resulting from PROMs. More research is needed to examine possible related factors to improve implementation and a more frequent use of PROMs in the future.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence. Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU. Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%-36%) and protocol or logistical reasons (0%-7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%). Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

A comparative survey of Nigerian physiotherapists' familiarity with, knowledge of and utilisation of standard outcome measures: 10 years after initial survey

Background

The need for physiotherapists to use standardised outcome measures (SOMs) is recognised and recommended in clinical practice guidelines in many countries.

Aim

To evaluate changes in physiotherapy practice in Nigeria on the utilisation of SOMs and physiotherapists’ familiarity with and knowledge of SOMs over the past decade.

Methods

A comparative cross-sectional survey of present data with 2006 data was undertaken. The existing validated questionnaire of 2006 was used to assess physiotherapists’ familiarity with, knowledge of and utilisation of 16 SOMs.

Results

There was a noticeable change in familiarity with and utilisation of 16 SOMs in the current data and in knowledge. Between 52% and 90% of physiotherapists were not familiar with 14 SOMs in 2006, whereas 51.4% – 85.8% of physiotherapists were not familiar with 8 SOMs in 2016; 77% – 97% and 63.4% – 97.3% of physiotherapists were not utilising SOMs in the 2006 and 2016 data, respectively. The least utilised SOMs in 2006 were Western Ontario McMaster Osteoarthritis Index, Chedoke McMaster Stroke Assessment and SF-36 Health Survey; in 2016, it was only the Chedoke McMaster Stroke Assessment. The Visual Analogue Scale and Gross Motor Function Measure remained the most utilised in both data. Duration of practice, age and sex were significant factors for the utilisation of and familiarity with SOMs.

Conclusion

There was an improvement in the familiarity with, knowledge of and utilisation of SOMs over the past decade among Nigerian physiotherapists but the level of utilisation is unsatisfactory. Action is required if routine outcome measurement is to be achieved.

Clinical Implications

Utilisation of SOMs is part of core standards of physiotherapy practice for effective management of patients. Although the utilisation of SOMs improved over the past 10 years, it is very low. Therefore, studies directed at finding factors responsible for low utilisation of SOMs among Nigerian physiotherapists are warranted.

Exercise and Dementia in Nursing Homes: Views of Staff and Family Carers

This paper reports the qualitative component of a randomized controlled trial which evaluated the impact and feasibility of a physical exercise intervention on individuals living with dementia in nursing homes. Interviews were conducted with 10 staff and nine family carers about their views and opinions of physical exercise (n = 19). Thematic content analysis revealed both benefits and barriers to physical exercise for individuals living with dementia in nursing homes. Another theme was the influences of knowledge and understanding on individuals' views of physical exercise. The involvement of staff and family carers in research encourage their involvement in the implementation of research into clinical practice. This can help to improve provisions of meaningful and beneficial activities for individuals living with dementia in nursing homes. The views and opinions of individuals living with dementia in nursing homes were not considered, though it would be beneficial to include them in future research.

Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study

BACKGROUND

In 2013, the Royal Dutch Society for Physical Therapy launched the program "Quality in Motion." This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement.

PURPOSE

The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient-reported outcome measures (PROMs) in physical therapist practices.

METHODS

A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self-assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemar's symmetry chi-squared test were used to summarize the feasibility of implementing PROMs.

RESULTS

PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre- and posttreatment PROM use increased from 12.2% to 39.5%.

LIMITATIONS

It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists.

CONCLUSION

Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.

A systematic review of interventions to increase the use of standardized outcome measures by rehabilitation professionals

OBJECTIVE

To determine the types and effectiveness of interventions to increase the knowledge about, attitudes towards, and use of standardized outcome measures in rehabilitation professionals.

DATA SOURCES

An electronic search using Medline, EMBASE, PsycINFO, CINAHL, Ergonomics Abstracts, Sports Discus. The search is current to February 2016.

STUDY SELECTION

All study designs testing interventions were included as were all provider and patient types. Two reviewers independently conducted a title and abstract review, followed by a full-text review.

DATA EXTRACTION

Two reviewers independently extracted a priori variables and used consensus for disagreements. Quality assessment was conducted using the Assessment of Quantitative Studies published by the Effective Public Health Practice Group.

DATA SYNTHESIS

We identified 11 studies involving at least 1200 providers. Nine of the studies showed improvements in outcome measure use rates but only three of these studies used an experimental or quasi-experimental design. Eight of the studies used an educational approach in the intervention and three used audit and feedback. Poor intervention description and quality of studies limited recommendations.

CONCLUSIONS

Increased attention to testing interventions focused on known barriers, matched to behavior change techniques, and with stronger designs is warranted.