Developing IntegRATE: a fast and frugal patient-reported measure of integration in health care delivery

Implementing shared decision making for early-stage breast cancer treatment using a coproduction learning collaborative: the SHAIR Collaborative protocol

BACKGROUND

Shared decision making (SDM) in breast cancer care improves outcomes, but it is not routinely implemented. Results from the What Matters Most trial demonstrated that early-stage breast cancer surgery conversation aids, when used by surgeons after brief training, improved SDM and patient-reported outcomes. Trial surgeons and patients both encouraged using the conversation aids in routine care. We will develop and evaluate an online learning collaborative, called the SHared decision making Adoption Implementation Resource (SHAIR) Collaborative, to promote early-stage breast cancer surgery SDM by implementing the conversation aids into routine preoperative care. Learning collaboratives are known to be effective for quality improvement in clinical care, but no breast cancer learning collaborative currently exists. Our specific aims are to (1) provide the SHAIR Collaborative resources to clinical sites to use with eligible patients, (2) examine the relationship between the use of the SHAIR Collaborative resources and patient reach, and (3) promote the emergence of a sustained learning collaborative in this clinical field, building on a partnership with the American Society of Breast Surgeons (ASBrS).

METHODS

We will conduct a two-phased implementation project: phase 1 pilot at five sites and phase 2 scale up at up to an additional 32 clinical sites across North America. The SHAIR Collaborative online platform will offer free access to conversation aids, training videos, electronic health record and patient portal integration guidance, a feedback dashboard, webinars, support center, and forum. We will use RE-AIM for data collection and evaluation. Our primary outcome is patient reach. Secondary data will include (1) patient-reported data from an optional, anonymous online survey, (2) number of active sites and interviews with site champions, (3) Normalization MeAsure Development questionnaire data from phase 1 sites, adaptations data utilizing the Framework for Reporting Adaptations and Modifications-Extended/-Implementation Strategies, and tracking implementation facilitating factors, and (4) progress on sustainability strategy and plans with ASBrS.

DISCUSSION

The SHAIR Collaborative will reach early-stage breast cancer patients across North America, evaluate patient-reported outcomes, engage up to 37 active sites, and potentially inform engagement factors affecting implementation success and may be sustained by ASBrS.

Psychometric assessment of the consideRATE questions, a new measure of serious illness experience, with an online simulation study

OBJECTIVE

To assess the psychometric properties of the consideRATE questions, a measure of serious illness experience.

METHODS

We recruited people at least 50 years old via paid panels online, with US-Census-based quotas. We randomized participants to a patient experience story at two time points. Participants completed a series of measures, including the consideRATE questions. We assessed convergent (Pearson's correlation), discriminative (one-way ANOVA with Tukey's test for multiple comparisons) and divergent (Pearson's correlation) validity. We also assessed intra-rater reliability (intra-class correlation) and responsiveness to change (t-tests).

RESULTS

We included 809 individuals in our analysis. We established convergent validity (r = 0.77; p < 0.001); discriminative validity (bad/neutral stories [mean diff=0.4; p < 0.001]; neutral/ good stories [mean diff=1.3; p < 0.001]) and moderate divergent validity (r = 0.57; p < 0.001). We established sensitivity to change in all stories (bad/good [mean diff=1.52; p < 0.001]; good/bad [mean diff= -1.68; p < 0.001]; neutral/bad [mean diff= -0.57; p < 0.001]; good/neutral [mean diff= -1.11; p < 0.001]; neutral/good [mean diff= 1.1; p < 0.001]) but one (bad/neutral [mean diff= 0.4; p < 0.07]). Intra-rater reliability was demonstrated between time points (r = 0.77; p < 0.001).

CONCLUSIONS

the consideRATE questions were reliable and valid in a simulated online test.

PRACTICE IMPLICATIONS

the consideRATE questions may be a practical way to measure serious illness experience and the effectiveness of interventions to improve it.

A study of the development path of key disciplines in the Guang'an hospital based on construction of west China's compact medical consortium hospitals

OBJECTIVE

To investigate the development path of key disciplines in Guang'an Hospital based on the construction of West China's compact medical consortium hospitals.

METHODS

The urological medical staff and facilities in Guang'an Hospital were selected as the study subjects. The urological medical staff were interviewed, and a detailed investigation and analysis of the current development of urology and the allocation of experts and medical equipment and resources were performed, so as to promote the development of key disciplines in Guang'an Hospital.

RESULTS

We aim to focus on the operational targets of the compact medical consortium while remaining committed to the construction of disciplines of urology. Meanwhile, the relationship between patients and health care providers was coordinated in regard to health care services. The mean of compactness of the dimensions involved in the targets of the operational body of patients was 4.71, while that of the improvement of the medical and health environment was 4.88. The allocated proportion of healthcare resources was optimized, and the operational efficiency was improved. If an excellent medical service experience was provided, the obtained data are statistically significant.

CONCLUSION

Based on the medical consortium, the assessment model of scientific experimental methods, and with the goal of improving the quality of medical treatment regarding urology, the responsibilities of urologists are further defined. A standardized training plan was conducted, with assessment systems of disciplines and better access systems of urologists are formulated and improved, and therefore the construction of key disciplines is promoted, thereby providing more references for the construction and development of key disciplines of urology.

Measuring Patient Experiences of Integration in Health Care Delivery: Psychometric Validation of IntegRATE Under Controlled Conditions

The objective of this study was to assess the psychometric properties of IntegRATE—a 4-item patient-reported measure of integration in health care delivery—under controlled conditions. Adults who reported having received health care in the previous year were exposed to a fictional health care scenario featuring good, mixed, or poor integration on 1 or 2 occasions. They were then asked to imagine themselves as a patient in the scenario and complete IntegRATE and other measures. The data collected were analyzed to assess the discriminative, concurrent, and divergent validity of IntegRATE and its test–retest reliability and responsiveness using both “sum score” and “top score” scoring approaches. Six-hundred people participated in the study with 190 taking part on 2 occasions. The IntegRATE sum score demonstrated discriminative validity, concurrent validity, divergent validity, and responsiveness and partially demonstrated test–retest reliability. The IntegRATE top score demonstrated concurrent validity, divergent validity, and responsiveness and partially demonstrated discriminative validity and test–retest reliability. We conclude that the IntegRATE sum score exhibits encouraging psychometric properties and performs more optimally than the IntegRATE top score.

User-Centered Design of the consideRATE Questions, a Measure of People's Experiences When They Are Seriously Ill

CONTEXT

No brief patient-reported experience measure focuses on the most significant concerns of seriously ill individuals.

OBJECTIVES

The objective of the study was to develop the consideRATE questions.

METHODS

This user-centered design study had three phases. We reviewed the literature and consulted stakeholders, including caregivers, clinicians, and researchers, to identify the elements of care most important to patients (Phase 1). We refined items based on cognitive interviews with patients, families, and clinicians (Phase 2). We piloted the measure with patients and families (Phase 3).

RESULTS

Phase 1 resulted in seven questions addressing the following elements: 1) care team attention to patients' physical symptoms, 2) emotional symptoms, 3) environment of care, 4) respect for patients' priorities, 5) communication about future plans, 6) communication about financial and similar affairs, and 7) communication about illness trajectory. Phase 2 participants included eight patients, eight family members, and seven clinicians. We added an open-text comment option. We did not identify any other issues that were important enough to participants to include. Response choices ranged from one (very bad) to four (very good), with a not applicable option (does not apply). Phase 3 involved 15 patients and 16 family members and demonstrated the acceptability of the consideRATE questions. Most reported that the questions were not distressing, disruptive, or confusing. Completion time averaged 2.4 minutes (range 1-5).

CONCLUSION

Our brief patient-reported serious illness experience measure is based on what matters most to patients, families, and clinicians. It was acceptable to patients and families in a regional sample. It has promise for use in clinical settings.

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Background

Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods

We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery.

Results

Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions

Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary

The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices.

Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.

Conversation aids with pictures and text helped women make better breast cancer surgery choices.

A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.

Spanish Validation of the "User Reported Measure of Care Coordination" Questionnaire for Older People with Complex, Chronic Conditions

Introduction: Older people with complex, chronic conditions often receive insufficient or inefficient care provision, and few instruments are able to measure their perception of care provision. The “User Reported Measure of Care Coordination” instrument has been satisfactorily used to evaluate chronic care provision and integration. The aim of this study is to validate this instrument in Spanish. Methods: The questionnaire was adapted and validated in two phases: translation and cultural adaptation of the questionnaire and psychometric property measurement. Study population were chronic care conditions patients. Results: A total of 332 participants completed test re-test as part of the questionnaire validation process. The final version of the questionnaire had 6 domains: Health and Well-being (D1), Health day to day (D2), Social Services (D3), Planned Care (D4), Urgent Care (D5), and Hospital Care (D6). Cronbach’s alpha for the overall questionnaire was 0.86, indicating good internal consistency. When analyzing each domain, only Planned Care (D4) and Urgent Care (D5) had Cronbach’s Alphas slightly lower than 0.7, although this could be related to the low number of items in each domain. A good temporal stability was observed for the distinct subscales and items, with intraclass correlation coefficients varying from 0.412 to 0.929 (p < 0.05). Conclusion: The adapted version of the “User Reported Measure of Care Coordination” into Spanish proved to be a practical tool for use in our daily practice and an efficient instrument for assessment of care coordination in chronic, complex conditions in older people across services and levels of care.

The Patient Experience of Integrated Care Scale: A Validation Study among Patients with Chronic Conditions Seen in Primary Care

Introduction:

Valid and comprehensive instruments to measure integrated care are required to capture patient experience and improve quality of patient care. This study aimed to validate the Patient Experience of Integrated Care Scale (PEICS), among patients with chronic conditions seen in primary care.

Methods:

One hundred and fifty-nine (159) French-speaking adults with at least one chronic condition were recruited in two family medicine clinics in Quebec (Canada) and completed the 17-item PEICS (T1). Fifty (50) participants completed it a second time 2 weeks later (T2). The internal consistency of the scale was assessed using Cronbach’s alpha, the test-retest reliability with the intraclass correlation coefficient (ICC), and concurrent validity using three dimensions of the Continuity of Care from Multiple Clinicians (CC-MC), with Spearman’s rank correlation coefficients.

Results:

Cronbach’s alpha for the questionnaire was 0.88 (95% CI: 0.85 to 0.91). The intraclass correlation coefficient was 0.81 (95% CI: 0.64 to 0.90) and Spearman’s rank correlation coefficient with the three dimensions of the CC-MC varied from 0.44 to 0.54.

Conclusions and discussion:

The PEICS showed good psychometric properties. This scale could be used in a population with chronic conditions followed in primary care to measure patient experience of integrated care.

What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Background

Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata.

Methods

We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions’ sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed.

Discussion

Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality.

Trial registration

NCT03136367 at ClinicalTrials.gov

Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5109-2) contains supplementary material, which is available to authorized users.

Developing a User Reported Measure of Care Co-ordination

Introduction:

Older people with chronic conditions often receive poor care because of the fragmented way in which their services are delivered from multiple sources. Providers have limited tools to directly capture the views of older people about their experiences of care co-ordination. The study aim was to design and test a survey tool to capture the experiences of older people with chronic conditions regarding how well their health and (where applicable) social care was co-ordinated.

Method:

To inform the questionnaire development, we reviewed the literature on existing surveys and care co-ordination theory, and on the health status of our target audience (people aged 65 or over with one or more chronic conditions and not in hospital or residential institutions). We also consulted stakeholders including those working in health and social care services and those with expertise in the subject area. We grouped questions around experiences of care in three dimensions: care in the home environment, planned transitions in care and unplanned situations. We also designed the questions so they could be mapped onto three recognised dimensions of continuity of care – management continuity, information continuity and relational continuity – as articulated in the international literature. The questionnaire was tested using focus groups and cognitive interviews and piloted with people aged 65 and over with at least one chronic condition, using a postal survey. We used service user records in 32 general practices located in four areas and a population database held by one local authority in England as the sampling frame.

Results:

The pilot achieved an overall response rate of 27.6% (n = 562 responses). Ninety five percent of respondents answered 30 or more of the 46 questions and three respondents answered fewer than 10 questions. Twenty four items achieved one or more positive correlations greater than 0.5 with other survey items and four instances of positive associations greater than 0.7 were found.

Discussion/conclusion:

The growing focus on care co-ordination demonstrates the need for a tool that can capture the experiences of patients accessing care across organisational and professional boundaries, to inform the improvement of care co-ordination activities from a patient perspective. Early results suggest that our tool may have a contribution to make in these areas. However, more work is required to test the efficacy of the tool on a larger scale and in different settings, and to find ways of improving response rates.

Development and evaluation of the "BRISK Scale," a brief observational measure of risk communication competence

OBJECTIVE

To develop and evaluate a brief observational measure of clinical risk communication competence.

METHODS

A 4-item checklist-type measure, the BRISK (Brief Risk Information Skill) Scale, was developed by selecting and refining items from a more comprehensive measure of clinical risk communication competence. Six volunteer raters received brief training on the measure and then used the BRISK Scale to evaluate 52 video-recorded encounters between 2nd-year medical students and standardized patients conducted as part of an Observed Structured Clinical Examination (OSCE) involving a risk communication task. Internal consistency reliability, inter-rater reliability, and criterion validity were assessed.

RESULTS

Raters reported no difficulties using the BRISK Scale; scores across all raters and subjects ranged from 0 to 16 with a mean score of 6.49 (SD=3.17). The BRISK Scale showed good internal consistency reliability (α=0.64), and inter-rater reliability at the scale level (Intraclass Correlation Coefficient (ICC)=0.79 for consistency, and 0.75 for absolute agreement) and individual-item level (ICC range: 0.62-.91). Novice raters' BRISK Scale scores were highly correlated (r=0.84, p<0.01) with expert raters' scores on the Risk Communication Content measure, a more comprehensive measure of risk communication competence.

CONCLUSIONS

The BRISK Scale is a promising new brief observational measure of clinical risk communication competence.

Cognitive biases associated with medical decisions: a systematic review

Background

Cognitive biases and personality traits (aversion to risk or ambiguity) may lead to diagnostic inaccuracies and medical errors resulting in mismanagement or inadequate utilization of resources. We conducted a systematic review with four objectives: 1) to identify the most common cognitive biases, 2) to evaluate the influence of cognitive biases on diagnostic accuracy or management errors, 3) to determine their impact on patient outcomes, and 4) to identify literature gaps.

Methods

We searched MEDLINE and the Cochrane Library databases for relevant articles on cognitive biases from 1980 to May 2015. We included studies conducted in physicians that evaluated at least one cognitive factor using case-vignettes or real scenarios and reported an associated outcome written in English. Data quality was assessed by the Newcastle-Ottawa scale. Among 114 publications, 20 studies comprising 6810 physicians met the inclusion criteria. Nineteen cognitive biases were identified.

Results

All studies found at least one cognitive bias or personality trait to affect physicians. Overconfidence, lower tolerance to risk, the anchoring effect, and information and availability biases were associated with diagnostic inaccuracies in 36.5 to 77 % of case-scenarios. Five out of seven (71.4 %) studies showed an association between cognitive biases and therapeutic or management errors. Of two (10 %) studies evaluating the impact of cognitive biases or personality traits on patient outcomes, only one showed that higher tolerance to ambiguity was associated with increased medical complications (9.7 % vs 6.5 %; p = .004). Most studies (60 %) targeted cognitive biases in diagnostic tasks, fewer focused on treatment or management (35 %) and on prognosis (10 %). Literature gaps include potentially relevant biases (e.g. aggregate bias, feedback sanction, hindsight bias) not investigated in the included studies. Moreover, only five (25 %) studies used clinical guidelines as the framework to determine diagnostic or treatment errors. Most studies (n = 12, 60 %) were classified as low quality.

Conclusions

Overconfidence, the anchoring effect, information and availability bias, and tolerance to risk may be associated with diagnostic inaccuracies or suboptimal management. More comprehensive studies are needed to determine the prevalence of cognitive biases and personality traits and their potential impact on physicians’ decisions, medical errors, and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0377-1) contains supplementary material, which is available to authorized users.