Using Patient Reported Outcomes Measures to Promote Integrated Care

Barriers and facilitators to the uptake of electronic collection and use of patient-reported measures in routine care of older adults: a systematic review with qualitative evidence synthesis

Objective

The aims of this systematic review were to (1) synthesize the available qualitative evidence on the barriers and facilitators influencing implementation of the electronic collection and use of patient-reported measures (PRMs) in older adults' care from various stakeholder perspectives and (2) map these factors to the digital technology implementation framework Non-adoption, Abandonment, challenges to the Scale-up, Spread, Sustainability (NASSS) and behavior change framework Capability, Opportunity, Motivation, Behaviour (COM-B).

Materials and Methods

A search of MEDLINE, CINAHL Plus, and Web of Science databases from 1 January 2001 to 27 October 2021 was conducted and included English language qualitative studies exploring stakeholder perspectives on the electronic collection and use of PRMs in older adults' care. Two authors independently screened studies, conducted data extraction, quality appraisal using the Critical Appraisal Skills Programme (CASP), data coding, assessed confidence in review findings using Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE CERQual), and mapped the findings to NASSS and COM-B. An inductive approach was used to synthesize findings describing the stakeholder perspectives of barriers and facilitators.

Results

Twenty-two studies were included from the 3368 records identified. Studies explored older adult, caregiver, healthcare professional, and administrative staff perspectives. Twenty nine of 34 review findings (85%) were graded as having high or moderate confidence. Key factors salient to older adults related to clinical conditions and socio-cultural factors, digital literacy, access to digital technology, and user interface. Factors salient to healthcare professionals related to resource availability to collect and use PRMs, and value of PRMs collection and use.

Conclusion

Future efforts to implement electronic collection and use of PRMs in older adults' care should consider addressing the barriers, facilitators, and key theoretical domains identified in this review. Older adults are more likely to adopt electronic completion of PRMs when barriers associated with digital technology access, digital literacy, and user interface are addressed. Future research should explore the perspectives of other stakeholders, including those of organizational leaders, digital technology developers and implementation specialists, in various healthcare settings and explore factors influencing implementation of PREMs.

PROSPERO registration number

CRD42022295894.

Unveiling the burden of COPD: perspectives on a patient-reported outcome measure to support communication in outpatient consultations-an interview study among patients

Introduction

Chronic Obstructive Pulmonary Disease (COPD) profoundly affects physical, psychological, and social aspects of life, yet these issues often remain unaddressed. Patient-Reported Outcomes Measures (PROM) have the potential to address these issues by promoting person-centered communication. However, their impact in COPD practice remains uncertain. This study aimed to investigate how patients with COPD perceive the usefulness of a new holistic PROM for general palliative care (PRO-Pall) before and during outpatient consultations.

Methods

Semi-structured telephone interviews were conducted with patients diagnosed with moderate to very severe COPD, 2-5 days after consultation at a respiratory outpatient clinic in Denmark. Interviews were transcribed verbatim and analyzed inductively using qualitative content analysis.

Results

Nine patients (five males; mean age: 66 years) participated in the study with four themes emerging: (1) Unlocking thoughts: Completing PRO-Pall stimulated patients' self-reflection, which revealed previously overlooked COPD-related issues, particularly psychosocial challenges. (2) Unmasking concerns: Patients felt encouraged to be honest, rather than concealing their concerns. (3) Breaking the ice: PRO-Pall responses enabled direct questioning by healthcare professionals during consultations, initiating discussions on patients' sensitive yet vital COPD-related matters. (4) Deepening the dialogue: Healthcare professionals' targeted and attentive approach fostered more holistic and meaningful discussions, providing most patients with a deeper understanding of psychosocial issues affecting their well-being.

Conclusion

Completing PRO-Pall prior to outpatient consultations prompted most patients with COPD to unveil previously unacknowledged psychosocial challenges. During consultations, addressing these challenges initiated open discussions on individual concerns, enhancing most patients' understanding of the multifaceted burden of COPD.

What are the anticipated benefits, risks, barriers and facilitators to implementing person-centred outcome measures into routine care for children and young people with life-limiting and life-threatening conditions? A qualitative interview study with key stakeholders

BACKGROUND

There is a growing evidence-base underpinning implementation of person-centred outcome measures into adult palliative care. However evidence on how best to achieve this with children facing life-threatening and life-limiting conditions is limited.

AIM

To identify the anticipated benefits, risks, barriers and facilitators to implementing person-centred outcome measures for children with life-limiting and life-threatening conditions.

DESIGN

Cross-sectional qualitative semi-structured interview study with key stakeholders analysed using Framework analysis informed by the adapted-Consolidated Framework for Implementation Research.

SETTING/PARTICIPANTS

A total of n = 26 children with life-limiting or life-threatening conditions, n = 40 parents/carers, n = 13 siblings and n = 15 health and social care professionals recruited from six hospitals and three children's hospices and n = 12 Commissioners of health services.

RESULTS

All participants were supportive of future implementation of person-centred outcome measures into care. Anticipated benefits included: better understanding of patient and family priorities, improved communication and collaborative working between professionals and families and standardisation in data collection and reporting. Anticipated risks included increased workload for staff and measures not being used as intended. Implementation barriers included: acceptability and usability of outcome measures by children; burden and capacity of parents/carers regarding completion; privacy concerns; and language barriers. Implementation facilitators included designing measures using language that is meaningful to children and families, ensuring potential benefits of person-centred outcome measures are communicated to encourage 'buy-in' and administering measures with known and trusted professional.

CONCLUSIONS

Implementation of person-centred outcome measures offer potential benefits for children with life-limiting and life-threatening conditions. Eight recommendations are made to maximise benefits and minimise risks in implementation.

Patient-reported outcomes in integrated health and social care: A scoping review

Background

Patient-reported outcomes (PROs) have potential to support integrated health and social care research and practice; however, evidence of their utilisation has not been synthesised.

Objective

To identify PRO measures utilised in integrated care and adult social care research and practice and to chart the evidence of implementation factors influencing their uptake.

Design

Scoping review of peer-reviewed literature.

Data sources

Six databases (01 January 2010 to 19 May 2023).

Study selection

Articles reporting PRO use with adults (18+ years) in integrated care or social care settings.

Review methods

We screened articles against pre-specified eligibility criteria; 36 studies (23%) were extracted in duplicate for verification. We summarised the data using thematic analysis and descriptive statistics.

Results

We identified 159 articles reporting on 216 PRO measures deployed in a social care or integrated care setting. Most articles used PRO measures as research tools. Eight (5.0%) articles used PRO measures as an intervention. Articles focused on community-dwelling participants (35.8%) or long-term care home residents (23.9%), with three articles (1.9%) focussing on integrated care settings. Stakeholders viewed PROs as feasible and acceptable, with benefits for care planning, health and wellbeing monitoring as well as quality assurance. Patient-reported outcome measure selection, administration and PRO data management were perceived implementation barriers.

Conclusion

This scoping review showed increasing utilisation of PROs in adult social care and integrated care. Further research is needed to optimise PROs for care planning, design effective training resources and develop policies and service delivery models that prioritise secure, ethical management of PRO data.

Self-reported MeasUrement of Physical and PsychosOcial Symptoms Response Tool (SUPPORT-dialysis): systematic symptom assessment and management in patients on in-centre haemodialysis - a parallel arm, non-randomised feasibility pilot study protocol

INTRODUCTION

Patients with kidney failure experience symptoms that are often under-recognised and undermanaged. These symptoms negatively impact health-related quality of life and are associated with adverse clinical outcomes. Regular symptom assessment, using electronic patient reported outcomes measure (ePROMs) linked to systematic symptom management, could improve such outcomes. Clinical implementation of ePROMs have been successful in routine oncology care, but not used for patients on dialysis. In this study, we describe a pilot study of ePROM-based systematic symptom monitoring and management intervention in patients treated with in-centre haemodialysis.

METHODS AND ANALYSIS

This is a parallel-arm, controlled pilot of adult patients receiving in-centre maintenance haemodialysis. Participants in the intervention arm will complete ePROMs once a month for 6 months. ePROMs will be scored real time and the results will be shared with participants and with the clinical team. Moderate-severe symptoms will be flagged using established cut-off scores. Referral options for those symptoms will be shared with the clinical team, and additional symptom management resources will also be provided for both participants and clinicians. Participants in the control arm will be recruited at a different dialysis unit, to prevent contamination. They will receive usual care, except that they will complete ePROMs without the presentation of results to participants of the clinical team. The primary objectives of the pilot are to assess (1) the feasibility of a larger, randomised clinical effectiveness trial and (2) the acceptability of the intervention. Interviews conducted with participants and staff will be assessed using a content analysis approach.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the University Health Network (REB#21-5199) and the William Osler Health System (#23-0005). All study procedures will be conducted in accordance with the standards of University Health Network research ethics board and with the 1964 Helsinki declaration and its later amendments. Results of this study will be shared with participants, patients on dialysis and other stakeholders using lay language summaries, oral presentations to patients and nephrology professionals. We will also be publishing the results in a peer-reviewed journal and at scientific meetings.

PROTOCOL VERSION

4 (16 November 2022).

TRIAL REGISTRATION NUMBER

NCT05515991.

Self-reported characteristics of people seeking primary care physiotherapy in Denmark: A cross-sectional study

BACKGROUND

Limited knowledge exists on the self-reported characteristics of patients seeking primary care physiotherapy in Denmark.

OBJECTIVES

To describe primary symptom site, co-occurrent pain sites, pain intensity, symptom duration, and number of symptom episodes in patients seeking primary care physiotherapy using patient-reported data.

METHODS

Cross-sectional study of patients seeking primary care physiotherapy within a nationwide network of clinics in Denmark (FysioDanmark® ). Data from the FysioDanmark® clinical database with patient-reported information obtained from questionnaires distributed to patients prior to their first consultation were used. This included primary symptom site, co-occurrent pain sites, pain intensity (0-10 numeric rating scale), symptom duration, and number of symptom episodes.

RESULTS

Data from 61,097 patients (57% female) aged 42 years (interquartile range 29-53) and 63,566 first visits were included. The most common reasons for seeking care were back- (22.9%), non-specific- (19.8%) and shoulder symptoms (15.9%). The majority of patients (89.4%) reported symptoms lasting longer than 7 days, and many experienced recurrent episodes. Median pain intensity ranged from 3 to 5 across primary symptom sites and age groups. In general, females reported higher pain intensity than males.

CONCLUSION

Danish patients seeking primary care physiotherapy most commonly presented with back, non-specific, and shoulder symptoms, with mild-to-moderate pain lasting longer than 7 days, and many with recurrent episodes.

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

[Encuesta Internacional de Indicadores de Salud Referidos por los Pacientes: el protocolo del Estudio PaRIS en España.]

OBJECTIVE

The PaRIS Survey is an initiative led by the Organization for Economic Cooperation and Development in twenty-one countries, including Spain, to promote people-centred health care. The objective of the study aimed to describe PROMS and PREMS (Patient Reported Outcomes and Experience Measures, respectively) from patients who were in contact with Primary Care Centres, in order to establish a set of reliable, valid and internationally comparable indicators.

METHODS

A cross-sectional study with two questionnaires will be carried out: one applied online for professionals from Primary Care Centres and another by telephone or online for patients aged forty-five and older of the same Health Care Centres. The domains covered are: characteristics of the Health Centre and of the professionals; sociodemographic characteristics of the patients; lifestyles; health care capacities; PROMs and PREMs.

CONCLUSIONS

The study offers a unique opportunity to evaluate the health outcomes and experiences of the care received in Primary Care from patient's perspective. This information is essential to help policymakers better understand the performance of their health system and how it could be improved, particularly in relation to chronic care in Primary Care.

Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Background

We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.

Objective(s), study design, settings and participants

Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.

Results

A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.

Limitations

Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.

Conclusions

We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.

Future work

Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.

Study registrations

This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.

Ethical challenges and principles in integrated care

INTRODUCTION

Integrated care is an established approach to delivery in parts of the healthcare infrastructure, and an ideal which, it is claimed, should be realized system-wide. Its ethical weight derives from its defence of a view about how healthcare ought to operate. Although the goal of integration is laudable, it is ethically and practically complex, involving trade-offs.

SOURCES OF DATA

Considerable evidence attests to widespread enthusiasm for integration, given the need to prevent harm and extend the reach of scarce resources. Equally, evidence increasingly highlights the obstacles to successfully translating this ideal into practice.

AREAS OF AGREEMENT

The principle that healthcare should be seamless, ensuring that patients do not come to harm through gaps in care enjoys broad agreement. There is a similar consensus that placing the patient's perspective at the centre of decision-making is vital, since this enables identification of these gaps.

AREAS OF CONTROVERSY

Integrating care by making it seamless entails blurring boundaries of care domains. This risks undermining the locus of responsibility for care decisions via confusion about who has ownership of specialist knowledge where domains overlap. There is a lack of consensus about how successful integration should be measured.

GROWING POINTS

More research into the relative cost-effectiveness of upstream public health investment in preventing chronic ill-health caused by modifiable lifestyle factors vs integrating care for people already ill; further research into ethical implications of integration in practice, which can be obscured by the simplicity of the fundamental normative principle guiding integration in theory.

Dutch translation and validation of the Communicative Participation Item Bank (CPIB)-short form

BACKGROUND

Several conditions and diseases can result in speech problems that can have a negative impact on everyday functioning, referred to as communicative participation. Subjective problems with acquired speech problems are often assessed with the speech handicap index (SHI). To assess generic participation problems, the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) questionnaire is frequently used. The English questionnaire Communicative Participation Item Bank-short form (CPIB short form) is a 10-item valid, reliable instrument that assesses communicative participation. In the absence of a Dutch equivalent, translation and validation of the CPIB short form was required.

AIMS

To translate the CPIB short form into Dutch, and to determine its psychometric properties for the group of adults with speech problems resulting from a neurological aetiology or head and neck cancer.

METHODS & PROCEDURES

Translation of the CPIB short form was performed following the instructions of the European Organisation for Research and Treatment for Cancer (EORTC). In a cross-sectional multi-centre study, participants completed the Dutch CPIB short form together with the SHI and USER-P, and the CPIB a second time after 2 weeks. We assessed internal consistency and test-retest reliability of the CPIB. Construct validity was assessed based on correlations with SHI, USER-P and speech assessments.

OUTCOMES & RESULTS

In the validation study, 122 participants were included: 51 with dysarthria due to different neurological disorders, 48 with speech problems due to head and neck cancer treatment and 23 healthy controls. Internal consistency of the items was high (Cronbach's alpha = 0.962), the intraclass correlation coefficient (ICC) for test-retest reliability was high 0.908 (95% CI = 0.870-0.935). Construct validity was supported by a strong correlation between the Dutch CPIB short form and the SHI total score (SHI total r_s = 0.887) and a moderate correlation between the Dutch CPIB-10 and the USER-P subscales (USER-P Frequency r_s = 0.365; USER-P restrictions and USER-P satisfaction r_s = 0.546). A moderate correlation was found between the Dutch CPIB-10 and the speech performance assessments (degree of distortedness r = -0.0557; p ≤ 0.001; degree of intelligibility r = 0.0562).

CONCLUSIONS & IMPLICATIONS

The Dutch CPIB short form provides a valid and reliable tool for clinical practice and research purposes. It allows clinicians to start using this PROM in clinical and research practice to systematically investigate the impact of the speech problems on communicative participation in a Dutch-speaking population.

WHAT THIS PAPER ADDS

What is already known on the subject Communicative participation allows people to take part in life situations, but can be affected by acquired speech problems. The CPIB is a patient-reported outcome measure for the assessment of this concept. For the English language the 46-item bank and a 10-item short form is available. What this paper adds to existing knowledge This paper describes the process of translation of the CPIB short form into Dutch, and confirms its reproducibility and validity. What are the potential or actual clinical implications of this work? With this validated Dutch version of the CPIB short form available, professionals can implement this tool in clinical and research practice to systematically evaluate communicative participation.

Differential Item Functioning of the Jaw Functional Limitation Scale

AIMS

To assess the differential item functioning (DIF) of the Jaw Functional Limitation Scale (JFLS) due to gender, age, and language (English vs Spanish).

METHODS

JFLS data were collected from a consecutive sample of 2,115 adult dental patients from HealthPartners dental clinics in Minnesota. Participants with missing data were excluded, and analyses were performed using data from 1,678 participants. Whether the item response theory (IRT) model assumptions of essential unidimensionality and local independence held up for the JFLS was examined. Then, using Samejima's graded response model, the IRT log-likelihood ratio approach was used to detect DIF. The magnitude and impact of DIF based on Raju's noncompensatory DIF (NCDIF) cutoff value of 0.096, Cohen's effect sizes, and test (or scale) characteristic curves were also assessed.

RESULTS

Essential unidimensionality was confirmed, but locally dependent items were found on the JFLS. A few items were flagged with statistically significant DIF after adjustment for multiple comparisons. The NCDIF indices associated with all DIF items were < 0.096, and they had small effect sizes of ≤ 0.2. The differences between the expected scores shown in the test characteristic curves were little to none.

CONCLUSION

The present results support the use of the JFLS summary score to obtain psychometrically robust score comparisons across English- and Spanish-speaking, male and female, and younger and older dental patients. Overall, the magnitude of DIF was relatively small, and the practical impact minimal.

Co-creation of a Patient-Reported Outcome Measure for Older People Living with Frailty Receiving Acute Care (PROM-OPAC)

Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

BACKGROUND

Coordination, cooperation and efficient use of resources is vital for the health- and social care sector if it is to meet the needs of an aging population. Integrated care is a patient-centred approach to provision of care aiming to improve quality of care and overcome fragmented care through co-productive partnerships and may positively affect quality of care and health outcomes, especially among those in need of highly coordinated care services.

AIM

To compare patient-reported outcomes (PROs) among patients undergoing total hip replacement (THR) in the integrated care system in Norrtälje Municipality and in the standard care system in other municipalities in Region Stockholm, Sweden.

METHODS

Swedish Hip Arthroplasty Register PRO data during 2008-2015 were compared 1 year after THR among patients (≥50 years) in integrated care (n = 407) and standard care (n = 3501) systems using linear (EQ VAS score), logistic (EQ-5D-3L dimensions) and negative binomial (hip pain VAS score) regressions. Analyses were adjusted for the preoperative factors age, sex, BMI, ASA class and type of incision.

RESULTS

1-year postoperatively, patients in the integrated care system did not report their health significantly different from patients receiving standard care. Exceptions: Female patients in integrated care reported less problems with self-care (OR:0.52; 0.29-0.96) and patients above 70 years reported more problems with mobility (OR: 1.37; 1.01-1.87).

CONCLUSION

No significant differences were found between the two care systems for postoperative PROs. A longer follow-up time and analyses by socioeconomic groups would be valuable.

Impetus of US hospital leaders to invest in patient-reported outcome measures (PROMs): a qualitative study

OBJECTIVES

Though hospital leaders across the USA have invested significant resources in collection of patient-reported outcome measures (PROMs), there are very limited data on the impetus for hospital leadership to establish PROM programmes. In this qualitative study, we identify the drivers and motivators of PROM collection among hospital leaders in the USA.

DESIGN

Exploratory qualitative study.

SETTING

Thirty-seven hospital leaders representing seven different institutions with successful PROMs programs across twenty US states.

METHODS

Semistructured interviews conducted with hospital leaders. Transcripts were analysed using thematic analysis.

RESULTS

Leaders strongly believe that collecting PROMs is the 'right thing to do' and that the culture of the institution plays an important role in enabling PROMs. The study participants often believe that their institutions deliver superior care and that PROMs can be used to demonstrate the value of their services to payors and patients. Direct financial incentives are relatively weak motivators for collection of PROMs. Most hospital leaders have reservations about using PROMs in their current state as a meaningful performance metric.

CONCLUSION

These findings suggest that hospital leaders feel a strong moral imperative to collect PROMs, which is also supported by the culture of their institution. Although PROMs are used in negotiations with payors, direct financial return on investment is not a strong driver for the collection of PROMs. Understanding why leaders of major healthcare institutions invest in PROMs is critical to understanding the role that PROMs play in the US healthcare system.

A Standard Set of Value-Based Patient-Centered Outcomes and Measures of Overall Health in Adults

BACKGROUND

The definition of population-specific outcomes is an essential precondition for the implementation of value-based health care. We developed a minimum standard outcome set for overall adult health (OAH) to facilitate the implementation of value-based health care in tracking, comparing, and improving overall health care outcomes of adults across multiple conditions, which would be of particular relevance for primary care and public health populations.

METHODS

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international panel (patients, clinicians, and topic experts). Following the development of a conceptual framework, a modified Delphi method (supported by public consultations) was implemented to identify, in sequence, the relevant domains, the best instruments for measuring them, the timing of measurement, and the relevant adjustment variables.

FINDINGS

Outcomes were identified in relation to overall health status and the domains of physical, mental, and social health. Three instruments covering these domains were identified: PROMIS Scale v1.2-Global Health (10 items), WHO Wellbeing Index (5 items), and the WHO Disability Assessment Schedule 2.0 (12 items). Case-mix variables included a range of sociodemographic and biometric measures. Yearly measurement was proposed for all outcomes and most case-mix variables.

INTERPRETATION

The ICHOM OAH Standard Set has been developed through consensus-based methods based on predefined criteria following high standards for the identification and selection of high-quality measures The involvements of a wide range of stakeholders supports the acceptability of the set, which is readily available for use and feasibility testing in clinical settings.

A systematic review and recommendations for prom instruments for older people with frailty in emergency care

Introduction

The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of ‘Autonomy’ and ‘Functioning’. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population.

Methods

In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production.

Results

Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from ‘doubtful’ to ‘very good’. Most instruments had strong evidence for measurement properties. PROMs mainly assessed ‘Functioning’ constructs, with limited coverage of ‘Autonomy’. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty.

Conclusions

Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00438-x.

What matters most in acute care: an interview study with older people living with frailty

Background

Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty.

Methods

Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review.

Results

The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were ‘Autonomy’ (information, control, and security) and ‘Functioning’ (physical, psychosocial, and relief). A novel ‘security’ theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others.

Conclusions

Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support.

Age and Ageing journal 50th anniversary commentary seriesWhy illness is more important than disease in old age

Clinical reasoning and research in modern geriatrics often prioritises the disease concept. This is understandable as it has brought impressive advances in medicine (e.g. antibiotics, vaccines, successful cancer treatment and many effective surgeries). However, so far the disease framework has not succeeded in getting us to root causes of many age-related chronic diseases (e.g. Alzheimer’s disease, diabetes, osteoarthritis). Moreover, in aging and disease constructs alone fail to explain the variability in illness presentations.

Therefore, we propose to apply the underused illness concept in a new way by reconsidering the importance of common symptoms in the form of a dynamic network of symptoms as a complementary framework. We show that concepts and methods of complex system thinking now enable to fruitfully monitor and analyse the multiple interactions between symptoms in such in networks, offering new routes for prognosis and treatment. Moreover, close attention to the symptoms that bother older persons may also improve weighing the therapeutic objectives of well-being and survival and aligning treatment targets with the patients’ priorities.

The potential of dividing the oxford knee score into subscales for predicting clinically meaningful improvements in pain and function of patients undergoing total knee arthroplasty

BACKGROUND

Subdividing the Oxford Knee Score (OKS) into a pain component scale (OKS-PCS) and a function component scale (OKS-FCS) for predicting clinically meaningful improvements may provide a basis for identifying patients in need of enhanced support from health care professionals to manage pain and functional challenges following total knee arthroplasty.

AIM

To assess the potential of dividing the OKS into subscales for predicting clinically meaningful improvements in pre- and postoperative pain and function by comparing two different versions of extracting pain and function derived from the OKS.

METHODS

This retrospective observational cohort study included 201 patients undergoing total knee arthroplasty. Multiple logistic regression analysis was applied for binary classification of whether patients achieved clinically meaningful improvements in pain and function.

RESULTS

The best overall version for predicting clinically meaningful improvements had an area under the receiver operating characteristic curve of 0.79 for both pain and function, whereas Nagelkerke's R² was 0.322 and 0.334, respectively.

CONCLUSION

The findings indicate that it is reasonable to subdivide the OKS into subscales for predicting clinically meaningful improvements in pain and function. However, more studies are needed to compare various types of classification algorithms in larger patient populations.

Benefits, Challenges, and Opportunities of Integrating Patient-Reported Outcome Measures in Geriatric Oncology to Advance Patient Screening for Functional Fitness for Treatment

OBJECTIVES

To discuss potential benefits, challenges, and opportunities of integrating patient-reported outcome measures in geriatric oncology, with the goal being to advance patient screening for 'functional fitness for treatment.'

DATA SOURCES

This is narrative review of the relevant literature using PubMed.

CONCLUSION

Patient screening in geriatric cancer care can be driven by patient self-reports. Most of the research on patient-reported outcome measures in cancer care to date has involved, in different proportions and to different extents, older patients with cancer (≥70 years of age). However, reports specifically targeting implementation of patient-reported outcome measures in geriatric cancer care are surprisingly fewer. The International Society of Geriatric Oncology Priorities Initiative calls for more research into the use of patient-reported outcome measures for older adults with cancer. More feasibility studies will be required to evaluate patient-reported outcome measures as fit-for-purpose, reporting frequency, patient burden, integration and display of patient-reported information, and workflow impact. Developing, adapting, and validating patient-reported outcome measures for use in geriatric oncology will be key to ensure adequacy of measurement. Groundwork involving consultation of all potential end users of patient-reported information is paramount because there is no one size fits all. When the ground is ready for implementation adequate preparation, training, resources, and ongoing support will be needed.

IMPLICATIONS FOR NURSING PRACTICE

Working within the multidisciplinary team, nurses can promote patient screening that is led by the patient. Nursing roles can be developed, supported, expanded, or repurposed to involve greater use of patient-reported outcome measures for several key patient outcomes in geriatric cancer care.

ICF-Based Assessment of Functioning in Daily Clinical Practice. A Promising Direction Toward Patient-Centred Care in Patients With Low Back Pain

Background: Patient-centred care has received increased attention in recent years. Patient-Reported Outcomes (PROs) and shared decision-making are key components of Patient-Centred care. Low back pain (LBP) is a complex symptom affected by multiple, interacting factors. Therefore, evidence strongly recommend a biopsychosocial and patient-centred approach in the assessment and management. The International Classification of Functioning, Disability and Health (ICF) provide a biopsychosocial model for describing functioning and disability. ICF is widely acknowledged, but implementation into clinical practice is lacking. To support the use of a biopsychosocial and patient-centred approach in daily clinical practice among patients with LBP we developed a practice-friendly tool based on ICF; the LBP assessment tool.

Objective: To compare an ICF-based assessment facilitated by the LBP assessment tool with standard care in terms of the use of PROs and shared decision-making in order to promote patient-centred care in patients with LBP.

Methods: A non-randomized controlled design was used. Eligible patients were allocated to one of two groups: the ICF group, assessed with the LBP assessment tool or the control group, assessed with a conventional LBP assessment. Primary outcome includes use of PROs. Secondary outcomes include use of a graphical overview displaying the patient profile and shared decision-making. A patient evaluation questionnaire was used to collect data.

Results: Seven hundred ten patients were assessed for eligibility of whom 531 were allocated to the ICF group (n = 299) or the control group (n = 232). A significantly higher use of PRO data (p < 0.00) and the patient profile (p < 0.00) was reported in favor of the ICF group. Patients in the ICF group also experienced being more involved in decision-making (p = 0.01).

Conclusions: This study showed that a functioning assessment, by means of the LBP assessment tool, increased use of PROs and shared decision-making when compared to a conventional LBP assessment. Additionally, this study demonstrated that routine use of ICF-based PRO data and shared decision-making promoted patient-centred care in patients with LBP. The LBP assessment tool may be a strong candidate for a user-friendly ICF-based tool with the potential to support health professionals in a shift toward a biopsychosocial and patient-centred approach to patients with LBP.

Health Care Equity in the Use of Advanced Analytics and Artificial Intelligence Technologies in Primary Care

The integration of advanced analytics and artificial intelligence (AI) technologies into the practice of medicine holds much promise. Yet, the opportunity to leverage these tools carries with it an equal responsibility to ensure that principles of equity are incorporated into their implementation and use. Without such efforts, tools will potentially reflect the myriad of ways in which data, algorithmic, and analytic biases can be produced, with the potential to widen inequities by race, ethnicity, gender, and other sociodemographic factors implicated in disparate health outcomes. We propose a set of strategic assertions to examine before, during, and after adoption of these technologies in order to facilitate healthcare equity across all patient population groups. The purpose is to enable generalists to promote engagement with technology companies and co-create, promote, or support innovation and insights that can potentially inform decision-making and health care equity.

Use of Patient-Reported Outcomes Measurement Information System (PROMIS) measures to characterise health status for patients seeking care from an orthopaedic provider: a retrospective cohort study

OBJECTIVES

Characterise the health status of patients newly consulting an orthopaedic specialist across eight clinical subspecialties.

DESIGN

Retrospective cohort.

SETTING

18 orthopaedic clinics, including 8 subspecialties (14 ambulatory and 4 hospital based) within an academic health system.

PARTICIPANTS

14 910 patients consulting an orthopaedic specialist for a new patient consultation who completed baseline Patient-Reported Outcomes Measurement Information System (PROMIS) measures associated with their appointment from 17 November 2017 to 13 May 2019. Patients were aged 55.72±5.8 years old, and 61.3% were female and 79.3% were Caucasian and 13.4% were black or African American. Patients who did not complete PROMIS measures or cancelled their appointment were excluded from the study.

PRIMARY OUTCOME

PROMIS domains of physical function, pain interference, pain intensity, depression, anxiety, fatigue, sleep disturbance and the ability to participate in social roles.

RESULTS

Mean PROMIS scores for physical function were (38.1±9.2), pain interference (58.9±8.1), pain intensity (4.6±2.5), depression (47.9±8.9), anxiety (49.9±9.5), fatigue (50.5±10.3), sleep disturbance (51.1±9.8) and ability to participate in social roles (49.1±10.3) for the entire cohort. Across the clinical subspecialties, neurosurgery, spine and trauma patients were most profoundly affected across almost all domains and patients consulting with a hand specialist reported the least limitations or symptoms across domains. There was a moderate, negative correlation between pain interference and physical functioning (r=-0.59) and low correlations between pain interference with anxiety (r=0.36), depression (r=0.39) as well as physical function and anxiety (r=-0.32) and depression(r=-0.30) and sleep (r=-0.31).

CONCLUSIONS

We directly compared clinically meaningful PROMIS domains across eight orthopaedic subspecialties, which would not have been possible with legacy measures alone. These results support PROMIS's utility as a common metric to assess and compare patient health status across multiple orthopaedic subspecialties.

Electronic health record-integrated approach for collection of patient-reported outcome measures: a retrospective evaluation

Background

The integration of Patient Reported Outcome Measures (PROMs) into clinical care presents many challenges for health systems. PROMs provide quantitative data regarding patient-reported health status. However, the most effective model for collecting PROMs has not been established. Therefore the purpose of this study is to report the development and preliminary evaluation of the standardized collection of PROMs within a department of orthopedic surgery at a large academic health center.

Methods

We utilized the Users’ Guide to Integrating Patient-Reported Outcomes in Electronic Health Records by Gensheimer et al., 2018 as a framework to describe the development of PROMs collection initiative. We framed our initiative by operationalizing the three aspects of PROM collection development: Planning, Selection, and Engagement. Next, we performed a preliminary evaluation of our initiative by assessing the response rate of patients completing PROMs (no. of PROMs completed/no. of PROMs administered) across the entire department (18 clinics), ambulatory clinics only (14 clinics), and hospital-based clinics only (4 clinics). Lastly, we reported on the mean response rates for the top 5 and bottom 5 orthopaedic providers to describe the variability across providers.

Results

We described the development of a fully-integrated, population health based implementation strategy leveraging the existing resources of our local EHR to maximize clinical utility of PROMs and routine collection. We collected a large volume of PROMs over a 13 month period (n = 10,951) across 18 clinical sites, 7 clinical specialties and over 100 providers. The response rates varied across the department, ranging from 29 to 42%, depending on active status for the portal to the electronic health record (MyChart). The highest single provider mean response rate was 52%, and the lowest provider rate was 13%. Rates were similar between hospital-based (26%) and ambulatory clinics (29%).

Conclusions

We found that our standardized PROMs collection initiative, informed by Gensheimer et al., achieved scope and scale, but faced challenges in achieving a high response rate commensurate with existing literature. However, most studies reported a targeted recruitment strategy within a narrow clinical population. Further research is needed to elucidate the trade-off between scalability and response rates in PROM collection initiatives.

Cutoff Values to Interpret Short-term Treatment Outcomes After Arthroscopic Meniscal Surgery, Measured With the Knee Injury and Osteoarthritis Outcome Score

OBJECTIVE

To determine the proportions of patients who (1) perceived their symptoms to be satisfactory, (2) perceived their treatment to have failed, or (3) perceived that they improved to an important degree at 3 months after arthroscopic meniscal surgery; and to determine Knee injury and Osteoarthritis Outcome Score (KOOS) subscale scores corresponding to the Patient Acceptable Symptom State (PASS), treatment failure, and the minimal important change (MIC) for improvement.

DESIGN

Prospective cohort study.

METHODS

Patients from the Knee Arthroscopy Cohort Southern Denmark who had arthroscopic meniscal surgery were included. The PASS, treatment failure, and MIC improvement values were calculated for the KOOS subscales with anchor-based approaches, using the adjusted predictive modeling method. Subgroup analyses were performed by stratifying by age (40 years or younger versus older than 40 years) and surgery type.

RESULTS

Six hundred fourteen patients (44% female; mean ± SD age, 50 ± 13 years) were included. At 3 months after arthroscopic meniscal surgery, 45% of patients perceived their symptoms to be satisfactory, 19% perceived the treatment to have failed, and 44% to 60% perceived that they had improved to an important degree across the 5 KOOS subscales (for PASS/treatment failure, respectively: pain, 74 and 60 points; symptoms, 72 and 61 points; function in activities of daily living, 81 and 68 points; sport and recreational function, 43 and 26 points; and knee-related quality of life, 52 and 40 points; for MIC improvement: pain, 12 points; symptoms, 8 points; function in activities of daily living, 12 points; sport and recreational function, 17 points; and knee-related quality of life, 9 points). The PASS values were 6 to 17 points higher for patients 40 years or younger compared to patients older than 40 years.

CONCLUSION

At 3 months after meniscal surgery, approximately half of the patients perceived their symptoms to have improved to an important degree, 4 in every 10 patients perceived their symptoms to be satisfactory, and 2 in every 10 patients perceived the treatment to have failed. J Orthop Sports Phys Ther 2021;51(6):281-288. Epub 30 Jan 2021. doi:10.2519/jospt.2021.10149.

Outcomes after kidney transplantation, let's focus on the patients' perspectives

Graft function and patient survival are traditionally the most used parameters to assess the objective benefits of kidney transplantation. Monitoring graft function, along with therapeutic drug concentrations and transplant complications, comprises the essence of outpatient management in kidney transplant recipients (KTRs). However, the patient's perspective is not always included in this process. Patients' perspectives on their health after kidney transplantation, albeit subjective, are increasingly acknowledged as valuable healthcare outcomes and should be considered in order to provide patient-centred healthcare. Such outcomes are known as patient-reported outcomes (PROs; e.g. health-related quality of life and symptom burden) and are captured using PRO measures (PROMs). So far, PROMs have not been routinely used in clinical care for KTRs. In this review we will introduce PROMs and their potential application and value in the field of kidney transplantation, describe commonly used PROMs in KTRs and discuss structural PROMs implementation into kidney transplantation care.

Assessment of functioning and disability in patients with low back pain - the low back pain assessment tool. Part 1: development

PURPOSE

To present the process used to develop the low back pain (LBP) assessment tool including evaluation of the initial content validity of the tool.

METHODS

The development process comprised the elements: definition of construct and content, literature search, item generation, needs assessment, piloting, adaptations, design, and technical production. The LBP assessment tool was developed to assess the construct "functioning and disability" as defined by the International Classification of Functioning, Disability and Health (ICF). Involvement of patients and health professionals was essential.

RESULTS

The elements were collapsed into five steps. In total, 18 patients and 12 health professionals contributed to the content and the design of the tool. The LBP assessment tool covered all ICF components shared among 63 ICF categories.

CONCLUSIONS

This study presents the process used to develop the LBP assessment tool, which is the first tool to address all ICF components and integrate biopsychosocial perspectives provided by patients and health professionals in the same tool. Initial evaluation of content validity showed adequate reflection of the construct "functioning and disability". Further work on the way will evaluate comprehensiveness, acceptability, and degree of implementation of the LBP assessment tool to strengthen its use for clinical practice.Implications for RehabilitationA biopsychosocial and patients-centred approach is a strong foundation for identifying the many relevant aspects related to low back pain (LBP).Responding to a lack of tools to support a biopsychosocial and patients-centred approach the LBP assessment tool was developed using a robust, multi-step process with involvement of patients and health professionals.The LBP assessment tool is a strong candidate for a user-friendly tool to facilitate use of the International Classification of Functioning, Disability and Health in routine clinical practice.

Functional impairment, symptom severity, and overall quality of life in patients with advanced lung or colorectal cancer in six European countries: baseline findings from the ACTION study

BACKGROUND

People with advanced cancer often suffer from various symptoms, which can arise from the cancer itself and its treatment, the illness experience, and/or co-morbid conditions. Important patient-reported outcomes such as functional status, symptom severity, and quality of life (QoL) might differ between countries, as countries vary with regard to contextual factors such as their healthcare system.

PURPOSE

To assess self-reported emotional functioning, physical functioning, symptoms, and overall QoL in patients with advanced lung or colorectal cancer from six European countries, particularly in relation to their country of residence.

METHODS

We used baseline patient data from the ACTION trial, including socio-demographic and clinical data as well as patient-reported data regarding functioning, symptoms, and overall QoL (EORTC QLQ-C15-PAL).

RESULTS

Data from 1117 patients (55% lung cancer stage III/IV, 45% colorectal cancer stage IV) were used. The highest (worst) average symptom score was found for fatigue. We found similarities but also important differences in the outcomes across countries. The best scores (the highest for emotional functioning and QoL, the lowest for symptoms) were reported by Dutch and Danish patients. Belgian patients reported relatively low emotional functioning.

CONCLUSION

The optimization of functioning, symptom relief, and overall QoL should be important objectives of healthcare professionals who take care of patients with advanced cancer. There are similarities, but also substantial differences across countries in functional status, symptoms, and overall QoL. Policymakers should take these differences into account and invest in offering health care catered to the needs of their population.

Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care

Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.

Structured patient interview to assess clinical outcomes in complicated urinary tract infections in the APEKS-cUTI study: pilot investigation

BACKGROUND

The APEKS-cUTI study demonstrated the non-inferiority of cefiderocol to imipenem-cilastatin in the primary endpoint of the composite of clinical and microbiological outcome in patients with complicated urinary tract infections (cUTIs). We piloted a structured patient interview (SPI) to evaluate clinical outcomes based on patient-reported symptoms while conducting this pivotal randomized, double-blind, phase-2 study. The objectives were to assess the value of the SPI, using its performance relative to physician assessment, and also to strengthen the value of patient-reported measures in conducting clinical trials for cUTI treatment.

METHODS

In addition to the protocol-defined clinical and microbiological outcomes, patients randomized in the APEKS-cUTI study were interviewed by the investigator or qualified study personnel at screening/baseline, early assessment (EA), end of treatment (EOT), test of cure (TOC), and follow-up (FUP). The 14-element questionnaire graded cUTI symptoms as absent or present, and if present, as mild, moderate, or severe. Changes in post-baseline symptoms based on patients' responses were rated by the interviewer. The overall clinical outcome was evaluated based on the responses provided by patients at each time point.

RESULTS

Among the 371 patients in the modified intention-to-treat population, the rate of SPI completion in each treatment arm exceeded 90% at each time point. SPI-assessed clinical cure rates were 89.7% in the cefiderocol arm and 84.9% in the imipenem-cilastatin arm. There was substantial agreement between SPI evaluation and investigator global assessment of clinical outcome at TOC and FUP, with lower agreement at EA and EOT.

CONCLUSION

This analysis suggests that patient-reported symptoms can be effectively captured in hospitalized patients with cUTI in a clinical trial setting. Development of a validated patient-reported outcome for use in such a setting is warranted.

REGISTRATION

NCT02321800 (registered on 22 December 2014).

Quality of Care Perceived by Older Patients and Caregivers in Integrated Care Pathways With Interviewing Assistance From a Social Robot: Noninferiority Randomized Controlled Trial

Background

Society is facing a global shortage of 17 million health care workers, along with increasing health care demands from a growing number of older adults. Social robots are being considered as solutions to part of this problem.

Objective

Our objective is to evaluate the quality of care perceived by patients and caregivers for an integrated care pathway in an outpatient clinic using a social robot for patient-reported outcome measure (PROM) interviews versus the currently used professional interviews.

Methods

A multicenter, two-parallel-group, nonblinded, randomized controlled trial was used to test for noninferiority of the quality of care delivered through robot-assisted care. The randomization was performed using a computer-generated table. The setting consisted of two outpatient clinics, and the study took place from July to December 2019. Of 419 patients who visited the participating outpatient clinics, 110 older patients met the criteria for recruitment. Inclusion criteria were the ability to speak and read Dutch and being assisted by a participating health care professional. Exclusion criteria were serious hearing or vision problems, serious cognitive problems, and paranoia or similar psychiatric problems. The intervention consisted of a social robot conducting a 36-item PROM. As the main outcome measure, the customized Consumer Quality Index (CQI) was used, as reported by patients and caregivers for the outpatient pathway of care.

Results

In total, 75 intermediately frail older patients were included in the study, randomly assigned to the intervention and control groups, and processed: 36 female (48%) and 39 male (52%); mean age 77.4 years (SD 7.3), range 60-91 years. There was no significant difference in the total patient CQI scores between the patients included in the robot-assisted care pathway (mean 9.27, SD 0.65, n=37) and those in the control group (mean 9.00, SD 0.70, n=38): P=.08, 95% CI –0.04 to 0.58. There was no significant difference in the total CQI scores between caregivers in the intervention group (mean 9.21, SD 0.76, n=30) and those in the control group (mean 9.09, SD 0.60, n=35): P=.47, 95% CI –0.21 to 0.46. No harm or unintended effects occurred.

Conclusions

Geriatric patients and their informal caregivers valued robot-assisted and nonrobot-assisted care pathways equally.

Trial Registration

ClinicalTrials.gov NCT03857789; https://clinicaltrials.gov/ct2/show/NCT03857789

A novel patient-reported outcomes instrument assessing the side effects of peanut oral immunotherapy

BACKGROUND

Patients treated with peanut oral immunotherapy (OIT) may experience adverse reactions, particularly during up-dosing.

OBJECTIVE

To develop the Side Effects of Peanut Oral Immunotherapy Diary (SEPOD), an electronic questionnaire assessing the daily side effects of peanut OIT in clinical trials.

METHODS

Content and design of the SEPOD were informed by empirical literature review and meetings with 3 allergy-immunology experts. Interviews to confirm content and inform revisions were conducted in 24 pediatric patients with peanut allergy (14 treated with peanut OIT) aged 6 to 17 years; children aged 6 to 11 years were interviewed with their caregiver.

RESULTS

The SEPOD was drafted after literature review and expert interviews; the initial measurement approach comprised 2 SEPOD versions, a patient-reported outcome (PRO) version for children aged 12 to 17 years, and a caregiver-administered PRO version for children aged 6 to 11 years with instructions for caregiver questionnaire administration. Pediatric patients were expected to respond independently on both versions. Patient interviews indicated that some younger children (ie, aged 6-8 years) had difficulty understanding questions, even when reading aloud; therefore, a caregiver-administered outcome version, identical in content to the caregiver-administered PRO version, was developed for this age group. The final electronic SEPOD covered 23 peanut OIT side effects within the following 7 domains: gastrointestinal, dermatologic, itching, nasal, and respiratory, swelling (eyelid or periorbital, lip, tongue, and throat), pain (tongue, mouth, and throat), and dizziness.

CONCLUSION

This study yielded the SEPOD, a new clinical outcome assessment instrument with various methods of administration that can be used to assess the side effects of peanut OIT experienced by pediatric patients in a clinical trial setting.

Development and pilot testing of quality improvement indicators for integrated primary dementia care

Background

Implementation of integrated primary care is considered an important strategy to overcome fragmentation and improve quality of dementia care. However, current quality indicator (QI) sets, to assess and improve quality of care, do not address the interprofessional context. The aim of this research was to construct a feasible and content-wise valid minimum dataset (MDS) to measure the quality of integrated primary dementia care.

Methods

A modified Delphi method in four rounds was performed. Stakeholders (n=15) (1) developed a preliminary QI set and (2) assessed relevance and feasibility of QIs via a survey (n=84); thereafter, (3) results were discussed for content validity during a stakeholder and (4) expert consensus meeting (n=8 and n=7, respectively). The stakeholders were professionals, informal caregivers, and care organisation managers or policy officers; the experts were professionals and researchers. The final set was pilot-tested for feasibility by multidisciplinary dementia care networks.

Results

The preliminary set consisted of 40 QIs. In the survey, mean scores for relevance ranged from 5.8 (SD=2.7) to 8.5 (SD=0.7) on a 9-point Likert scale, and 25% of all QIs were considered feasible to collect. Consensus panels reduced the set to 15 QIs to be used for pilot testing: 5 quality of care, 3 well-being, 4 network-based care, and 3 cost-efficiency QIs. During pilot testing, all QIs were fully completed, except for well-being QIs.

Conclusion

A valid and feasible MDS of QIs for primary dementia care was developed, containing innovative QIs on well-being, network-based care and cost-efficiency, in addition to quality of care QIs. Application of the MDS may contribute to development and implementation of integrated care service delivery for primary dementia care.

Evaluating patient-perceived control of atopic dermatitis: design, validation, and scoring of the Atopic Dermatitis Control Tool (ADCT)

Objectives: The Atopic Dermatitis Control Tool (ADCT) was designed to evaluate patient-perceived AD control and facilitate patient-physician discussion on long-term disease control.Methods: The study was performed in adult patients with AD. Development of the ADCT followed US Food and Drug Administration (FDA) guidelines on patient-reported outcome measures (PROMs). Qualitative research, including targeted literature review, interviews with clinical experts, and combined concept elicitation/cognitive debriefing with patients with AD, was conducted to provide a list of comprehensive concepts capturing AD control per physician and patient perspectives. Quantitative methods assessed psychometric properties of the instrument and defined the threshold for AD control.Results: The resulting pilot six-item ADCT, reflecting key concepts related to AD control, had 7-day recall and assessed symptoms and impacts on patients' everyday lives by severity and/or frequency. The ADCT showed good content validity (well understood by adult patients with AD), and quick completion time (<2 min). Psychometric analysis indicated no floor/ceiling effects for response distributions, particularly strong (r ≥ 0.80) inter-item correlations for the six ADCT items, robust construct validity (r > 0.50), and item-level discriminating ability (p < .03); this supported the derivation of a total score based on responses to all items. ADCT total score showed evidence of strong internal consistency reliability (Cronbach's alpha >0.80). A score ≥7 points was identified as an optimum threshold to identify patients whose AD is "not in control."Conclusions: No single validated instrument has been available to holistically evaluate patient-perceived AD control. The newly developed ADCT displays good-to-excellent content validity, construct validity, internal consistency, reliability, and discriminating ability.

Patient-Reported Outcome Measures in Routine Pediatric Clinical Care: A Systematic Review

Introduction: Integration of patient-reported outcome measures (PROMs) in routine clinical care is growing but lacks consolidated evidence around its impact on pediatric care. This systematic review aims to evaluate the impact of integrating PROMs in routine pediatric clinical care on various outcomes in pediatric clinical care. Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Library. Web of Science database was searched selectively to ensure extended coverage. Study Selection: We included longitudinal studies reporting on the integration of PROMs in routine pediatric clinical care of chronic diseases. Studies in languages other than English, published prior to the year 2000, and reporting on secondary data were excluded. Data Extraction: Two reviewers independently extracted data from included studies. Extracted data included citation of each study, type of healthcare setting, location of the study, characteristics of patient population, type of chronic disease, name and type of PROM, mode of administration, and reported outcomes. Results: Out of 6,869 articles, titles and abstracts of 5,416 articles and full text of 23 articles were screened in duplicate. Seven articles reporting results from six studies met eligibility criteria. Integration of PROMs increased the identification and discussion around health-related quality of life (HRQOL), especially in psychosocial and emotional domains, but showed mixed results with the impact on quality of care. No studies assessed the impact of integrating PROMs on healthcare utilization. Limitations: Due to significant heterogeneity in the studies, a meta-analysis was not conducted. Conclusions: Integrating PROMs could have a positive impact on HRQOL; however, further studies are required to determine the impact of PROMs in routine pediatric clinical care.