OP0209-HPR BRIDGE – A QUALITY IMPROVEMENT PROGRAM IN TEAM-BASED REHABILITATION: RESULTS FROM A MIXED METHODS STUDY

Background

There is a well-known variability in the quality of rehabilitation provided to patients with rheumatic and musculoskeletal diseases (RMDs). Elements to be improved are a higher standardization of the core content, optimal patient participation in goal setting and continuation of the process in tailored follow-up. More knowledge is needed on critical features for successful delivery of improvement programs in rehabilitation.

Objectives

To investigate how a team-based quality improvement program was implemented and how it influenced the quality in RMD rehabilitation.

Methods

This convergent mixed methods study is nested within a stepped-wedge, randomized controlled trial where providers at 8 rehabilitation-centers delivered traditional programs in the control phase (T1), and added the BRIDGE quality improvement program in the intervention phase (T2). The BRIDGE program addressed a dialog-based, multidisciplinary approach to support the patients’ self-management, comprising motivational interviewing, goal setting, plans for rehabilitation, feedback and monitoring of progress, and tailored follow up. Providers answered 19 structure indicators from a quality indicator (QI) set for RMD rehabilitation [1] at T1 and T2, and a program-fidelity checklist with 18 items at T2 (both scored 0-100%, 100=best). Qualitative data was collected in three focus groups (FG) with the BRIDGE providers, and analyzed using reflexive thematic analysis. Integration and discussion of findings from the different data sources are ongoing, in our research group.

Results

Median summary pass rate for the structure QIs for all centers increased from 53 to 90% between T1 and T2. Program-fidelity was high, with a median summary score of 94% (range 6–100%), but lowest for program-components related to follow-up and communication with external services. Themes developed from the FG interviews reflected that variations in how the program was implemented related to features of the providers and institutions. More specific; the delivery of high-quality rehabilitation depended on the degree to which the providers trained their communication skills, used available tools to support their practice, and grounded their interventions in professional reasons. Critical organisational features at the institutions were dedicated time for team-work based on the patients’ plans for self-management, and sufficient attention to needs for involvement of next of kin or external services. Additionally, better program-implementation occurred if providers experienced an institutional culture for quality improvement, such as educational initiatives from the leaders.

Preliminary integration of data is summarized in Figure 1. Congruent evidence in both quantitative and qualitative findings addressed the sustained needs for better quality in the area of follow-up across levels of care. However, the qualitative findings provided expanded insights on variability also in initial parts of the rehabilitation process. Presumably, these variations in delivery reported in interviews are important for the effectiveness of a quality improvement program, but difficult to capture in questionnaires.

Figure 1.

Complementary viewpoints on how the BRIDGE program was provided and how it influenced the quality of rehabilitation.

Conclusion

To target specific strategies for quality improvement, we suggest a combined attention not only to recommended care reflected in quality indicators and measurable aspects of fidelity, but also to contextual factors, including the providers’ confidence and skills needed to provide a high-quality delivery of all components in a rehabilitation improvement program.

References

[1]Johansen et al. A quality indicator set for use in rehabilitation team care of people with rheumatic and musculoskeletal diseases; development and pilot testing. BMC Health Serv Res. 2019;19(1).

Disclosure of Interests

None declared

Finalisation and validation of the rheumatoid arthritis impact of disease score, a patient-derived composite measure of impact of rheumatoid arthritis: a EULAR initiative

OBJECTIVE

A patient-derived composite measure of the impact of rheumatoid arthritis (RA), the rheumatoid arthritis impact of disease (RAID) score, takes into account pain, functional capacity, fatigue, physical and emotional wellbeing, quality of sleep and coping. The objectives were to finalise the RAID and examine its psychometric properties.

METHODS

An international multicentre cross-sectional and longitudinal study of consecutive RA patients from 12 European countries was conducted to examine the psychometric properties of the different combinations of instruments that might be included within the RAID combinations scale (numeric rating scales (NRS) or various questionnaires). Construct validity was assessed cross-sectionally by Spearman correlation, reliability by intraclass correlation coefficient (ICC) in 50 stable patients, and sensitivity to change by standardised response means (SRM) in 88 patients whose treatment was intensified.

RESULTS

570 patients (79% women, mean ± SD age 56 ± 13 years, disease duration 12.5 ± 10.3 years, disease activity score (DAS28) 4.1 ± 1.6) participated in the validation study. NRS questions performed as well as longer combinations of questionnaires: the final RAID score is composed of seven NRS questions. The final RAID correlated strongly with patient global (R=0.76) and significantly also with other outcomes (DAS28 R=0.69, short form 36 physical -0.59 and mental -0.55, p<0.0001 for all). Reliability was high (ICC 0.90; 95% CI 0.84 to 0.94) and sensitivity to change was good (SRM 0.98 (0.96 to 1.00) compared with DAS28 SRM 1.06 (1.01 to 1.11)).

CONCLUSION

The RAID score is a patient-derived composite score assessing the seven most important domains of impact of RA. This score is now validated; sensitivity to change should be further examined in larger studies.

Elaboration of the preliminary Rheumatoid Arthritis Impact of Disease (RAID) score: a EULAR initiative

BACKGROUND

Current response criteria in rheumatoid arthritis (RA) usually assess only three patient-reported outcomes (PROs): pain, functional disability and patient global assessment. Other important PROs such as fatigue are not included.

OBJECTIVE

To elaborate a patient-derived composite response index for use in clinical trials in RA, the RA Impact of Disease (RAID) score.

METHODS

Ten patients identified 17 domains or areas of health relevant for inclusion in the score, then 96 patients (10 per country in 10 European countries) ranked these domains in order of decreasing importance. The seven most important domains were selected. Instruments were chosen for each domain after extensive literature research of psychometric properties and expert opinion. The relative weight of each of the domains was obtained from 505 patients who were asked to "distribute 100 points" among the seven domains. The average ranks of importance of these domains were then computed.

RESULTS

The RAID score includes seven domains with the following relative weights: pain (21%), functional disability (16%), fatigue (15%), emotional well-being (12%), sleep (12%), coping (12%) and physical well-being (12%). Weights were similar across countries and across patient and disease characteristics. Proposed instruments include the Health Assessment Questionnaire and numerical ratings scales.

CONCLUSION

The preliminary RAID score is a patient-derived weighted score to assess the impact of RA. An ongoing study will allow the final choice of questionnaires and assessment of validity. This score can be used in clinical trials as a new composite index that captures information relevant to patients.

Performance of health status measures with a pen based personal digital assistant

BACKGROUND

Increasing use of self reported health status in clinical practice and research, as well as patient appreciation of monitoring fluctuations of health over time, suggest a need for more frequent collection of data. Electronic use of health status measures in the follow up of patients is a possible way to achieve this.

OBJECTIVE

To compare self reported health status measures in a personal digital assistant (PDA) version and a paper/pencil version for test-retest reliability, agreement between scores, and feasibility.

METHODS

30 patients with stable rheumatoid arthritis (mean age 61.6 years, range 49.8 to 70.0; mean disease duration, 16.7 years; 63% female; 67% rheumatoid factor positive; 46.6% on disease modifying antirheumatic drugs) completed self reported health status measures (pain, fatigue, and global health on visual analogue scales (VAS), rheumatoid arthritis disease activity index, modified health assessment questionnaire, SF-36) in a conventional paper based questionnaire version and on a PDA (HP iPAQ, model h5450). Completion was repeated after five to seven days.

RESULTS

Test-retest reliability was similar, as evaluated by the Bland-Altman approach, the coefficient of variation, and intraclass correlation coefficients. The scores showed acceptable agreement, but with a slight tendency to higher scores on VAS with the PDA than the paper/pencil version. No significant differences were seen for measures of feasibility (time to complete, satisfaction score), but 65.5% preferred PDA, 20.7% preferred paper, and 13.8% had no preference.

CONCLUSIONS

The clinimetric performance of paper/pencil versions of self reported health status measures was similar to an electronic version, using an inexpensive PDA.