Why it is hard to use PROMs and PREMs in routine health and care

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) show the results of healthcare activities as rated by patients and others. Patients or their proxies record feedback using questionnaires. These can enhance quality for all and tailored care for individuals. This paper describes obstacles that inhibit widespread use of PROMs and PREMs and some potential solutions.Implementation is a prerequisite for any innovation to succeed. Health and care services are complex and people need to be engaged at every level. Most people are cautious about proven innovations such as PROMs and PREMs but champions and leaders can help them engage. The NASSS framework (reasons for Non-adoption, Abandonment and failure to Scale up, Spread or Sustain digital health innovations) helps indicate that implementation is complex why it may be resisted.The Plan-Do-Study-Act (PDSA) approach aids implementation and helps ensure that everyone knows who should do what, when, where, how and why. Noise is an under-appreciated problem, especially when tracking patients over time such as before and after treatment. Interoperability of PROMs and PREMs with electronic health records should use Fast Health Interoperability Resources and internationally accepted coding schemes such as SNOMED CT and LOINC.Most projects need multiple measures to meet the needs of everyone involved. Measure selection should focus on their relevance, ease of use, and response rates.If these problems are avoided or mitigated, PROMs and PREMs can help deliver better patient outcomes, patient experience, staff satisfaction and health equity.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Routine measurement of patient experience

Patient experience is a key pillar of healthcare quality. We describe a framework of three short generic measures covering Patient Experience, Result Satisfaction and Service Integration. The Result Satisfaction measure is described for the first time.These measures capture twelve aspects of patient experience covering the relationship between patients and clinicians (Patient Experience), the immediate results of the consultation or treatment as perceived by patients (Result Satisfaction) and collaboration between different healthcare services and silos (Service Integration). Each measure has four items.These measures are compared with three national measures: the Friends and Family Test and the General Practice Patient Survey used in England, and HCAHPS used in US hospitals. The expected benefits of national measures are not being achieved and we need to think again about how best to tailor health services to meet patients' expectations.The three measures described (Patient Experience, Result Satisfaction and Service Integration) are generic, short and have low reading ages. They share common forms and scoring schemes, which mean that they can be used individually or in combination at all levels of a healthcare provider.

Mitochondrial Transfusion Improves Mitochondrial Function Through Up-regulation of Mitochondrial Complex II Protein Subunit SDHB in the Hippocampus of Aged Mice

The mitochondrial theory of aging is characterized by mitochondrial electron transport chain dysfunction. As a hallmark of aging, an increasing number of investigations have attempted to improve mitochondrial function in both aging and age-related disease. Emerging from these attempts, methods involving mitochondrial isolation, transfusion, and transplantation have taken center stage. In particular, mitochondrial transfusion refers to the administration of mitochondria from healthy tissue into the bloodstream or into tissues affected by injury, disease, or aging. In this study, methods of mitochondrial isolation and transfusion were developed and utilized. First, we found a significant decrease (p < 0.05) in the expression of mitochondrial complex proteins (I-V) in aged (12 months old) mouse brain tissue (C57BL/6 mice) in comparison to healthy young brain tissue (1 month old). To investigate whether healthy young mitochondria taken from the liver could improve mitochondrial function in older animals, we intravenously injected mitochondria isolated from young C57BL/6 mice into aged mice from the same strain. This study, for the first time, demonstrates that mitochondrial transfusion significantly (p < 0.05) improves mitochondrial function via the up-regulation of the mitochondrial complex II protein subunit SDHB in the hippocampus of aged mice. This result has identified a role for mitochondrial complex II in the aging process. Therefore, mitochondrial complex II could serve as a putative target for therapeutic interventions against aging. However, more importantly, methods of mitochondrial transfusion should be further tested to treat a variety of human diseases or disorders and to slow down or reverse processes of aging.

The realities and expectations of community involvement in COVID-19 research: a Consumer Reference Group perspective

BACKGROUND

Older adults have been disproportionately impacted by the COVID-19 pandemic. COVID-19 restrictions such as stay at home orders and physical distancing measures have been implemented to reduce older adults' risk of infection, however, such measures can have negative effects on older adults' mental health and social wellbeing. In 2020, the research team received funding as part of an Australian COVID-19 research grants program to investigate how services can better meet the mental health and social support needs of older adults during COVID-19. A Consumer Reference Group (CRG) was established to provide a community perspective on all research activities.

MAIN BODY

The CRG comprised of eight older adults aged 65 years and older living in Western Australia. Two members of the CRG were involved in the initial grant proposal, and one member worked for a not-for-profit organisation that provides support and advocacy for older adults. The CRGs role was to provide consumer and community perspectives on the research design, advise on study materials, facilitate links between consumers, the community, and researchers, and advocate on behalf of consumers and the community. The CRG was encouraged to reflect on the research project, their contributions, and the outcomes obtained. In this commentary, we document the CRGs contributions to the project, and record their reflections, including what went well, what were some challenges, the realities of conducting research during COVID-19, and lessons learnt.

CONCLUSION

The CRG were active participants in the research process. They shared their perspectives and made important contributions to the project. Through collaboration with the CRG, we were able to reach four key messages, underpinned by consumers lived experiences, that were used to co-develop knowledge translation products. These were disseminated to service providers and older adults.

Readiness for five digital technologies in general practice: perceptions of staff in one part of southern England

Background

Our aim was to understand how digital readiness within general practice varies between different technologies and to identify how demographic, workplace and external factors affect this. The technologies considered include electronic patient records, telehealth (text messaging and video consultations), patient online access, patient clinical apps and wearables, and social media.

Method

A digital readiness survey tool was developed and used in one area of southern England during Spring 2020. Semistructured qualitative interviews were also carried out with some practice staff and digital technology company representatives.

Results

GPs, nurses and non-clinical staff submitted 287 responses from 27 general practices (out of 33 invited).

Staff digital readiness differs significantly between technologies. The mean perceived digital competency scores on 0–100 scale (high is good) were electronic patient records (75.7), telehealth (64.2), patient online access (65.8), patient clinical apps and wearables (50.8), and social media (51.2).

Younger general practice staff, those in post for 5 or less years are more digitally competent and confident than older staff. This applies to both clinical and non-clinical staff. Older patient population, rurality and smaller practice size are associated with lower digital readiness. Readiness to use digital technology may have improved since the start of the COVID-19 pandemic but barriers remain in poor IT and mobile infrastructure, software usability and interoperability, and concerns about information governance.

Conclusions

Improving digital readiness in general practice is complex and multifactorial. Issues may be alleviated by using dedicated digital implementation teams and closer collaboration between stakeholders (GPs and their staff, patients, funders, technology companies and government).

Antimicrobial use in agriculture: critical review of the factors influencing behaviour

Antimicrobial resistance (AMR) is a global health emergency affecting humans and animals, diminishing the effectiveness of medication used to treat illness. The agri-food sector has attracted increased attention for imprudent antimicrobial use (AMU) and its contribution to AMR. Thus, ascertaining farmers' and veterinarians' behaviours surrounding AMU is essential to address imprudent AMU and generate behaviour change within the agri-food sector. Therefore, the aim of this critical review is to investigate, assess and collate the current body of evidence to identify psychosocial factors including knowledge, understanding, perceptions, attitudes and behaviours surrounding AMU. Database searches were limited to articles utilizing qualitative and quantitative methodologies, available in English with no restriction on publication year. Of the 1156 articles identified, 103 were retained for this review. Findings on the psychosocial aspects were thematically analysed. Five key themes emerged from the data: (i) knowledge and awareness of antimicrobials; (ii) attitudes towards antimicrobials; (iii) influential relationships; (iv) resources; and (v) factors influencing AMU. Results indicated that to overcome barriers experienced by key stakeholders, a carefully considered, evidence-based approach, incorporating behaviour change theory, is required when designing intricate interventions/strategies, in order to elicit successful and sustained AMU behaviour change.

Development of social contact and loneliness measures with validation in social prescribing

Aims

This paper describes two patient-reported measures of social contact and loneliness, which are closely related concepts. The first measure (R-Outcomes Social Contact measure) was developed from scratch, based on customer needs and literature review. It covers emotional and social aspects using positive terms. The second measure (R-Outcomes Loneliness measure) is adapted from the GSS Loneliness Harmonised Standard. Both measures are patient-reported outcome measures, based on patients’ own perception of how they feel.

Method

This development started in 2016 in response to customers’ requests to measure social contact/loneliness for patients in social prescribing projects.

Both measures are compared with three other loneliness measures (the GSS Loneliness Harmonised Standard, De Jong Gierveld and Campaign to End Loneliness). Both measures are short (36 and 21 words, respectively). Mean improvement is reported as a positive number on a 0–100 scale (where high is good).

We tested the psychometric performance and construct validity of the R-Outcomes Social Contact measure using secondary analysis of anonymised data collected before and after social prescribing interventions in one part of Southern England.

Results

In the validation study, 728 responses, collected during 2019–2020, were analysed. 90% were over 70 years old and 62% women. Cronbach’s α=0.76, which suggests that it is appropriate to use a single summary score. Mean Social Contact scores before and after social prescribing intervention were 59.9 (before) and 66.7 (after, p<0.001).

Exploratory factor analysis shows that measures for social contact, health status, health confidence, patient experience, personal well-being, medication adherence and social determinants of health are correlated but distinct factors. Construct validation shows that the results are consistent with nine hypotheses, based on the loneliness literature.

Conclusion

The R-Outcomes Social Contact measure has good psychometric and construct validation results in a population referred to social prescribing. It is complementary to other R-Outcomes measures.

Understanding farmers' and veterinarians' behavior in relation to antimicrobial use and resistance in dairy cattle: A systematic review

To tackle antimicrobial resistance, it is vital that farmers' and veterinarians' antimicrobial use behaviors and attitudes toward resistance are understood so that we can identify how beliefs and motives influence practices. Current literature details qualitative and quantitative research that explores the knowledge, attitudes and perceptions of dairy farmers and veterinarians with respect to antimicrobial resistance and antimicrobial practices, and the reported findings are varied and conflicting. Our objective was to conduct a systematic review to assess the evidence and knowledge gaps in the published literature. We identified articles via database searches of Embase, Medline, PubMed, Scopus, and Web of Science; we limited findings to published articles available in English with no publication year restrictions. Article screening was conducted at 3 levels: title, abstract, and full text. Of the 349 articles identified, 35 were retained for systematic review. Transparency of reporting was assessed for each study using the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings relating to dairy farmers' and veterinarians' knowledge, attitudes, and perceptions on antimicrobial resistance and practices were thematically analyzed. The comprehensiveness of reporting was variable: studies reported 5 to 26 of the 32 COREQ checklist items. Five key themes emerged from the data: knowledge and awareness of antimicrobial resistance; factors influencing farmer and veterinarian decision-making; perceived barriers and facilitators to reduced antimicrobial use; perceived responsibility for antimicrobial resistance; and the role of the farmer and veterinarian relationship in reducing antimicrobial use. Awareness of prudent antimicrobial use was not uniform between studies. Many factors influence farmers' and veterinarians' decisions to use antimicrobials, including animal welfare and available resources. The farmer-veterinarian relationship is a potential barrier or facilitator of reduced antimicrobial use, depending on the perceived relationship dynamic. Encouraging collaboration between farmers and veterinarians could lead to shared responsibility for reducing antimicrobial use. This review provided a coherent picture of what is currently known and identified gaps in the current knowledge to inform future behavioral intervention research. Increased knowledge, skill development, resources, engagement, and further research to address the gaps we identified are the main recommendations to effectively overcome barriers, elicit appropriate behavior change, and achieve reduced antimicrobial use in dairy cattle.

A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach

AIMS

To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes.

METHODS

We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals.

RESULTS

The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment.

CONCLUSIONS

We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

Measure what we want: a taxonomy of short generic person-reported outcome and experience measures (PROMs and PREMs)

INTRODUCTION

Health and care systems are complex and multifaceted, but most person-reported outcome and experience measures (PROMs and PREMs) address just one aspect. Multiple aspects need measuring to understand how what we do impacts patients, staff and services, and how these are affected by external factors. This needs survey tools that measure what people want, are valid, sensitive, quick and easy to use, and suitable for people with multiple conditions.

METHODS

We have developed a coherent family of short generic PROMs and PREMs that can be used in combination in a pick-and-mix way. Each measure has evolved iteratively over several years, based on literature review, user inputs and field testing. Each has has a common format with four items with four response options and is designed for digital data collection with standardised analytics and data visualisation tools. We focused on brevity and low reading age.

RESULTS

The results are presented in tabular format and as a taxonomy. The taxonomy is categorised by respondent type (patient or staff) and measure type. PROMs have subdomains: quality of life, individual care and community; PREMs have subdomains: service provided, provider culture and innovation. We show 22 patient-reported measures and 17 staff-reported measures. Previously published measures have been validated. Others are described for the first time.

DISCUSSION AND CONCLUSIONS

This family of measures is broad in scope but is not claimed to be comprehensive. Measures share a common look and feel, which enables common methods of data collection, reporting and data visualisation. They are used in service evaluation, quality improvement and as key performance indicators. The taxonomy helps to organise the whole, explain what each measure does and identify gaps and overlaps.

Comparison of staff and resident health status ratings in care homes

BACKGROUND

Many care home residents cannot self-report their own health status. Previous studies have shown differences between staff and resident ratings. In 2012, we collected 10 168 pairs of health status ratings using the howRu health status measure. This paper examines differences between staff and resident ratings.

METHOD

HowRu is a short generic person-reported outcome measure with four items: pain or discomfort (discomfort), feeling low or worried (distress), limited in what you can do (disability) and require help from others (dependence). A summary score (howRu score) is also calculated. Mean scores are shown on a 0-100 scale. High scores are better than low scores. Differences between resident and staff reports (bias) were analysed at the item and summary level by comparing distributions, analysing correlations and a modification of the Bland-Altman method.

RESULTS AND CONCLUSIONS

Distributions are similar superficially but differ statistically. Spearman correlations are between 0.55 and 0.67. For items, more than 92.9% of paired responses are within one class; for the howRu summary score, 66% are within one class. Mean differences (resident score minus staff score) on 0-100 scale are pain and discomfort (-1.11), distress (0.67), discomfort (1.56), dependence (3.92) and howRu summary score (1.26). The variation is not the same for different severities. At higher levels of pain and discomfort, staff rated their discomfort and distress as better than residents. On the other hand, staff rated disability and dependence as worse than did residents. This probably reflects differences in perspectives. Red amber green (RAG) thresholds of 10 and 5 points are suggested for monitoring changes in care home mean scores.

A Taxonomy for Survey Measures Used to Evaluate Complex Digital Health Innovations

Evaluators need to measure whether innovations help patients and staff, but have lacked the tools needed to do this as part of routine care. We provide a taxonomy for the classification of survey measures, which can be used together on a pick and mix basis. These are described in the context of the evaluation of digital health innovations.

Digital innovation evaluation: user perceptions of innovation readiness, digital confidence, innovation adoption, user experience and behaviour change

Background

Innovation spread is a key policy objective for health systems world-wide, but adoption success varies enormously. We have developed a set of short generic user-reported measures to help understand how and why healthcare innovations spread. This work builds on the literature and on practical experience in developing and using patient-reported outcome measures.

Measures

The Innovation Readiness Score measures user perceptions of how much they are open to and up-to-date with new ideas, and whether their organisations are receptive to and capable of innovation. It is based on Rogers’ classification of innovativeness (innovator, early adopter, early majority, etc).

The Digital Confidence Score rates users’ digital literacy and confidence to use digital products, with dimensions of familiarity, social pressure, support and digital self-efficacy.

The Innovation Adoption Score rates the adoption process in terms of coherence and reflective thought before, during and after implementation. It is based on Normalisation Process Theory.

The User Satisfaction measure assesses a digital product in terms of usefulness, ease of use, support and satisfaction.

The Behaviour Change measure covers user perceptions of their capability, opportunity and motivation to change behaviour, based on the COM-B model.

These measures have been mapped onto Greenhalgh’s NASSS Framework (non-adoption, abandonment and challenges to scale-up, spread and sustainability of health and care technologies).

Conclusion

These tools measure different aspects of digital health innovations and may help predict the success of innovation dissemination, diffusion and spread programmes.

Health status of care home residents: practicality and construct validity of data collection by staff at scale

Background

Medical diagnoses and assessed need for care are the prerequisites for planning and delivery of care to residents of care homes. Assessing the effectiveness of care is difficult. The aim of this study was to test the practicality and construct validity of the howRu health status measure using secondary analysis of a large data set.

Method

The data came from a Bupa Care Homes Census in 2012, which covered 24 506 residents in 395 homes internationally (UK, Australia and New Zealand). Staff completed optical mark readable forms about each resident using a short generic health status measure, howRu. Response rates were used to assess practicality and expected relationships between health status and independent variables were used to assess the construct validity.

Results and discussion

19,438 forms were returned (79.3%) in 360 care homes (91.1%); complete health status data were recorded for 18 617 residents (95.8% of those returned). Missing values for any health status items mostly came from a small number of homes. The relationships between howRu and independent variables support construct validity. Factor analysis suggests three latent variables (discomfort, distress and disability/dependence).

Conclusions

HowRu proved easy to use and practical at scale. The howRu health status measure shows good construct validity.

Development and initial testing of a Health Confidence Score (HCS)

Introduction

Patients need to feel confident about looking after their own health. This is needed to improve patient outcomes and clinical support. With few suitable tools available to measure self-care health confidence, we developed and validated a short, generic survey instrument for use in evaluation and quality improvement.

Methods

The Health Confidence Score (HCS) was developed through literature review, patient and expert focus groups and discussions. This paper reports an initial survey (n = 1031, study 1) which identified some issues and a further face-to-face survey (n = 378, study 2) to test the construct and concurrent validity of the final version. Scores were correlated against the My Health Confidence (MHC) rating scale, howRu (health status measure) and relevant demographics.

Results

The HCS is short (50 words) with good readability (reading age 8). It has four items covering health knowledge, capability to self-manage, access to help and shared decision-making; each has four response options (strongly agree, agree, neutral disagree). Items are reported independently and as a summary score.The mean summary score was 76.7 (SD 20.4) on 0-100 scale. Cronbach's alpha = 0.82. Exploratory factor analysis suggested that the four items relate to a single dimension. Correlation of the HCS summary score with MHC was high (Spearman r = 0.76). It was also associated with health status (Spearman r = 0.49), negatively with number of medications taken (r=-0.29) and age (r=-0.22) and not with ethnicity, having children or education level.

Conclusions

The HCS is short, easy to use, with good psychometric properties and construct validity. Each item is meaningful independently and the summary score gives an overall picture of health confidence.

Monitoring work well-being, job confidence and care provided by care home staff using a self-report survey

Background and method

In care homes, staff well-being, job confidence and opinion of the care provided to residents are central to morale and care quality. In this study, care home staff in the East Midlands region of England completed self-reported outcome and experience surveys in two rounds. Mean scores for each home are shown using a scale from 0 (all chose lowest option) to 100 (all chose highest option). High scores are good.

Results

In round 1, 332 staff in 15 homes submitted responses; in round 2, 207 staff in 9 homes. Mean scores in round 1 and round 2 were similar, although those of some homes scores differed significantly, cancelling each other out. Overall, Work Wellbeing mean score was 83 (care home range 48-97), with worthwhileness (92) the highest ranked item and anxiety at work (78) the lowest. Job Confidence mean score was 84 (range 59-94), with able to manage the work (86) highest and involvement in decisions that affect staff (79) lowest. Care Provided mean score was 86 (range 59-97), with treat people kindly (91) highest and well organised (80) lowest. Homes rated as outstanding by the Care Quality Commission had higher scores on average than those rated good, which were higher than those rated as needing improvement.

Conclusions

This study has demonstrated the practicality of measuring staff views of their Work Wellbeing, Job Confidence and Care Provided in care homes. Rather than wait for adverse quality outcomes to be detected, this approach offers a way to track staff morale and declared capability over time.

Personal Wellbeing Score (PWS)-a short version of ONS4: development and validation in social prescribing

Aims

Our aim was to develop a short generic measure of subjective well-being for routine use in patient-centred care and healthcare quality improvement alongside other patient-reported outcome and experience measures.

Methods

The Personal Wellbeing Score (PWS) is based on the Office of National Statistics (ONS) four subjective well-being questions (ONS4) and thresholds. PWS is short, easy to use and has the same look and feel as other measures in the same family of measures. Word length and reading age were compared with eight other measures.

Anonymous data sets from five social prescribing projects were analysed. Internal structure was examined using distributions, intra-item correlations, Cronbach’s α and exploratory factor analysis. Construct validity was assessed based on hypothesised associations with health status, health confidence, patient experience, age, gender and number of medications taken. Scores on referral and after referral were used to assess responsiveness.

Results

Differences between PWS and ONS4 include brevity (42 vs 114 words), reading age (9 vs 12 years), response options (4 vs 11), positive wording throughout and a summary score. 1299 responses (60% female, average age 81 years) from people referred to social prescribing services were analysed; missing values were less than 2%. PWS showed good internal reliability (Cronbach’s α=0.90). Exploratory factor analysis suggested that all PWS items relate to a single dimension. PWS summary scores correlate positively with health confidence (r=0.60), health status (r=0.58), patient experience (r=0.30) and age group (r=0.24). PWS is responsive to social prescribing intervention.

Conclusions

The PWS is a short variant of ONS4. It is easy to use with good psychometric properties, suitable for routine use in quality improvement and health services research.

The Load Model: an alternative to QALY

BACKGROUND

QALYs are widely used in health economic evaluation, but remain controversial, largely because they do not reflect how many people behave in practice. This paper presents a new conceptual model (Load Model) and illustrates it in comparison with the QALY model.

METHODS

Load is the average annual weight attributed to morbidity and mortality over a defined period, using weightings based on preference judgements. Morbidity Load is attributed to states of illness, according to their perceived severity. When people are in full health, Load is zero (no morbidity). Death is treated as an event with negative consequences, incurred in the year following death. Deaths may be weighted equally, with a fixed negative weight such as -100, or differ according to the context of death. After death, Load is zero. In a worked example, we use the standard gamble method to obtain a weighting for an illness state, for both Load and QALY models. A judge is indifferent between certainty of 1.5 years' illness followed by death, or a 50/50 chance of 1.5 years' full health or 1-year illness, each followed by death. The weightings calculated are applied to a hypothetical life, 72 years in full health followed by 3 years with illness then death, using both models. Three other hypothetical outcomes are also compared.

RESULTS

For an example life, the relative size of the morbidity component compared with the mortality component is much higher in the Load model than in the QALY model. When comparing alternative outcomes, there are also substantial differences between the two models.

CONCLUSIONS

In the Load model the weight of morbidity, relative to mortality, is very different from that in the QALY model. Given the role of the QALYs in economic evaluation, the implications of an alternative, which generates very different results, warrant further exploration.

Performance of EQ-5D, howRu and Oxford hip & knee scores in assessing the outcome of hip and knee replacements

BACKGROUND

We aimed to compare the performance of EQ-5D-3 L and howRu, which are short generic patient-reported outcome measures (PROMs), in assessing the outcome of hip and knee replacements, using the Oxford Hip Score (OHS) and the Oxford Knee Scores (OKS) for comparison.

METHODS

Outcome was assessed as the difference between pre-surgery and 6-month post-surgery scores. We used a large sample from the NHS PROMs database, which used EQ-5D-3 L, and a small cohort of patients having the same operations collected by MyClinicalOutcomes (MCO), which used howRu. Both cohorts completed the OHS (hips) or the OKS (knees).

RESULTS

The change (outcome) between pre-op and post-op scores as measured by howRu was greater than that measured by EQ-5D, relative to that measured by OHS or OKS. For hip replacements, the correlation for change measured by howRu and OHS was r = 0.77 (0.66-0.85). The corresponding correlation for change measured by EQ-5D Index and OHS was r = 0.64 (0.63-0.64). For knee replacements the correlation between change in howRu and OKS was r = 0.86 (0.75-0.92); between EQ-5D Index and OKS r = 0.59 (0.58-0.60).

CONCLUSIONS

For hip and knee replacement, the outcome measured by howRu was more highly correlated with that measured by the condition-specific Oxford Hip and Knee Scores than were EQ-5D Index or EQ-VAS. The magnitude of change before and after surgery was also greater.

Open Source Paradigm: A Synopsis of The Cathedral and the Bazaar for Health and Social Care

BACKGROUND

Open source software (OSS) is becoming more fashionable in health and social care, although the ideas are not new. However progress has been slower than many had expected.

OBJECTIVE

The purpose is to summarise the Free/Libre Open Source Software (FLOSS) paradigm in terms of what it is, how it impacts users and software engineers and how it can work as a business model in health and social care sectors.

METHOD

Much of this paper is a synopsis of Eric Raymond's seminal book The Cathedral and the Bazaar, which was the first comprehensive description of the open source ecosystem, set out in three long essays. Direct quotes from the book are used liberally, without reference to specific passages. The first part contrasts open and closed source approaches to software development and support. The second part describes the culture and practices of the open source movement. The third part considers business models.

CONCLUSION

A key benefit of open source is that users can access and collaborate on improving the software if they wish. Closed source code may be regarded as a strategic business risk that that may be unacceptable if there is an open source alternative. The sharing culture of the open source movement fits well with that of health and social care.

Mechanisms of vasodilation to PTH 1-84, PTH 1-34, and PTHrP 1-34 in rat bone resistance arteries

Parathyroid hormone (PTH) augments bone metabolism and bone mass when given intermittently. Enhanced blood flow is requisite to support high tissue metabolism. The bone arteries are responsive to all three PTH analogs, which may serve to augment skeletal blood flow during intermittent PTH administration.

INTRODUCTION

PTH augments bone metabolism. Yet, mechanisms by which PTH regulates bone blood vessels are unknown. We deciphered (1) endothelium-dependent and endothelium-independent vasodilation to PTH 1-84, PTH 1-34, and PTHrP 1-34, (2) the signaling pathways (i.e., endothelial nitric oxide synthase [eNOS], cyclooxygenase [COX], protein kinase C [PKC], and protein kinase A [PKA]), and (3) receptor activation.

METHODS

Femoral principal nutrient arteries (PNAs) were given cumulative doses (10(-13)-10(-8) M) of PTH 1-84, PTH 1-34, and PTHrP 1-34 with and without signaling pathway blockade. Vasodilation was also determined following endothelial cell removal (i.e., denudation), PTH 1 receptor (PTH1R) inhibition and to sodium nitroprusside (SNP; a nitric oxide [NO] donor).

RESULTS

Vasodilation was lowest to PTH 1-34, and maximal dilation was highest to PTHrP 1-34. Inhibition of eNOS reduced vasodilation to PTH 1-84 (-80 %), PTH 1-34 (-66 %), and PTHrP 1-34 (-48 %), evidencing the contribution of NO. Vasodilation following denudation was eliminated (PTH 1-84 and PTHrP 1-34) and impaired (PTH 1-34, 17 % of maximum), highlighting the importance of endothelial cells for PTH signaling. Denuded and intact PNAs responded similarly to SNP. Both PKA and PKC inhibition diminished vasodilation in all three analogs to varying degrees. PTH1R blockade reduced vasodilation to 1, 12, and 12 % to PTH 1-84, PTH 1-34, and PTHrP 1-34, respectively.

CONCLUSIONS

Vasodilation of femoral PNAs to the PTH analogs occurred via activation of the endothelial cell PTH1R for NO-mediated events. PTH 1-84 and PTHrP 1-34 primarily stimulated PKA signaling, and PTH 1-34 equally stimulated PKA and PKC signaling.

Prevalence and predictors of psychotropic medication use: results from the Northern Ireland Study of Health and Stress

BACKGROUND

To identify the predictors of psychotropic medication use and to determine rates and patterns of use in Northern Ireland (NI) among the general population and various subgroups.

METHOD

Analysis of data from the NI Study of Health and Stress, a representative household survey undertaken between 2004 and 2008 with 4340 individuals. Respondents were asked about prescribed psychotropic medication use in the previous 12 months along with a series of demographic questions and items regarding experience of traumatic life events. Mental health disorders were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Females, individuals aged 50-64 years old, those who were previously married, and those who had experienced a traumatic lifetime event were more likely to have taken any psychotropic medication. Use of any psychotropic medication in the population in the previous 12 months was 14.9%. Use among individuals who met the criteria for a 12-month mental health disorder was 38.5%. Almost one in ten individuals (9.4%) had taken an antidepressant.

CONCLUSIONS

Compared with other countries, NI has high proportions of individuals using psychotropic medication in both the general population and those who met the criteria for a 12-month mental disorder. However, these results still suggest possible under treatment of mental disorders in the country. In addition, rates of use in those with no disorder are relatively high. The predictors of medication use are similar to findings in other countries. Possible research and policy implications are discussed.

Metadata requirements for portals

Consensus around the requirements for metadata in patient and clinical portals would provide a sound basis for the adoption of standards. We propose a set of requirements for metadata in a way that is generic and platform independent. These requirements cover both Clinical Documents and Clinical Statements, addressing the what, who, when and where of each item.

Comparison of howRU and EQ-5D measures of health-related quality of life in an outpatient clinic

This paper reports on a head-to-head study of howRU and EQ-5D on patients with cardiovascular disease. howRU is a short generic measure of health-related quality of life comprising 39 words, designed for routine use, which we compare with EQ-5D (230 words). Patients attending a clinic completed both instruments. Completed data were available for 116 patients, 51% female, mean age 56 and SD 20. howRU is shorter, has better readability statistics, a higher completion rate, a wider range of states used and a smaller ceiling effect than EQ-5D. The correlations of howRU with EQ-5D are similar to those of EQ-5D with other validated instruments.

A short generic patient experience questionnaire: howRwe development and validation

Background

Patient experience is a key quality outcome for modern health services, but most existing survey methods are long and setting-specific. We identified the need for a short generic questionnaire for tracking patient experience.

Methods

We describe the development and validation of the howRwe questionnaire. This has two items relating to clinical care (treat you kindly; listen and explain) and two items relating to the organisation of care (see you promptly; well organised) as perceived by patients. Each item has four responses (excellent, good, fair and poor). The questionnaire was trialled in 828 patients in an orthopaedic pre-operative assessment clinic (PAC).

Results

The howRwe questionnaire is shorter (29 words) and more readable (Flesch-Kincaid grade score 2.2) than other questionnaires with broadly similar objectives. Psychometric properties in this sample are good with Cronbach’s α=0.82. Following a change to the appointments system in the clinic, howRwe showed improvement in promptness and organisation, but not in kindness and communication, showing that it can distinguish between the clinical and organisational aspects of patient experience.

Conclusions

howRwe meets the criteria for a short generic patient experience questionnaire that is suitable for frequent use. In the validation study of PAC patients, it showed good psychometric properties and concurrent, construct and discriminant validity.

The history of the Read Codes: the inaugural James Read Memorial Lecture 2011

General practitioner (GP) computing has its origins in the 1970s when the benefits of clinical coding and prescribing were demonstrated. During the early 1980s Dr James Read, working with Abies Informatics Ltd, developed the eponymous Read Codes, which were broader and more comprehensive than other schemes, yet intuitive and easy to use. In 1988 a joint working party of the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) recommended that the Read Codes be adopted nationally. The Read Codes have been used by almost all GPs in the UK since the mid-1990s. Many developments in general practice, including GP fundholding (where GPs held the budgets to commission elective care for their patients), the Quality and Outcomes Framework (QOF - pay for performance for improving chronic disease management) and GP commissioning (the current NHS reform in which primary care leads commissioning of services for their patients) would have been impossible without all GPs using a common clinical coding scheme. Systematized Nomenclature For Medicine - Clinical Terms (SNOMED CT) is a merger of the Read Codes with SNOMED RT - the original SNOMED reference terminology developed by the American College of Pathologists.

Sintero server scalable interoperability framework for DALLAS communities

We describe a prototype open source UK-scalable Health Information Exchange (HIE) to support patient-centric care, translational research and other secondary uses. It has been designed by interoperability experts to standardise information flows across the patient path—for example from home, work, mobile, clinical and community care locations. Sintero enables secure information sharing within the patient’s named ‘circle of care’ including family, third sector, social care, community pharmacy, specialist care networks and named statutory (e.g. NHS) carers. Patients may access to their own personal health records and manage consents for their sharing and secondary uses. Sintero’s infrastructure is a low-cost ‘commodity’ approach to delivering scalable DALLAS community solutions. It does this by taking a collaborative approach to capacity development, working with NHS informatics and frontline innovation centres towards efficient use of the technology by the workforce. There is a strong focus on delivery of patient value by continuous measurement and systematic feedback of outcomes. Sintero is being made available to UK DALLAS communities on a collaborative basis.

Evaluation of a new short generic measure of health status: howRu

BACKGROUND

Quality of life is paramount for patients and clinicians, but existing measures of health were not developed for routine use.

OBJECTIVES

This paper describes the development and testing of a new generic tool for measuring health related quality of life (HRQoL) with direct comparison to the SF-12 Health Survey.

METHODS

The new tool (howRu) has four items (discomfort, distress, disability and dependence), rated using four levels (none, a little, quite a lot and extreme), providing 256 possible states (4(4)); it has an aggregate scoring scheme with a range from 0 (worst) to 12 (best). Psychometric properties were examined in a telephone survey, which also recorded SF-12.

RESULTS

The howRu script is shorter than SF-12 (45 words vs 294 words) and has better readability statistics. 2751 subjects, all with long-term conditions (average age 62, female 62.8%), completed the survey; 21.7% were at the ceiling (no reported problems on any dimension); 0.9% at the floor. Inter-item correlations, Cronbach's alpha and principal factor analysis suggest that a single summary score is appropriate. Correlations between the physical and mental components of both howRu and SF-12 were as expected. Across all patients the howRu score was correlated with PCS-12 (r=0.74), MCS-12 (r=0.49) and the sum of PCS-12 and MCS-12 (r=0.81). Subjects were classified by howRu score, primary condition, the number of conditions suffered, age group, duration of illness and area of residence. Across all six classifications, the correlation of the mean howRu score with the mean PCS-12 for each class was r=0.91, with MCS-12, r=0.45 and with the sum of PCS-12 and MCS-12, r=0.97.

CONCLUSIONS

howRu is a new short generic measure of HRQoL, with good psychometric properties. It generates similar aggregate results to SF-12. It could provide a quick and easy way for practitioners to monitor the health of patients with long-term conditions.

Prevention of errors and user alienation in healthcare IT integration programmes

The design, development and implementation stages of integrated computer projects require close collaboration between users and developers, but this is particularly difficult where there are multiple specialties, organisations and system suppliers. Users become alienated if they are not consulted, but consultation is meaningless if they cannot understand the specifications showing exactly what is proposed. We need stringent specifications that users and developers can review and check before most of the work is done. Avoidable errors lead to delays and cost over-runs. The number of errors is a function of the likelihood of misunderstanding any part of the specification, the number of individuals involved and the number of choices or options. One way to reduce these problems is to provide a conceptual design specification, comprising detailed Unified Modelling Language (UML) class and activity diagrams, data definitions and terminology, in addition to conventional technology-specific specifications. A conceptual design specification needs to be straightforward to understand and use, transparent and unambiguous. People find structured diagrams, such as maps, charts and blueprints, easier to use than reports or tables. Other desirable properties include being technology-independent, comprehensive, stringent, coherent, consistent, composed from reusable elements and computer-readable (XML). When users and developers share the same agreed conceptual design specification, this can be one of the master documents of a formal contract between the stakeholders. No extra meaning should be added during the later stages of the project life cycle.

Developing a socio-economic measure to monitor access to tuberculosis services in urban Lilongwe, Malawi

OBJECTIVES

To develop locally appropriate measures of poverty for the National Tuberculosis Programme (NTP), Malawi, and to assess access to tuberculosis (TB) services by different socio-economic groups by establishing a socio-economic profile of current TB patients

DESIGN

A quantitative proxy measure of poverty was developed through regression analysis of data from the 1998 national Malawi Integrated Household Survey. A qualitative assessment of poverty was conducted in poor and non-poor settlements in urban Lilongwe to identify key indicators of socio-economic status. Both quantitative and qualitative indicators were used to assess the socioeconomic status of 179 TB patients who participated in a cross-sectional survey.

FINDINGS

The proxy measure of poverty and the qualitative indicators demonstrated similar ability to measure the poverty status of patients. The poverty head count among patients using the quantitative and qualitative indicators were 78% and 70%, respectively. Geographical analysis showed that 60% were from non-poor areas and only 15% (26/139) were from squatter settlements.

CONCLUSION

This study established a strategy for monitoring access to TB services using a proxy measure of poverty and qualitative indicators. This is a vital first step in developing an evidence base for pro-poor equitable TB services.

l -Arginine Transport in the Human Coronary and Peripheral Circulation

Background— Nitric oxide synthase (NOS) uses arginine for the production of nitric oxide (NO). High intracellular concentrations of arginine suggest that NOS activity should be independent of plasma arginine supply. However, under certain conditions, increased plasma arginine concentrations appear to be associated with increased NOS activity. The purpose of this study was to explore arginine transport within the human coronary and peripheral circulation

Methods and Results— Mass-labeled 15 N 2 -arginine was infused to steady state before cardiac catheterization in 31 patients. After diagnostic angiography, a catheter was placed in the coronary sinus. The transcardiac concentration gradient (aorta−coronary sinus) of 15 N 2 -arginine was used as a measure of arginine transport at baseline and during infusions of acetylcholine and N G -monomethyl- l -arginine (L-NMMA). No gradient was detected at rest. During the infusion of acetylcholine, a significant gradient was detected (2.5±1.2 μmol/L, P =0.01) corresponding to a fractional extraction of 11.7±7.5%. This is consistent with in vitro studies that suggest that stimulation of NOS induces arginine transport. During the infusion of L-NMMA, the concentration of 15 N 2 -arginine increased in the coronary sinus, producing a gradient of −3.9±1.3 μmol/L ( P =0.0002), corresponding to a fractional production of 20.5±5.0%. This is consistent with in vitro studies that suggest that L-NMMA induces the efflux of arginine from the cell to the extracellular space via transporter-mediated transstimulation.

Conclusions— The use of steady-state 15 N 2 -arginine to examine transorgan l -arginine gradients represents a novel tool for the study of l -arginine transport and the mechanisms of endothelial and NOS dysfunction.

Why British GPs use computers and hospital doctors do not

Almost all general medical practitioners (GPs) in the UK use computers, compared with less than one in ten of hospital doctors. This paper explains how this unexpected situation came about over a thirty-year period, identifying some of the successes and failures of British medical computing along the way. Twelve separate factors are considered. The major determinants have not been technical, but rather a strong tide of political backing for general practice and leadership from the profession at the highest level, which have combined to build an appropriate regulatory framework and financial incentives that have encouraged GPs to embrace computers. Hospital computing has some difficulties not met by GPs, but the main factor preventing progress has been the lack of any real incentive positive (carrot) or negative (stick), for hospital doctors to use computers.