Maria Santana

Implementing patient-reported outcomes assessment in clinical practice: a review of the options and considerations

PurposeWhile clinical care is frequently directed at making patients “feel better,” patients’ reports on their functioning and well-being (patient-reported outcomes [PROs]) are rarely collected in routine clinical practice. The International Society for Quality of Life Research (ISOQOL) has developed a User’s Guide for Implementing Patient-Reported Outcomes Assessment in Clinical Practice. This paper summarizes the key issues from the User’s Guide.MethodsUsing the literature, an ISOQOL team outlined considerations for using PROs in clinical practice; options for designing the intervention; and strengths, weaknesses, and resource requirements associated with each option.ResultsImplementing routine PRO assessment involves a number of methodological and practical decisions, including (1) identifying the goals for collecting PROs in clinical practice, (2) selecting the patients, setting, and timing of assessments, (3) determining which questionnaire(s) to use, (4) choosing a mode for administering and scoring the questionnaire, (5) designing processes for reporting results, (6) identifying aids to facilitate score interpretation, (7) developing strategies for responding to issues identified by the questionnaires, and (8) evaluating the impact of the PRO intervention on the practice.ConclusionsIntegrating PROs in clinical practice has the potential to enhance patient-centered care. The online version of the User’s Guide will be updated periodically.

Training clinicians in how to use patient-reported outcome measures in routine clinical practice

IntroductionPatient-reported outcome measures (PROs) were originally developed for comparing groups of people in clinical trials and population studies, and the results were used to support treatment recommendations or inform health policy, but there was not direct benefit for the participants providing PROs data. However, as the experience in using those measures increased, it became obvious the clinical value in using individual patient PROs profiles in daily practice to identify/monitor symptoms, evaluate treatment outcomes and support shared decision-making. A key issue limiting successful implementation is clinicians’ lack of knowledge on how to effectively utilize PROs data in their clinical encounters.MethodsUsing a change management theoretical framework, this paper describes the development and implementation of three programs for training clinicians to effectively use PRO data in routine practice. The training programs are in three diverse clinical areas (adult oncology, lung transplant and paediatrics), in three countries with different healthcare systems, thus providing a rare opportunity to pull out common approaches whilst recognizing specific settings. For each program, we describe the clinical and organizational setting, the program planning and development, the content of the training session with supporting material, subsequent monitoring of PROs use and evidence of adoption. The common successful components and practical steps are identified, leading to discussion and future recommendations.ResultsThe results of the three training programs are described as the implementation. In the oncology program, PRO data have been developed and are currently evaluated; in the lung transplant program, PRO data are used in daily practice and the integration with electronic patient records is under development; and in the paediatric program, PRO data are fully implemented with around 7,600 consultations since the start of the implementation.ConclusionAdult learning programs teaching clinicians how to use and act on PROs in clinical practice are a key steps in supporting patient engagement and participation in shared decision-making. Researchers and clinicians from different clinical areas should collaborate to share ideas, develop guidelines and promote good practice in patient-centred care.

Development and evaluation of evidence-informed quality indicators for adult injury care.

Objective:To develop and evaluate evidence-informed quality indicators of adult injury care. Background:Injury is a leading cause of morbidity and mortality, but there is a lack of consensus regarding how to evaluate injury care. Methods:Using a modification of the RAND/UCLA Appropriateness Methodology, a panel of 19 injury and quality of care experts serially rated and revised quality indicators identified from a systematic review of the literature and international audit of trauma center quality improvement practices. The quality indicators developed by the panel were sent to 133 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation. Results:A total of 84 quality indicators were rated and revised by the expert panel over 4 rounds of review producing 31 quality indicators of structure (n = 5), process (n = 21), and outcome (n = 5), designed to assess the safety (n = 8), effectiveness (n = 17), efficiency (n = 6), timeliness (n = 16), equity (n = 2), and patient-centeredness (n = 1) of injury care spanning prehospital (n = 8), hospital (n = 19), and posthospital (n = 2) care and secondary injury prevention (n = 1). A total of 101 trauma centers (76% response rate) rated the indicators (1 = strong disagreement, 9 = strong agreement) as targeting important health improvements (median score 9, interquartile range [IQR] 8–9), easy to interpret (median score 8, IQR 8–9), easy to implement (median score 8, IQR 7–8), and globally good indicators (median score 8, IQR 8–9). Conclusions:Thirty-one evidence-informed quality indicators of adult injury care were developed, shown to have content validity, and can be used as performance measures to guide injury care quality improvement practices.

Quality indicators used by trauma centers for performance measurement.

BACKGROUND: To describe the quality indicators (QIs) that trauma centers use for quality measurement and performance improvement. Measuring and reporting quality of care is a critical step to improve the quality of care. QIs compare actual trauma care against ideal criteria and identify patients in whom care may have been suboptimal and should be further reviewed. METHODS: Three hundred thirty verified trauma centers in the United States, Canada, Australia, and New Zealand had their websites reviewed and leadership surveyed regarding QI use. The indicators identified were classified according to definition specifications, phase of care, Institute of Medicine aims, and contents. RESULTS: Two hundred fifty-one centers responded to the survey (76%) and the majority (97%) indicated that they use QIs. We obtained 10,587 QIs from 262 centers (survey responses and website review) of which 1,102 were unique indicators. The QIs primarily assessed the safety (49%), effectiveness (32%), efficiency (27%), and timeliness (22%) of hospital processes (64%) and outcomes (24%). The majority of indicators were used by a small number of centers (551 of 1,102 unique indicators used by single centers). CONCLUSION: Our study provides the first description of the QIs used by verified trauma centers in four high-income countries with similar systems of trauma care. The majority of trauma centers measure QIs designed to examine the safety, effectiveness, efficiency, and timeliness of hospital processes and outcomes. Opportunities exist to standardize existing QIs to allow broader implementation and develop new QIs to examine patient-centered care and equality of care.

Adoption of e-health technology by physicians: a scoping review

Objective The goal of this scoping review was to summarize the current literature identifying barriers and opportunities that facilitate adoption of e-health technology by physicians. Design Scoping review. Setting MEDLINE, EMBASE, and PsycINFO databases as provided by Ovid were searched from their inception to July 2015. Studies captured by the search strategy were screened by two reviewers and included if the focus was on barriers and facilitators of e-health technology adoption by physicians. Results Full-text screening yielded 74 studies to be included in the scoping review. Within those studies, eleven themes were identified, including cost and liability issues, unwillingness to use e-health technology, and training and support. Conclusion Cost and liability issues, unwillingness to use e-health technology, and training and support were the most frequently mentioned barriers and facilitators to the adoption of e-health technology. Government-level payment incentives and privacy laws to protect health information may be the key to overcome cost and liability issues. The adoption of e-health technology may be facilitated by tailoring to the individual physician’s knowledge of the e-health technology and the use of follow-up sessions for physicians and on-site experts to support their use of the e-health technology. To ensure the effective uptake of e-health technologies, physician perspectives need to be considered in creating an environment that enables the adoption of e-health strategies.

Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions.

Background The complex process of discharging patients from acute care to community care requires a multifaceted interaction between all health care providers and patients. Poor communication in a patient’s discharge can result in post hospital adverse events, readmission, and mortality. Because of the gravity of these problems, discharge planning has been emphasized as a potential solution. The purpose of this paper is to identify communication barriers to effective discharge planning in an acute care unit of a tertiary care center and to suggest solutions to these barriers. Methods Health care providers provided comments to a single open-ended question: “What are the communication barriers between the different health care providers that limit an effective discharge of patients from Unit 36?” We conducted qualitative thematic analysis by identifying themes related to communication barriers affecting a successful discharge process. Results Three broad themes related to barriers to the discharge process were identified: communication, lack of role clarity and lack of resources. We also identified two themes for opportunities for improvement, ie, structure and function of the medical team and need for leadership. Conclusion While it was evident that poor communication was an overarching barrier identified by health care providers, other themes emerged. In an effort to increase inter-team communication, “bullet rounds”, a condensed form of discharge rounds, were introduced to the medical teaching unit and occurred on a daily basis between the multidisciplinary team. To help facilitate provider-patient communication, electronic transfer of care summaries were suggested as a potential solution. To help role clarity, a discharge coordinator and/or liaison was suggested. Communication can be enhanced through use of electronic discharge summaries, bullet rounds, and implementation of a discharge coordinator(s). The findings from this study can be used to aid future researchers in devising appropriate discharging strategies that are focused around the patient and inter-health care provider communication.

The Seamless Transfer of Care A Pilot Study Assessing the Usability of an Electronic Transfer of Care Communication Tool

The purpose of this pilot study was to explore the feasibility of implementing a new electronic transfer of care (TOC) tool. The study was conducted in a Canadian tertiary care center. Brief survey instruments were completed by acute care physicians, community-based physicians, and patients to assess providers’ perspectives on the usability of the novel electronic tool. The units of analysis were physician and patient perceptions. Mixed methods were used including descriptive statistical analyses and qualitative thematic analysis. Twenty-eight unique acute care physicians completed 100 electronic TOC summaries, and 44 unique community-based physicians rated quality and pertinence of the summaries. Twenty-two patients responded to a follow-up telephone call. The novel TOC communication tool was generally well received by physicians and patients, and it is now being evaluated in a large-scale clinical trial assessing hard clinical outcomes. The information presented herein provides a template for assessment of such information system innovations.

A qualitative analysis of a consensus process to develop quality indicators of injury care.

BackgroundConsensus methodologies are often used to create evidence-based measures of healthcare quality because they incorporate both available evidence and expert opinion to fill gaps in the knowledge base. However, there are limited studies of the key domains that are considered during panel discussion when developing quality indicators.MethodsWe performed a qualitative content analysis of the discussions from a two-day international workshop of injury control and quality-of-care experts (19 panel members) convened to create a standardized set of quality indicators for injury care. The workshop utilized a modified RAND/UCLA Appropriateness method. Workshop proceedings were recorded and transcribed verbatim. We used constant comparative analysis to analyze the transcripts of the workshop to identify key themes.ResultsWe identified four themes in the selection, development, and implementation of standardized quality indicators: specifying a clear purpose and goal(s) for the indicators to ensure relevant data elements were included, and that indicators could be used for system-wide benchmarking and improving patient outcomes; incorporating evidence, expertise, and patient perspectives to identify important clinical problems and potential measurement challenges; considering context and variations between centers in the health system that could influence either the relevance or application of an indicator; and contemplating data collection and management issues, including availability of existing data sources, quality of data, timeliness of data abstraction, and the potential role for primary data collection.ConclusionOur study provides a description of the key themes of discussion among a panel of clinical, managerial, and data experts developing quality indicators. Consideration of these themes could help shape deliberation of future panels convened to develop quality indicators.

Trauma center volume and quality improvement programs.

BACKGROUND: Growing evidence suggests that for many treatments, a relationship exists between provider volume and patient outcomes. This relationship is less clear in injury management. We sought to evaluate whether a relationship exists between trauma center volume and the nature of quality improvement (QI) programs. METHODS: This is a survey of 154 verified adult trauma centers in the United States, Canada, Australia, and New Zealand (76% response rate) regarding their QI programs. Centers were classified according to American College of Surgeons annual volume requirements for a Level I center (low volume vs. high volume) and QI programs compared. RESULTS: All participating trauma centers reported using a trauma registry and measuring quality of care. Low-volume centers were more likely than high-volume centers to use quality indicators for evaluating triage and patient flow (18% vs. 13%, p < 0.001), effectiveness of care (33% vs. 30%, p = 0.016), and efficiency of care (29% vs. 23%, p < 0.001). High-volume centers were more likely to use quality indicators for evaluating medical errors and adverse events (30% vs. 36%, p < 0.001) and the use of guidelines/protocols (2% vs. 3%, p = 0.001). Report cards (41% vs. 59%, p = 0.025) and internal benchmarking (79% vs. 91%, p = 0.040) were less frequently reported to be used by low-volume than high-volume centers. CONCLUSIONS: Both low- and high-volume centers reported being engaged in QI. Small differences in the types of quality indicators used by centers were observed according to volume, with high-volume centers more likely than low-volume centers to use report cards and benchmarking as QI tools. LEVEL OF EVIDENCE: IV, therapeutic study.

The development and testing of a survey to measure patient and family experiences with injury care

BACKGROUND To deliver patient-centered trauma care, we must capture patient and family experiences with the services they receive. We developed and pilot tested a survey to measure patient and family experiences with major injury care. METHODS We conducted a structured literature review and focus groups to generate survey items. We pilot tested the survey at a Level I trauma center and assessed feasibility of implementation and construct validity with Spearman’s correlation coefficients. Open ended questions were qualitatively analyzed to explore whether responses corroborated survey content. RESULTS We developed a survey with two parts: acute care component (46 items) and post–acute care component (27 items) with nine domains. We offered the survey (acute care component offered before hospital discharge, post–acute care component offered 1–7 months after discharge) to 170 patients/families, of whom 134 (79%) responded. Patients were primarily male (73%) with major injuries (median Injury Severity Score, 18; interquartile range, 16–25). Overall, respondents for both the acute care and post–acute care components of the survey reported being completely (47% vs. 26%), very (37% vs. 38%), or mostly (16% vs. 21%) satisfied with their injury care, whereas a minority reported being slightly (0% vs. 9%) or very (0% vs. 6%) dissatisfied (p = 0.002 Fischer’s exact test). Most survey items were significantly correlated with overall satisfaction (46 of 60 items). Almost all qualitatively identified themes matched survey domains, adding support to the survey content. CONCLUSION This pilot study demonstrates the feasibility of implementing a survey to capture patient and family experiences associated with major injury care and provides preliminary evidence of the instrument’s content and construct validity. LEVEL OF EVIDENCE Epidemiologic study, level III.