Maryann Street

A systematic review of reliable and valid tools for the measurement of patient participation in healthcare

Introduction Patient participation in healthcare is recognised internationally as essential for consumer-centric, high-quality healthcare delivery. Its measurement as part of continuous quality improvement requires development of agreed standards and measurable indicators. Aim This systematic review sought to identify strategies to measure patient participation in healthcare and to report their reliability and validity. In the context of this review, patient participation was constructed as shared decision-making, acknowledging the patient as having critical knowledge regarding their own health and care needs and promoting self-care/autonomy. Methods Following a comprehensive search, studies reporting reliability or validity of an instrument used in a healthcare setting to measure patient participation, published in English between January 2004 and March 2014 were eligible for inclusion. Results From an initial search, which identified 1582 studies, 156 studies were retrieved and screened against inclusion criteria. Thirty-three studies reporting 24 patient participation measurement tools met inclusion criteria, and were critically appraised. The majority of studies were descriptive psychometric studies using prospective, cross-sectional designs. Almost all the tools completed by patients, family caregivers, observers or more than one stakeholder focused on aspects of patient–professional communication. Few tools designed for completion by patients or family caregivers provided valid and reliable measures of patient participation. There was low correlation between many of the tools and other measures of patient satisfaction. Conclusion Few reliable and valid tools for measurement of patient participation in healthcare have been recently developed. Of those reported in this review, the dyadic Observing Patient Involvement in Decision Making (dyadic-OPTION) tool presents the most promise for measuring core components of patient participation. There remains a need for further study into valid, reliable and feasible strategies for measuring patient participation as part of continuous quality improvement.

Initial experience in 115 patients with the retrievable Cook Celect vena cava filter

The aim of this study was to evaluate our experience with the retrievable Cook Celect inferior vena cava (IVC) filter (William Cook, Europe) with regard to insertion, efficiency, ease of retrieval, and any associated complications. A retrospective review was performed of 115 patients (41 female, 74 male, mean age 47.97 years) who underwent Cook Celect IVC filter insertion between December 2005 and October 2007. Filter insertion was successful in all patients. Of the 115 filters inserted, 57 have been successfully retrieved (49.6%) to date. The successful retrieval rate from attempted retrieval was 93.4%. The mean dwell time of successfully retrieved filters was 114.9 days (range 14–267 days). Failed retrievals were due to a thrombosed vena cava (n = 1) and endothelialisation of the filter (n = 3). In the failed retrieval group the mean implantation time was 142 days (range 78–211 days). While this is the first retrospective clinical study on the Cook Celect filter, results to date are promising. We demonstrated an efficacious filter with a high successful retrieval rate of 93.4% and a low complication rate. The filter was assessed with extended dwell times (range 14–267 days). Failed retrieval secondary to hook endothelialisation continues to be an issue with this filter. We recognize that a limitation of our study was the lack of systematic follow‐up for clinically silent complications. Further studies to evaluate longer term outcomes and effectiveness of this filter are warranted.

Radiation exposure and the justification of computed tomography scanning in an Australian hospital emergency department.

In an emergency department (ED), computed tomography (CT) is particularly beneficial in the investigation of high‐speed trauma patients. With the advent of multidetector CT (MDCT) scanners, it is becoming faster and easier to conduct scans. In recent years, this has become evident with an increasing number of CT requests. Patients who have multiple CT scans during their hospital stay can receive radiation doses that have an increased theoretical risk of induction of cancer. It is essential that the clinical justification for each CT scan be considered on an individual basis and that due consideration is given to the radiation risk and possible diagnostic benefit. The current lack of a central State or Commonwealth data repository for medical images is a contributing factor to excessive radiation dosage to the population. The principles of justification and radiation risks are discussed in this study.

In‐reach nursing services improve older patient outcomes and access to emergency care

To identify the impact of in‐reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care.

Determining criteria to assess patient readiness for discharge from postanaesthetic care: an international Delphi study

AIMS AND OBJECTIVES To obtain expert consensus on essential criteria required to assess patient readiness for discharge from the postanaesthetic care unit. BACKGROUND A patients condition can deteriorate after surgery, and the immediate postoperative period is recognised internationally as a time of increased risk to patient safety. A recent systematic review identified evidence-based assessment criteria for the safe discharge of patients from the postanaesthetic care unit and identified gaps in the evidence. DESIGN Descriptive consensus study using the Delphi method. METHODS Members of international clinical specialist groups with expertise in anaesthesia or postanaesthetic care participated in three consultation rounds. Online surveys were used to determine expert consensus with regard to aspects of postanaesthetic care and specific criteria for assessing patient readiness for discharge. Three rounds of surveys were conducted from May 2011-September 2012. RESULTS Twenty-three experts contributed to the panel. Consensus, that is, at least 75% agreement, was reached in regard to 24 criteria considered essential (e.g. respiratory rate 100%; pain 100%; heart rate 95%; temperature 91%). Consensus was also reached for 15 criteria not considered essential (e.g. appetite 96%; headache 76%). Consensus was not obtained for a further 10 criteria. Participants (95%) agreed that a discharge tool was important to ensure safe patient discharge. CONCLUSION Consensus was achieved by a panel of international experts on the use of a tool to assess patient readiness for discharge from postanaesthesia care unit and specific variables to be included or excluded from the tool. Further work is required to develop a tool and test its reliability and validity. RELEVANCE TO CLINICAL PRACTICE The findings of this study have informed the development of an evidence-based tool to be piloted in a subsequent funded study of nursing assessment of patient readiness for discharge from the postanaesthetic care unit.

Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities

The purpose of this retrospective, cross-sectional study was to determine the prevalence of advance care planning (ACP) among older people presenting to an Emergency Department (ED) from the community or a residential aged care facility. The study sample comprised 300 older people (aged 65+ years) presenting to three Victorian EDs in 2011. A total of 150 patients transferred from residential aged care to ED were randomly selected and then matched to 150 people who lived in the community and attended the ED by age, gender, reason for ED attendance and triage category on arrival. Overall prevalence of ACP was 13.3% (n = 40/300); over one-quarter (26.6%, n = 40/150) of those presenting to the ED from residential aged care had a documented Advance Care Plan, compared to none (0%, n = 0/150) of the people from the community. There were no significant differences in the median ED length of stay, number of investigations and interventions undertaken in ED, time seen by a doctor or rate of hospital admission for those with an Advance Care Plan compared to those without. Those with a comorbidity of cerebrovascular disease or dementia and those assessed with impaired brain function were more likely to have a documented Advance Care Plan on arrival at ED. Length of hospital stay was shorter for those with an Advance Care Plan [median (IQR) = 3 days (2-6) vs. 6 days (2-10), P = 0.027] and readmission lower (0% vs. 13.7%). In conclusion, older people from the community transferred to ED were unlikely to have a documented Advance Care Plan. Those from residential aged care who were cognitively impaired more frequently had an Advance Care Plan. In the ED, decisions of care did not appear to be influenced by the presence or absence of Advance Care Plans, but length of hospital admission was shorter for those with an Advance Care Plan.

Emergency Department access targets and the older patient: A retrospective cohort study of Emergency Department presentations by people living in Residential Aged Care Facilities

BACKGROUND There is limited research on the effect of emergency access targets on health outcomes for older patients from Residential Aged Care Facilities. The aims were to: (1) identify length of stay for Residential Aged Care patients relative to access targets; and (2) examine hospital admission rates, readmission rates, inpatient costs and mortality. METHODS Retrospective cohort study of all emergency presentations for Residential Aged Care patients in 2009 at one Australian metropolitan health service. RESULTS The 4637 emergency presentations by 3184 Residential Aged Care patients in 2009 represented 3.4% of all emergency presentations. Mean length of stay was 7.9 hours (SD=4.5 hours); 84% of Residential Aged Care patients remained in the Emergency Department longer than four hours. Admitted patients were 3.6 times more likely to spend more than eight hours in the Emergency Department compared with those not admitted (p<0.001). Patients in the urgent triage category were 9.5 times more likely to spend more than eight hours in the Emergency Department compared to patients triaged as non-urgent (p<0.001). Inpatient costs were associated with length of admission and median cost per day was

Effects of an intradialytic resistance training programme on physical function: a prospective stepped-wedge randomized controlled trial

AUD 1175. CONCLUSION Few Residential Aged Care patients were discharged within the four hours access target. This has implications for health care outcomes and costs associated with providing emergency care for patients living in Residential Aged Care Facilities.

Measuring patient participation in health care: a comprehensive systematic review protocol

BACKGROUND Intradialytic exercise programmes are important because of the deterioration in physical function that occurs in people receiving haemodialysis. Unfortunately, exercise programmes are rarely sustained in haemodialysis clinics. The aim of this study was to determine the efficacy of a sustainable resistance exercise programme on the physical function of people receiving haemodialysis. METHODS A total of 171 participants from 15 community satellite haemodialysis clinics performed progressive resistance training using resistance elastic bands in a seated position during the first hour of haemodialysis treatment. We used a stepped-wedge design of three groups, each containing five randomly allocated cluster units allocated to an intervention of 12, 24 or 36 weeks. The primary outcome measure was objective physical function measured by the 30-s sit-to-stand (STS) test, the 8-foot timed up and go (TUG) test and the four-square step test. Secondary outcome measures included quality of life, involvement in community activity, blood pressure and self-reported falls. RESULTS Exercise training led to significant improvements in physical function as measured by STS and TUG. There was a significant average downward change (β = -1.59, P < 0.01) before the intervention and a significant upward change after the intervention (β = 0.38, P < 0.01) for the 30-s STS with a similar pattern noted for the TUG. CONCLUSION Intradialytic resistance training can improve the physical function of people receiving dialysis.

Multisite Analysis of the Timing and Outcomes of Unplanned Transfers from Subacute to Acute Care

Review question/objective The primary objective of this review is to generate a list of evidence‐based determinants used for assessing patient participation. The review will synthesize the best available evidence for assessing patient participation in health care. Patient participation is the active involvement of the patient in planning, delivery, monitoring and evaluation of their own care. A patient is an individual receiving care services from an organization providing health care. In the context of this review, patient participation will include the active involvement of non‐professional carers/caregivers (e.g. family members and significant others) who support the patient, particularly adults who are unable to advocate on their own behalf (e.g. those with cognitive impairment). The review questions are: What are the available instruments that can be used to measure patient participation in healthcare? What criteria do available instruments incorporate? Are the identified instruments used to measure patient participation in healthcare reliable and valid? What is the feasibility of the identified instruments to measure patient participation in healthcare? What other available strategies can be used to assess patient participation in healthcare? What are the components of other available strategies? Are other identified strategies feasible to assess patient participation in healthcare? Background Promoting patient participation is recognized as a component of high quality health care, and there is evidence that a patient‐centered focus can result in significant benefits in terms of care quality and experience of care. Outcomes relating to quality of care include a reduction in mortality,1 readmission rates,2 length of stay and infection,3 as well as improved adherence to treatment regimens,4 and improved functional status.5 Involvement of the patient in quality improvement initiatives can lead to improved quality of care,6‐8 as well as better patient outcomes.9‐11 Hospitals that provide patient‐centered care have financial benefits including reduced length of stay, lower inpatient costs, decreased adverse events, higher employee retention rates, reduced operating costs and decreased malpractice claims.12 Measurement of patient participation in health care is a relatively new concept, introduced in western Europe, North America and Australia over the previous 25 years.13 The World Health Organization World Alliance for Patient Safety is actively focused on the role that patients and their families could play in the improvement of health care.14 Evidence is emerging that patient participation can enhance decision making processes, reduce medical errors, optimize self‐management for patients with chronic illness and improve patient adherence to health care practices.15 As such, health services internationally now include consumer‐centered care and partnering with consumers as an aspect of service delivery and design. In 1998, Cahill observed that a standardized definition of patient participation and reliable, valid measures for assessing the extent to which this concept is executed in practice are needed.16 Over a decade later, the concept of patient participation remains poorly defined. Various terms, including patient involvement, partnership, empowerment, collaboration and patient‐centered care are used interchangeably.15 Despite the now common practice of gathering feedback from patients, its use to stimulate quality improvement remains poorly characterized. In an overview of measurement of patient participation in health care, Coulter, Fitzpatrick et al., highlighted the first stage of the measurement process as being the development of agreed standards, each with a set of measureable indicators focused on patient‐centered care and patient priorities.17 Development of measurable indicators has been a focus of health service quality improvement internationally. In 2006, the Organization for Economic Co‐operation and Development (OECD) prepared an overview of health care quality indicators in 23 countries represented in the OECD; laying the foundation for international benchmark indicators that embrace and build upon health service quality frameworks already implemented in six major OECD countries (Australia, Canada, Denmark, the Netherlands, the United Kingdom and the United States).18 Within Australia, 10 National Safety and Quality Health Service (NSQHS) standards have been designed to protect the public from harm and to improve the quality of health service provision.19 These standards are integral to the Australian health care accreditation process, as they determine the criteria on which an organizations performance will be assessed, and indicators against which performance will be measured. Similarly, other OECD countries document standards and quality indicators that are comparable to those used in the Australian setting.18 The second Australian NSQHS standard, ‘Partnering with Consumers’, describes the systems and strategies to create a consumer‐centered health system through inclusion of consumers in the development and design of quality health care.19 This requires active involvement of consumers in the review, design and implementation of health services with a goal of improved safety, quality and efficiency. Thus, the first stage of the process defined by Coulter, Fitzpatrick et al., in which agreed standards are defined, is prescribed within the NSQHS Standards.17 Equally, health care quality indicators in other OECD countries prescribe to the principle of consumer involvement, variously referred to as patient centeredness, patient focus or responsiveness.18 The development of measureable indicators of patient participation is ongoing both in Australia and internationally. The Australian Institute of Health and Welfare (AIHW) includes ‘patient experience’ as a national quality indicator to be reported by health care facilities that encompasses patient satisfaction, involvement in and support for health care, but specific ways in which this should be measured and reported remain undefined.20 The OECD is also yet to finalize its work on measurable quality indicators of patient participation.18 Reliable strategies to measure and evaluate the achievement of quality indicators of patient participation have therefore received minimal attention within the NSQHS Standards structure; although work identifying the most appropriate measurement strategies is ongoing. As part of the OECD project on quality indicators in health care, the Norwegian Knowledge Center for Health Services reviewed surveys that have been used to measure patient experience in international health care settings. The reviewers identified numerous large scale patient surveys that have been undertaken in OECD and non‐OECD countries to measure patient experiences, and identified both qualitative and quantitative strategies that could be adopted by health care facilities, including some surveys that were under development at the time of the review.18 Elwyn, Edwards et al., reviewed instruments for measuring patient involvement in shared decision making and found existing instruments had not been specifically developed to measure patient involvement, were developed for different purposes and were not validated.21 In their comprehensive report on measuring patient experience with health care services, Coulter, Fitzpatrick et al., outlined a range of measurement strategies including surveys, interviews, focus groups, patient diaries, ‘mystery shopping’ and journey mapping.17 However, the authors did not report the implementation, validation or effectiveness of these tools. Health care services currently use a range of strategies to evaluate patient‐centered care and partnerships with patients and their significant others. The two primary approaches to measuring patient participation are external observation methods and self‐report instruments. Examples of tools using external observation for measuring patient involvement in shared decision making are the Option Scale,22 and Rochester Participatory Decision‐Making Scale (RPAD).23 More often, health care services rely on self‐report instruments for measuring patient satisfaction and experience. Surveys are often given to a patient when they leave hospital after a period of inpatient care, or the patient is asked to complete a questionnaire prior to discharge. Post discharge feedback may provide more reliable information about the quality of care because respondents have had time to reflect on their experiences.17 More recently, rapid feedback involving online surveys have also been used.24 Although some of the items in these surveys relate to patient participation in their health care, the focus is often patient satisfaction and experience, rather than involvement. A review of patient experience and satisfaction surveys conducted within public and private hospitals in Australia identified that 80% of surveys included items which related to patient participation in care decisions.25 The Australian Commission on Safety and Quality in Health Care has hosted a series of roundtable meetings where experts have provided advice towards the development of core common questions for hospital patient experience measurement. However, it is important to note that the evidence‐base for criteria to measure patient participation in health care and improvements as a result of patient participation was not established. This systematic review endeavors to provide an updated synthesis of evidence on effective strategies through which patient involvement in health care can be measured and assessed, with a goal of assisting health care services to demonstrate patient‐centered care in practice and benchmark their performance on the international stage. The primary outcome for this review will be a preliminary list of evidence‐based criteria used for assessing patient participation. Specifically, this will assist