Type of clinical outcomes used by healthcare professionals to evaluate health-related quality of life domains to inform clinical decision making for chronic pain management

Using Implementation Science to Evaluate the Implementation of Patient-Reported Outcome Measures (PROMs) in a Clinical Heart Failure Care Setting

Background

Patients with heart failure (HF) can experience a poor quality-of-life (QOL), recurring hospitalizations, and progressive disease symptoms. Patient-reported outcome measures (PROMs) integrate patients' voices into clinical care, by assessing patient symptoms, function, and QOL. In 2022, PROMs were incorporated into the electronic health record system (Epic) at a large academic hospital in Toronto, Ontario, Canada. The purpose of this study was to use implementation-science frameworks to systematically evaluate the uptake and integration of PROMs into clinical HF care.

Methods

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework guided this mixed-methods, 1-year, quality-improvement project. Data sources included the following: clinician use of PROMs; patient-level data on completed PROMs; and semistructured interviews with clinicians. The PROM was the Kansas City Cardiomyopathy Questionnaire-12, which captures 4 domains related to HF-symptom frequency, physical limitations, social limitations, and QOL (KCCQ-12 is used as an example case of PROMs in general). Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed using behaviour-change frameworks and latent content analysis.

Results

Over the course of 1 year, more patients were assigned to PROMs, a higher proportion of patients completed PROMs, and approximately 80% of patients had high scores on the questionnaire. Clinicians experience barriers-related to attention and decision processes, the environmental context, and their professional role-to integrating PROMs into practice. Suggested changes to improve PROM uptake include adding language licenses for PROM translations, reducing cognitive load for clinicians who are assigning and interpreting PROMs in the Epic system, and championing modelling of use of PROMs in practice.

Conclusions

This study demonstrates the benefit of using implementation science frameworks, to evaluate the implementation of PROMs in practice and provide actionable recommendations to health systems.

Identifying domains of health-related quality of life: the perspective of individuals with low back pain

BACKGROUND

Identifying the most relevant HRQOL domains for LBP from the perspective of individuals with lived experience with LBP is necessary to prioritize domains that will be most informative for evaluating the impact of pain and interventions while overcoming the burden of using long-form assessment tools. This study aimed to identify which domains of HRQOL are most important from the perspective of individuals with chronic LBP.

METHODS

Semi-structured interviews were conducted with 26 individuals with LBP. Participants first responded to questions related to the impact of their LBP on their HRQOL. Then, using a card sorting method, they were asked to select and indicate HRQOL domains that were most relevant to them from a list of 18 cards that represented different HRQOL domains. Participants were asked to explain the reasoning for their selection.

RESULTS

Participants identified physical activity restriction (50%), severity of pain (31%), social activity restriction (23%), and work performance restriction (23%) as the most important domains. The most frequently selected HRQOL domains during card sorting were social function (69%), pain intensity (62%), physical function (58%), fatigue (58%), and pain interference (42%).

CONCLUSION

The most important domains of HRQOL perceived by participants were pain intensity, social function, physical function, fatigue, and pain interference. Identifying these domains will inform clinical decision-making and guide treatment choices for health care providers.

Cross-Cultural Validation of Health and Quality of Life Measures for Children in Hong Kong

Objective

The Pediatric Quality of Life Inventory (PedsQL™) 4.0 is a health-related quality of life (HRQOL) measure designed for clinical practice and research, health policy evaluation, and general population surveys. There is a dearth of instruments measuring quality of life in children which are available in Chinese and validated for Chinese populations. Therefore, this study attempted to establish the Hong Kong populations' norms for the Chinese version of PedsQL™ and examined the psychometric properties of the measure for this population.

Methods

Sixty-nine children (aged 7 to 12 years) and their parents completed the child self-report and the parent proxy report, respectively, of the PedsQL™ 4.0 Generic Module. To evaluate construct validity, a group comparison of children with special educational needs (SEN) (n = 21) and those with typical development (TD) (n = 48) was conducted. Differences based on age group and gender and parent–child agreement on the perception of the child's HRQOL were also examined.

Results

Children with SEN had a lower quality of life perception than those with TD in the physical, social, and schooling domains. No significant differences in emotional health were found between the two groups. The differences between the children with SEN and with TD varied based on age group and gender. The differences between the parents' and children's perceptions of the children's HRQOL were insignificant in this sample.

Conclusion

Norms for the Chinese version of the PedsQL™ 4.0 Generic Module for the Hong Kong population were established in the study, and both the child self-report and parent proxy report were found to be reliable and valid for this population.

Psychological Interventions for Women with Persistent Pelvic Pain: A Survey of Mental Health Clinicians

Objective

To establish which psychological therapies mental health professionals use with reference to the treatment of women with persistent pelvic pain conditions. This research investigates overall therapies and specific techniques that clinicians believe are the most effective with this patient group, and the challenges mental health clinicians face in administering interventions. The study aims to suggest improvements to clinical practice and establish directions for targeted future research.

Design

Cross-sectional survey design.

Methods

An online survey was developed to ask mental health clinicians questions regarding the therapies and techniques they use with women experiencing persistent pelvic pain, their perspective on their practice in this area. The survey was advertised on relevant social media and professional websites. Survey results were tabled, and chi-square statistical analyses were undertaken to examine differences in therapy use according to country and profession.

Results

Mental health clinicians predominantly utilized cognitive behavioral therapy, acceptance and commitment therapy and associated techniques for women with persistent pelvic pain conditions. The results of the chi-square analyses showed that psychologists were more likely to use cognitive behavioral therapy or acceptance and commitment therapy, than counsellors who preferred counselling interventions. Chi-square analyses showed that Australian clinicians used acceptance and commitment therapy with a higher frequency than mental health clinicians in other countries. Clinicians provided multiple insights into their experiences working with women affected by persistent pelvic pain and their opinions as to valuable future research directions.

Conclusion

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness therapies were most commonly used by mental health clinicians working with women with persistent pelvic pain conditions, despite severely limited evidence for the use of these psychological interventions in this client group.

Unmet needs in the management of functional impairment in patients with chronic pain: a multinational survey

Background: A survey of European Pain Federation 2019 attendees was conducted to identify unmet needs in chronic pain patients. Materials & methods: Four questions were asked focusing on functional impairment in chronic pain, including who are at increased risk and ways to better identify and manage these patients. Results: In total 143 respondents indicated that key issues were lack of knowledge, lack of resources/time to assess and manage chronic pain and lack of sufficient tools to identify patients at risk for functional impairment. Education and training of primary care physicians, simplified guidelines and practical tools for assessment and use of multidisciplinary teams to treat chronic pain were recommended. Conclusion: There are many unmet needs in the management of functional impairment in chronic pain patients.

Prospective application of implementation science theories and frameworks to inform use of PROMs in routine clinical care within an integrated pain network

PURPOSE

The objective of this study is to present the implementation science approaches that were used before implementing electronic patient-reported outcome measures (ePROMs) across an integrated chronic pain network that includes primary, rehabilitation, and hospital-based care.

METHODS

The Theoretical Domains Framework (TDF) was used to identify potential barriers and enablers to the use of ePROMS by primary care clinicians. In rehabilitation and tertiary care, the Consolidated Framework for Implementation (CFIR) was used to guide the identification of determinants of implementations, through observation of workflow, patient and clinician surveys, and clinician interviews. A mixed-method concurrent design comprising a quantitative and qualitative analysis was used. The results were reviewed by a steering committee to iteratively inform the ePROM implementation plan. The Proctor framework of evaluation was used to guide the development of an evaluation plan for the implementation of ePROMs in the integrated chronic pain network.

RESULTS

Both frameworks provided similar results with respect to healthcare provider knowledge, behaviour, and experience interpreting PROM scores. The TDF and CFIR frameworks differed in identifying organizational-level determinants. The resultant implementation plan was structured around the adoption of PROMs to inform individual treatment planning and quality improvement. The evaluation plan focused on implementation and impact outcomes to evaluate the ePROM intervention.

CONCLUSIONS

The TDF and CFIR guided the development of a multi-component knowledge translation and training intervention that will address multiple gaps and barriers to implementation of PROMs across the integrated network. The ePROM intervention will aim to increase clinicians' knowledge and skills and foster best practices.

Core patient-reported outcome domains for routine clinical care in chronic pain management: patients' and healthcare professionals' perspective

PURPOSE

To identify a core patient-reported outcome (PRO) domain set to be used in routine clinical care in settings offering specialized and supra-specialized multidisciplinary care to individuals with chronic pain (CP).

METHODS

Two online cross-sectional surveys were administered: one with healthcare professionals (HCPs) and one with individuals with CP. Both surveys included domains of health-related quality of life (HRQoL) from the Patient-Reported Outcomes Measurement Information System (PROMIS) framework. The patients' survey also included the Patient Generated Index (PGI). Areas affected by CP identified in the PGI were mapped to The International Classification of Functioning, Disability and Health (ICF).

RESULTS

According to HCPs, the five most relevant HRQoL domains to be assessed in routine clinical care were pain interference, pain intensity, physical function, anxiety and depression. The five areas that were the most valued by individuals with CP were recreation and leisure; global mental function; work and employment; household tasks and walking and moving. In total, these represented 74% of all nominated areas. When triangulating both frameworks (ICF/PROMIS) and perspectives (HCPs/patients), 10 core PRO domains were identified: pain interference, pain intensity, physical function, sleep disturbance, anxiety, depression, ability to participate in social roles and activities, fatigue, sleep-related impairments and self-efficacy.

CONCLUSIONS

This study identified 10 core PRO domains covering the physical, psychological and social consequences of CP on an individual's life from the perspective of individuals with CP and HCPs. The results can help identify appropriate PRO measures to assess the outcomes of multidisciplinary interventions.

Occupational Factors Associated with Health-Related Quality of Life in Nursing Professionals: A Multi-Centre Study

Background: Nursing professionals are exposed to stressful situations arising from the work context that may affect health-related quality of life (HRQoL). The objective of this study was to analyse the relationship between sociodemographic and work-related variables regarding HRQoL in nursing professionals. Methods: A multi-centre, cross-sectional descriptive design was used. The participants consisted 1521 nurses working in healthcare centres, in both primary care and hospital care, in the eight provinces of the Andalusian Public Health System (APHS), Spain. Sociodemographic and work-related variables were analysed: Compassion fatigue, compassion satisfaction and burnout were measured using the professional quality of life questionnaire (ProQOL), and HRQoL was measured using the SF-12 health questionnaire. Results: Compassion fatigue, burnou, and, to a lesser extent, compassion satisfaction significantly influence the physical and mental components of HRQoL. The simple regression analysis showed that burnout and compassion fatigue were significantly associated with the mental component of HRQoL. Gender influenced the mental component of HRQoL. The rest of the sociodemographic and work-related variables were not significantly related to HRQoL. Conclusion: Work-related stress and repeated contact with situations of suffering influence HRQoL. Health systems must implement programmes to increase the emotional well-being of workers.