Patient-reported outcomes in the Swedish National Quality Registers

Post-diagnostic support for persons with young-onset dementia - a retrospective analysis based on data from the Swedish dementia registry SveDem

BACKGROUND

Approximately 3.9 million persons worldwide have young-onset dementia. Symptoms related to young-onset dementia present distinct challenges related to finances, employment, and family. To provide tailored support, it is important to gain knowledge about the formal support available for persons with young-onset dementia. Therefore, this paper aims to describe formal support for persons with young-onset dementia in Sweden and the factors influencing this support.

METHODS

This retrospective study used data on persons under 65 years of age (n = 284) from The Swedish Registry for Cognitive/Dementia Disorders (SveDem) between 2021 and 2022. SveDem was established to monitor the quality of dementia care in Sweden. Characteristics of participants were obtained, including age, sex, dementia diagnosis, MMSE, medications, accommodation, and care setting. Descriptive statistics and logistic regression were used to test for associations between participant characteristics and post-diagnostic support.

RESULTS

Information and educational support were usually offered to the person with young-onset dementia (90.1%) and their family (78.9%). Approximately half of the sample were offered contact with a dementia nurse (49.3%), counsellor (51.4%), or needs assessor (47.9%). A minority (28.5%) were offered cognitive aids. Six regression models were conducted based on participant characteristics to predict the likelihood that persons were offered support. Support was not predicted by age, sex, children at home, accommodation, or medications. Lower MMSE scores (p < .05) and home help (p < .05) were significantly associated with offer of a needs assessor. Living together was a significant predictor (p < .01) for information and educational support offered to the family. Care setting significantly predicted (p < .01) an offer of information and educational support for the person and family members, as well as contact with a counsellor.

CONCLUSION

This study indicates potential formal support shortages for persons with young-onset dementia in some areas of dementia care. Despite equal support across most characteristics, disparities based on care setting highlight the importance of specialised dementia care. Pre-diagnostic support is minimal, indicating challenges for persons with young-onset dementia to access these services before diagnosis. While our study has identified areas in need of improvement, we recommend further research to understand the changing support needs of those with young-onset dementia.

Evaluating person-centered care in neurological outpatient care: a mixed-methods content validity study

BACKGROUND

Person-centered care (PCC) is gaining increased attention. PCC concerns the whole person behind the disease and can improve care for people with long-term conditions such as multiple sclerosis (MS) and Parkinson's disease (PD). However, there is a lack of tools to assess PCC from the patients' perspective, particularly in outpatient care. The Person-Centered Care instrument for outpatient care (PCCoc) is an instrument under development with the intention to fill this gap. The aim of this study was to test the user-friendliness and content validity of the PCCoc as experienced by persons with MS and PD in neurological outpatient care.

METHODS

Twenty persons with MS or PD completed the 35-item PCCoc followed by an interview regarding the instrument's intelligibility and ease of use to assess its user-friendliness. Participants then rated the relevance of each item. These ratings were used to calculate the content validity index (CVI) for individual items (I-CVI) and for the overall scale (S-CVI).

RESULTS

It took a median of 5 min for participants to complete the PCCoc. Instrument instructions were found clear, items easy to understand, and response categories distinct. No important missing areas were reported. I-CVI values ranged between 0.75 and 1, and S-CVI was 0.96.

CONCLUSIONS

We found support for the user-friendliness and content validity of the PCCoc among persons with MS and PD, suggesting that the PCCoc can be useful for evaluating and developing PCC in neurological outpatient care. Further testing in broader contexts, including psychometric testing, is warranted to establish its usefulness.

Sporadic deficient mismatch repair in colorectal cancer increases the risk for non-colorectal malignancy: A European multicenter cohort study

BACKGROUND AND OBJECTIVES

Disparities between tumors arising via different sporadic carcinogenetic pathways have not been studied systematically. This retrospective multicenter cohort study evaluated the differences in the risk for non-colorectal malignancy between sporadic colorectal cancer (CRC) patients from different DNA mismatch repair status.

METHODS

A retrospective European multicenter cohort study including in total of 1706 CRC patients treated between 1996 and 2019 in three different countries. The proficiency (pMMR) or deficiency (dMMR) of mismatch repair was determined by immunohistochemistry. Cases were analyzed for tumor BRAFV600E mutation, and BRAF mutated tumors were further analyzed for hypermethylation status in the promoter region of MLH1 to distinguish between sporadic and hereditary cases. Swedish and Finish patients were matched with their respective National Cancer Registries. For the Czech cohort, thorough scrutiny of medical files was performed to identify any non-colorectal malignancy within 20 years before or after the diagnosis of CRC. Poisson regression analysis was performed to identify the incidence rates of non-colorectal malignancies. For validation purposes, standardized incidence ratios were calculated for the Swedish cases adjusted for age, year, and sex.

RESULTS

Of the 1706 CRC patients included in the analysis, 819 were female [48%], median age at surgery was 67 years [interquartile range: 60-75], and sporadic dMMR was found in 188 patients (11%). Patients with sporadic dMMR CRC had a higher incidence rate ratio (IRR) for non-colorectal malignancy before and after diagnosis compared to patients with a pMMR tumor, in both uni- (IRR = 2.49, 95% confidence interval [CI] = 1.89-3.31, p = 0.003) and multivariable analysis (IRR = 2.24, 95% CI = 1.67-3.01, p = 0.004). This association applied whether or not the non-colorectal tumor developed before or after the diagnosis of CRC in both uni- (IRR = 1.91, 95% CI = 1.28-2.98, p = 0.004), (IRR = 2.45, 95% CI = 1.72-3.49, p = 0.004) and multivariable analysis (IRR = 1.67,95% CI = 1.05-2.65, p = 0.029), (IRR = 2.35, 95% CI = 1.63-3.42, p = 0.005), respectively.

CONCLUSION

In this retrospective European multicenter cohort study, patients with sporadic dMMR CRC had a higher risk for non-colorectal malignancy than those with pMMR CRC. These findings indicate the need for further studies to establish the need for and design of surveillance strategies for patients with dMMR CRC.

Patient-Reported Experiences and Associated Factors in a Norwegian Radiotherapy Setting: An Explorative Cross-Sectional Study

Introduction

Radiotherapy is the main treatment modality in cancer. There is sparse knowledge on how patients with cancer experience their radiotherapy trajectory, and which factors might be associated with patients' experiences.

Objectives

The aim of the present study was to explore how adults with cancer receiving radiotherapy evaluate the quality of their care, utilizing a patient-reported experience measure, and how patient- and service-related characteristics are associated with their evaluation.

Methods

An explorative cross-sectional study using a self-completed questionnaire to assess patients' radiotherapy experiences was performed. Participants were recruited consecutively, within their last week of treatment, from two different hospitals in Norway from January 2021 to January 2022. Four hundred and eighty paper questionnaires were distributed to recruited patients, 240 at each hospital. Questionnaires were self-completed at home and returned by mail. The instrument person-centered coordinated care experience questionnaire (P3CEQ) was used. In addition to this, participants completed the European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) and The Sense of Coherence 13 scale (SOC-13). Data were analyzed using descriptive statistics, parametric tests, and unadjusted/adjusted linear regression models were estimated.

Results

The study included 373 patients. Patients evaluated quality of care in terms of P3CEQ scores, with a mean score of 19.5 (standard deviation = 5.4). Lowest scores were identified in areas concerning person-centeredness and service coordination. There were no significant differences in P3CEQ scores between the younger and older groups. Having a partner and better SOC-13 scores were independently associated with the overall patient-reported experience score, whereas age was not.

Conclusion

Patient-reported experience scores indicate that improvements are needed in some areas, such as informing and involving patients in the planning and coordination of their care. Findings suggest paying special attention to patients without a partner to offer patients the best possible care.

Painful differences between different pain scale assessments: The outcome of assessed pain is a matter of the choices of scale and statistics

OBJECTIVES

Perceived pain is a multi-factorial subjective variable, commonly measured by numeric rating scales, verbal descriptive scales (VDS), or by a position on an analogue line (VAS). A major question is whether an individual's VAS and VDS pain assessments, on the same occasion, could be comparable. The aim was to compare continuous and discretized VAS pain data with verbal descriptive pain datasets from the Oswestry Disability Index (ODI) and the European Quality of Life Scale (EQ-5D) in paired pain datasets.

METHODS

The measurement level of data from any type of scale assessments is ordinal, having rank-invariant properties only. Non-parametric statistical methods were used. Two ways of discretizing the VAS-line to VAS-intervals to fit the number of the comparing VDS-categories were used: the commonly used (equidistant VAS,VDS)-pairs and the (unbiased VAS,VDS)-pairs of pain data. The comparability of the (VAS,VDS)-pairs of data of perceived pain was studied by the bivariate ranking approach. Hence, each pair will be regarded as ordered, disordered, or tied with respect to the other pairs of data. The percentage agreement, PA, the measures of disorder, D, and of order consistency, MA, were calculated. Total interchangeability requires PA = 1 and MA = 1.

RESULTS

The wide range of overlapping of (VAS,VDS)-pairs indicated that the continuous VAS data were not comparable to any of the VDS pain datasets. The percentage of agreement, PA; in the (equidistant VAS,ODI) and (equidistant VAS, EQ-5D) pairs were 38 and 49%, and the order consistency, MA, was 0.70 and 0.80, respectively. Corresponding results for the (unbiased VAS,VDS)-pairs of pain data were PA: 54 and 100%, and MA: 0.77 and 1.0.

CONCLUSION

Our results confirmed that perceived pain is the individual's subjective experience, and possible scale-interchangeability is only study-specific. The pain experience is not possible to be measured univocally, but is possible for the individual to rate on a scale.

Performance measurement and user-centeredness in the healthcare sector: Opening the black box adapting the framework of Donabedian

The framework of Donabedian is widely applied to performance assessment at the healthcare system level. Donabedian categorised the care quality measurement around three dimensions, namely structure, process, and outcomes. The first dimension concerns the inputs; the second one, the combinations of factors and inputs; the last one, the effectiveness in terms of patients' health status. Donabedian early included in the last dimension the patient satisfaction. Nevertheless, nowadays, outcomes are generally measured through hard endpoints, such as re-admissions and mortality indicators. Recently, the Patient-Reported Outcome Measures (PROMs) have been included among the outcome measures within the Donabedian framework. How to move the concept of patient-centeredness to a macro level, including the patient point of view in care quality measurement, evaluation, and improvement? This paper integrates the Donabedian structure-process-outcome framework, by incorporating in the proper dimension the patient-indicators, namely the abovementioned PROMs and Patient-Reported Experience Measures (PREMs). While PROMs are clearly measures of outcome, PREMs can be collocated in the process dimension, since they can be useful for mapping processes and care pathways, in a lean perspective, as well as in the outcome dimension, because inherently linked to outcome, and enablers of patient-centeredness.

Development and psychometric evaluation of TEXP-Q: a questionnaire measuring transition and transfer experiences in emerging adults with type 1 diabetes

BACKGROUND

During transition to adulthood and transfer to adult healthcare, emerging adults with chronic conditions are at risk of deteriorating disease control, well-being, and acute, as well as long-term complications. Despite an increasing call for person-centred healthcare services attuned to young peoples' needs, few validated instruments exist pinpointing adolescents' and emerging adults' experiences of preparation for transition and transfer. Thus, the overarching purpose of this study was to develop a person-centred, clinically applicable instrument (Transitional care EXPeriences Questionnaire, TEXP-Q) adjustable to different chronic conditions, although the focus in the present study was Type 1 Diabetes. The specific aim was, therefore, to describe the development and psychometric evaluation of TEXP-Q in emerging adults with Type 1 Diabetes.

METHODS

Initial development of the TEXP-Q was inspired by existing research. Items were formulated in accordance with consensus recommendations for developing patient-reported measures, and extra consideration was taken to ensure person-centredness. Psychometric evaluation comprised two phases: In phase I, data from cognitive interviews, content validity indexing, and judgement of an expert panel provided information on face and content validity. In phase II, data from a cross-sectional study conducted at eight adult diabetes outpatient clinics in Sweden (n = 163) allowed for explorative factor analysis (EFA), as well as calculation of content validity, reliability and responsiveness.

RESULTS

Combining results from cognitive interviews, content validity index values and expert panel judgement, a test version of TEXP-Q was developed, the content and face validity of which were considered good. This version consisted of 17 items answered on a five-point Likert scale, and three open-ended questions answered in free text. During EFA, four items were removed, and a three-factor solution was recognised as most adequate, accounting for 60% cumulative variance and one single cross-loading. After EFA, the instrument comprised 13 questions, divided into three latent factors. Cronbach's alpha for the complete instrument was 0.866, which indicates good internal consistency. Crohnbach's alpha approximated to 0.8 for all factors respectively.

CONCLUSION

TEXP-Q is a newly developed, person-centred instrument which has proven to be both valid and reliable when applied to youths with T1D. The questionnaire fills a need for instruments focusing on emerging adults' experiences of preparation for transition and transfer.

Development and Integration of Patient-Reported Measures into E-Health System: Pilot Feasibility Study

Patient-centered care is recognized as a key element in recent healthcare management strategies. However, the integrated collection of patient feedback capturing the entire journey of patients with complex medical conditions remains understudied. Herein, we aimed to describe the development of an instrument prototype for the collection of PROMs and PREMs that would encompass a whole patient journey at a single time point. We further describe the process of its integration into a hospital's information system (HIS) and the results of a pilot feasibility study in adult patients with kidney and hematological diseases. We developed an instrument consisting of original PREM and generic EQ-5D-5L questionnaires. E-questionnaires were handled with REDCap software (version 12.5.14) and integrated into the HIS. Patients refusing to use e-questionnaires (48%) were offered paper administration and were older (64 vs. 50 years). The overall response rate for e-questionnaires was 57.1% with a median completion time of 2.0 and 3.7 min for PROM and PREM, respectively. Psychological and social services and primary care setting (diagnosis establishment and involvement in continuous care) were identified as most problematic. The majority of PREM dimensions encompassing different levels of care significantly correlated with PROM responses. Our data indicate the feasibility and potential relevance of the proposed approach, although wider-scale studies in diverse settings are needed.

Optimizing Patient-Reported Outcome Collection and Documentation in Medical Music Therapy: Process-Improvement Study

BACKGROUND

To measure the effectiveness of nonpharmacologic interventions delivered during clinical care, investigators need to ensure robust and routine data collection without disrupting individualized patient care or adding unnecessary documentation burden.

OBJECTIVE

A process-improvement study was undertaken to improve documentation consistency and increase the capture of patient-reported outcomes (PROs; ie, stress, pain, anxiety, and coping) within a medical music therapy (MT) team.

METHODS

We used 2 Plan-Do-Study-Act (PDSA) cycles to improve documentation processes among an MT team (13.3 clinical full-time equivalent staff). Trainings focused on providing skills and resources for optimizing pre- and postsession PRO collection, specific guidelines for entering session data in the electronic health record, and opportunities for the team to provide feedback. Two comparisons of therapists' PRO collection rates were conducted: (1) between the 6 months before PDSA Cycle 1 (T0) and PDSA Cycle 1 (T1), and (2) between T1 and PDSA Cycle 2 (T2).

RESULTS

Music therapists' rates of capturing any PRO within MT sessions increased significantly (P<.001) from T0 to T1 and from T1 to T2 for all domains, including stress (4/2758, 0.1% at T0; 1012/2786, 36.3% at T1; and 393/775, 50.7% at T2), pain (820/2758, 29.7% at T0; 1444/2786, 51.8% at T1; and 476/775, 61.4% at T2), anxiety (499/2758, 18.1% at T0; 950/2786, 34.1% at T1; and 400/775, 51.6% at T2), and coping (0/2758, 0% at T0; 571/2786, 20.5% at T1; and 319/775, 41.2% at T2). Music therapists' feedback and findings from a retrospective analysis were used to create an improved electronic health record documentation template.

CONCLUSIONS

Rates of PRO data collection improved within the medical MT team. Although the process improvement in this study was applied to a nonpharmacologic MT intervention, the principles are applicable to numerous inpatient clinical providers. As hospitals continue to implement nonpharmacologic therapies in response to the Joint Commission's recommendations, routine PRO collection will provide future researchers with the ability to evaluate the impact of these therapies on pain relief and opioid use.

Adapting and usability testing of the Kansas city cardiomyopathy questionnaire (KCCQ) in a heart failure clinic in Tanzania: the Swahili KCCQ

BACKGROUND

The integration of patient-reported outcome measures (PROMS) into health care delivery systems is being increasingly recognized as an important component of quality, person-centered care, especially for chronic illnesses like congestive heart failure (CHF). However, while PROMS are increasingly being used to follow up CHF patients in high income countries, their use in sub-Saharan Africa is still limited. We adapted the Kansas City Cardiomyopathy Questionnaire (KCCQ-23), an internationally validated, CHF-specific PROM and tested its use in measuring outcomes in an outpatient CHF clinic at a cardiac referral hospital in Tanzania.

METHODS

Adaptation of the KCCQ-23 included translation into Swahili by linguistic experts, in-depth cognitive debriefing in native Swahili-speaking CHF patients, and input from Tanzanian Cardiologists, PROMS experts, and the tool developer. Using a cross-sectional design, we tested the usability and observed the results of the translated KCCQ-23 in a convenience sample of 60 CHF patients attending outpatient clinic at the Jakaya Kikwete Cardiac Institute (JKCI) in Dar es Salaam.

RESULTS

The survey was successfully completed by 59 (98.3%) of 60 enrolled participants. The mean (SD) age of participants was 54.9 (14.8) years (range 22-83), 30.5% were women and 72.2% had class 3 or 4 New York Heart Association (NYHA) symptoms at enrollment. The overall KCCQ-23 score was low, with a mean (SD) score of 21.7 (20.4) indicating generally very poor to poor patient reported outcomes in this population. The mean (SD) scores for the specific KCCQ-23 domains were 15.25 (24.2) for social limitation, 23.8 (27.4) for physical limitation, 27.1 (24.1) for quality of life and 40.7 (17.0) for self-efficacy. No socio-demographic or clinical characteristics were associated with their overall KCCQ-23 scores. Comparing the short version (KCCQ-12) with the full KCCQ-23 revealed excellent correlation between the two (r = 0.95; p < 0.0001).

CONCLUSIONS

We successfully translated a validated tool, the Swahili KCCQ, for use in improving the care of patients with CHF in Tanzania and a broader population of Swahili-speaking patients. Both the Swahili KCCQ-12 and KCCQ-23 can be used, with similar outcomes. Work to expand the use of the tool in the clinic and other settings is planned.

The implementation of the 2017 national policy on patient-reported outcomes in Denmark: An overview of developments after six years

Driven by the potential values of using more patient-centred approaches in health care, the Danish government, regions and municipalities have agreed to introduce a standardised use of patient-reported outcomes (PRO) in all healthcare sectors in Denmark. Expecting benefits in particular at the individual patient level, the work to implement the national PRO policy is carried out under the auspices of the Ministry of Health. This highly systematic and comprehensive work elevates the development of PRO to a national level and centres around three main elements: development and feasibility tests of standardised PRO instruments within specific clinical areas, the development and implementation of a PRO instrument repository and a national IT infrastructure for the sharing of data across healthcare sectors. The paper describes these elements together with reports on the current state of implementation after six years of activities. PRO instruments have been developed and tested within eight clinical areas and - as intended - they show promising value for patients as well as healthcare professionals with respect to individual patient care. It has taken time for the supporting IT infrastructure to become fully operational in practice and, likewise, the strengthening of the implementation in and across healthcare sectors has required - and continues to require - considerable efforts from all stakeholders.

Scaling and spreading the electronic capture of patient-reported outcomes using a national surgical quality improvement programme: a feasibility study protocol

INTRODUCTION

Patient-reported outcomes (PROs) are important for research, patient care and quality assessment; however, large-scale collection among the US surgical patient population has been limited. A structured implementation and dissemination programme focused on electronic PRO collection could improve the use of PROs data to improve surgical care. This study aims to (1) evaluate the feasibility of PRO collection among a larger volume of surgical patients through the stepwise implementation of PRO collection processes in a sample of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals; (2) identify best practices and barriers to PRO collection through qualitative study of participating hospitals and patients; and (3) evaluate the utility of PROs at detecting differences in the quality of care among surgical patients.

METHODS AND ANALYSIS

ACS NSQIP-participating hospitals are being recruited, and patients at participating hospitals who undergo elective surgical procedures receive invitations via e-mail or short message service 'text'message to complete PROs after surgery. Validated PRO measures which evaluate physical and mental health-related quality of life, pain, fatigue, physical function and shared decision-making were selected. The scalability of PRO collection will be assessed by site enrolment, patient accrual and response rates. Qualitative interviews and focus groups will be performed with patients and hospital personnel to identify best practices and barriers to successful enrolment and PRO collection. Multivariable hierarchical regression models will be used to evaluate the distinctness of PROs from clinical outcomes captured in ACS NSQIP and the ability of PROs to detect differences in hospital performance.

ETHICS AND DISSEMINATION

This study was reviewed by the Advarra Institutional Review Board (IRB) and deemed to be exempt from IRB oversight. Findings will be disseminated through peer-reviewed manuscripts, reports and presentations.

The impact of a targeted education package on the knowledge, attitudes, and utilisation of patient reported outcome measures amongst chiropractors in Australia

BACKGROUND

Patient Reported Outcome Measures (PROMs) have been shown to be valid and reliable indicators of health status and treatment outcomes, however, the current knowledge, understanding, and utilisation of PROMs within the Australian Chiropractic profession is limited. This study used the New World Kirkpatrick Model (NWKM) to evaluate whether an online PROM education package could improve knowledge, confidence, attitude, and utilisation of PROMs by chiropractors in Australia.

METHODS

A longitudinal cohort interventional study of chiropractors in Australia. The recruitment phase and data collection period occurred from November 2020 - May 2021. Participants completed three online surveys two weeks before, four weeks after, and 12 weeks after receiving an online education package that included ten evidence-based region-specific modules on PROMs. Survey questions were grouped into five subthemes for analysis according to the NWKM levels: (1) Reaction; (2) Learning - knowledge; (3) Learning - confidence; (4) Behaviour - attitude; (5) and Behaviour - utilisation).

RESULTS

Of the 116 participants that enrolled in the study, 43 completed all three survey and were included in the analysis. There was very positive reaction to the education package with mean response scores (1-5 Likert scale) for the reaction questions ranging from 3.75 to 4.43. There was a small, but significant, increase in knowledge (out of 32) at four weeks (24.3 ± 6.1) and 12 weeks after receiving the education package (27.2 ± 5.5), compared to baseline (27.4 ± 5.1). There was no effect of the intervention on clinician confidence or attitude towards PROMs. Utilisation of function- and pain-related PROMs did not change after the intervention. There was a small and significant (p < 0.05) increase in utilisation of health-related PROMs 12 weeks after the intervention.

CONCLUSION

Despite modest improvements in knowledge, which were retained 12 weeks after the educational package was provided, there was no evidence that participant confidence, attitude, or utilisation of PROMs changed because of the intervention. While the respondents' have positive attitudes and beliefs regarding PROMs use, further education surrounding the clinical translation process into clinical practice is required. Caution is advised when interpreting these findings due to the low participant response and completion rate with the potential for selection bias and the inability to generalise the results.

Capturing Meaningful Outcomes in -Pediatric Neurology: Further Reflections on Principles, Challenges, and Opportunities

Patient and public involvement in health care is considered indispensable in the way we conduct daily pediatric neurology practice, and in the development and utilization of health outcome measurements. This essay examines what meaningful quality evaluations and measurements are, describes the development of approaches to measuring health and outcomes, explores the potential applications of patient-reported outcome measures in pediatric neurology, and identifies opportunities and challenges in using patient-reported outcome measurements in our daily clinical practice. Recent developments have transformed our attitude on how to help children with neurological and developmental conditions and their families: specifically, (1) the recognition of the fundamental rights of children with disabilities; (2) the application of the framework of the International Classification of Functioning, Disability and Health by the World Health Organization that views health from the perspective of both biopsychosocial strengths and functional abilities; (3) the application of qualitative research methodologies to children with neurological conditions and their caregivers to elucidate what they consider essential for their own good health and well-being; and (4) the development of core outcome measurements sets for children and adults with various neurological and developmental conditions. In summary, supporting patients in their role as full partners in clinical care and research enables them to contribute their experiential knowledge and helps ensure that results are relevant and address patient needs, preferences, and priorities. Recognizing the importance of involving young people in their health management decisions has become central in contemporary medicine and needs to be part of the curriculum of all health care professionals.

Patient-reported outcome measures in spine surgery: A systematic review

Background

Steadily increasing expenditure in the United States health-care system has led to a shift toward a value-based model that focuses on quality of care and cost-effectiveness. Operations involving the spine rank among some of the most common and expensive procedures performed in operating rooms nationwide. Patient-reported outcomes measures (PROMs) are a useful tool for reporting levels of outcome and analyzing patient recovery but are both under-utilized and nonstandardized in spine surgery.

Methods

We conducted a systematic review of the literature using the PubMed database, focusing on the most commonly utilized PROMs for spine disease as well as spinal deformity. The benefits and drawbacks of these PROMs were then summarized and compared.

Results

Spine-specific PROMs were based on the class of disease. The most frequently utilized PROMs were the Neck Disability Index and the modified Japanese Orthopaedic Association scale; the Oswestry Disability Index and the Roland-Morris Disability Questionnaire; and the Scoliosis Research Society 22-item questionnaire (SRS-22) for cervicothoracic spine disease, lumbar spine disease, and spinal deformity, respectively.

Conclusion

We found limited, though effective, use of PROMs targeting specific classes of disease within spine surgery. Therefore, we advocate for increased use of PROMs in spine surgery, in both the research and clinical settings. PROM usage can help physicians assess subjective outcomes in standard ways that can be compared across patients and institutions, more uniquely tailor treatment to individual patients, and engage patients in their own medical care.

Toward System-Wide Implementation of Patient-Reported Outcome Measures: A Framework for Countries, States, and Regions

OBJECTIVES

This study aimed to develop a framework facilitating (1) the maturity assessment of healthcare systems regarding patient-reported outcome measure (PROM) implementation and (2) the comparison of different healthcare systems' PROM implementation levels to guide discussions and derive lessons for regional, state-level, and national PROM initiatives.

METHODS

Guided by the grounded theory methodology, a PROM healthcare system implementation framework was developed following multiple steps. Based on interviews with 28 experts from 12 countries and a literature review, a framework was drafted and refined through 29 additional validation interviews.

RESULTS

The resulting framework comprises 5 implementation stages along 7 dimensions. Implementation stages range from "first experimentation" to "system-wide adoption and a vibrant ecosystem." The dimensions are grouped into patient-reported outcome (PRO) measurement and PRO utilization, the former with the dimensions "scope and condition coverage," "metric and process standardization," and "tools and information technology-based solutions" and the latter with "patient empowerment and clinical decision support," "reporting and quality improvement," and "rewarding and contracting." The "culture and stakeholder involvement" dimension connects both groups. Although a concerted implementation approach across dimensions can be observed in advanced countries, others show a more uneven adoption.

CONCLUSIONS

The framework and its preliminary application to different healthcare systems demonstrate (1) the importance of coherent progress across complementing dimensions and (2) the relevance of PROM integration across clinical specialties and care sectors to strengthen patient-centered care. Overall, the framework can facilitate dialogues between stakeholders to analyze the current PROM implementation status and strategies to advance it.

Quality improvements of healthcare trajectories by learning from aggregated patient-reported outcomes: a mixed-methods systematic literature review

Background

In healthcare, analysing patient-reported outcome measures (PROMs) on an aggregated level can improve and regulate healthcare for specific patient populations (meso level). This mixed-methods systematic review aimed to summarize and describe the effectiveness of quality improvement methods based on aggregated PROMs. Additionally, it aimed to describe barriers, facilitators and lessons learned when using these quality improvement methods.

Methods

A mixed-methods systematic review was conducted. Embase, MEDLINE, CINAHL and the Cochrane Library were searched for studies that described, implemented or evaluated a quality improvement method based on aggregated PROMs in the curative hospital setting. Quality assessment was conducted via the Mixed Methods Appraisal Tool. Quantitative data were synthesized into a narrative summary of the characteristics and findings. For the qualitative analysis, a thematic synthesis was conducted.

Results

From 2360 unique search records, 13 quantitative and three qualitative studies were included. Four quality improvement methods were identified: benchmarking, plan-do-study-act cycle, dashboards and internal statistical analysis. Five studies reported on the effectiveness of the use of aggregated PROMs, of which four identified no effect and one a positive effect. The qualitative analysis identified the following themes for facilitators and barriers: (1) conceptual (i.e. stakeholders, subjectivity of PROMs, aligning PROMs with clinical data, PROMs versus patient-reported experience measures [PREMs]); (2a) methodological—data collection (i.e. choice, timing, response rate and focus); (2b) methodological—data processing (i.e. representativeness, responsibility, case-mix control, interpretation); (3) practical (i.e. resources).

Conclusion

The results showed little to no effect of quality improvement methods based on aggregated PROMs, but more empirical research is needed to investigate different quality improvement methods. A shared stakeholder vision, selection of PROMs, timing of measurement and feedback, information on interpretation of data, reduction of missing data, and resources for data collection and feedback infrastructure are important to consider when implementing and evaluating quality improvement methods in future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00893-4.

What is already known on this topic

The aggregated patient-reported outcome measures (PROMs) can be used for analytical and organizational aspects of improving and regulating healthcare, but there is little empirical evidence regarding the effectiveness of aggregated PROMS.

What this study adds

This study adds a detailed overview of the types of quality improvement methods and recommendations for implementation in practice.

How this study might affect research, practice or policy

Researchers and policy-makers should consider the barriers, facilitators and lessons learned for future implementation and evaluation of quality improvement methods, as presented in this manuscript, to further advance this field.

‘We are data rich but information poor’: how do patient-reported measures stimulate patient involvement in quality improvement interventions in Swedish hospital departments?

Objective

This study aimed to investigate if and how patient-reported measures from national and local monitoring stimulate patient involvement in hospital quality improvement (QI) interventions. We were also interested in the factors that influence the level and degree of patient involvement in the QI interventions.

Methods

The study used a qualitative, descriptive design. Inspired by the Framework Method, we created a working analytical framework. Four hospital departments participated in the data collection. Collaborating with a QI leader from each department, we identified the monitoring systems for the patient-reported measures that were used to initiate or evaluate QI interventions. Thereafter, the level and degree of patient involvement and the factors that influenced this involvement were analysed for all QI interventions. Data were mapped in an Excel spreadsheet to analyse connections and differences.

Results

Departments used patient-reported measures from both national and local monitoring systems to initiate or evaluate their QI interventions. Thirty-one QI interventions were identified and analysed. These interventions were mainly conducted at the direct care and organisational levels. By participating in questionnaires, patients were involved to the degree of consultation. Patients were not involved to the degree of partnership and shared leadership for the identified QI interventions.

Conclusions

Overall, hospital departments have limited knowledge regarding patient-reported measures and how they are best applied in QI interventions and how they support improvements. Applying patient-reported measures to hospital QI interventions does not enhance patient involvement beyond the degree of consultation.

Feedback of aggregate patient-reported outcomes (PROs) data to clinicians and hospital end users: findings from an Australian codesign workshop process

OBJECTIVES

Patient-reported outcomes (PROs) are increasingly used to measure the patient's perspective of their outcomes following healthcare interventions. The aim of this study was to determine the preferred formats for reporting service-level PROs data to clinicians, researchers and managers to support greater utility of these data to improve healthcare and patient outcomes.

SETTING

Healthcare professionals receiving PRO data feedback at the health service level.

PARTICIPANTS

An interdisciplinary Project Working Group comprised of clinicians participated in three workshops to codesign reporting templates of summarised PRO data (modified Rankin Scale, EuroQol Five Dimension Descriptive System, EuroQol Visual Analogue Scale and Hospital Anxiety and Depression Scale) using a modified Delphi process. An electronic survey was then distributed to short list the preferred templates among a broad sample of clinical end users. A final workshop was undertaken with the Project Working Group to review results and reach consensus on the final templates.

PRIMARY AND SECONDARY OUTCOME MEASURES

The recommendation of preferred PRO summary data feedback templates and guiding principles for reporting aggregate PRO data to clinicians was the primary outcome. A secondary outcome was the identification of perceived barriers and enablers to the use of PRO data in hospitals. For each outcome measure, quantitative and qualitative data were summarised.

RESULTS

31 Working Group members (19 stroke, 2 psychology, 1 pharmacy, 9 researchers) participated in the workshops, where 25/55 templates were shortlisted for wider assessment. The survey was completed by 114 end users. Strongest preferences were identified for bar charts (37/82 votes, 45%) and stacked bar charts (37/91 votes, 41%). At the final workshop, recommendations to enhance communication of PROs data for comparing health service performance were made including tailoring feedback to professional roles and use of case-mix adjustment to ensure fair comparisons.

CONCLUSIONS

Our research provides guidance on PROs reporting for optimising data interpretation and comparing hospital performance.

Classifying outcomes in secondary and tertiary care clinical quality registries-an organizational case study with the COMET taxonomy

BACKGROUND

The choice of what patient outcomes are included in clinical quality registries is crucial for comparable and relevant data collection. Ideally, a uniform outcome framework could be used to classify the outcomes included in registries, steer the development of outcome measurement, and ultimately enable better patient care through benchmarking and registry research. The aim of this study was to compare clinical quality registry outcomes against the COMET taxonomy to assess its suitability in the registry context.

METHODS

We conducted an organizational case study that included outcomes from 63 somatic clinical quality registries in use at HUS Helsinki University Hospital, Finland. Outcomes were extracted and classified according to the COMET taxonomy and the suitability of the taxonomy was assessed.

RESULTS

HUS clinical quality registries showed great variation in outcome domains and in number of measures. Physiological outcomes were present in 98%, resource use in all, and functioning domains in 62% of the registries. Patient-reported outcome measures were found in 48% of the registries.

CONCLUSIONS

The COMET taxonomy was found to be mostly suitable for classifying the choice of outcomes in clinical quality registries, but improvements are suggested. HUS Helsinki University Hospital clinical quality registries exist at different maturity levels, showing room for improvement in life impact outcomes and in outcome prioritization. This article offers an example of classifying the choice of outcomes included in clinical quality registries and a comparison point for other registry evaluators.

Predictors of health-related quality of life after cardiac surgery: a systematic review

BACKGROUND

Health-related quality of life (HRQoL) is important in determining surgical success, particularly from the patients' perspective.

AIMS

To identify predictors for HRQoL outcome after cardiac surgery in order to identify potentially modifiable factors where interventions to improve patient outcomes could be targeted.

METHODS

Electronic databases (including MEDLINE, CINAHL, Embase) were searched between January 2001 and December 2020 for studies determining predictors of HRQoL (using a recognised and validated tool) in adult patients undergoing cardiac surgery. Data extraction and quality assessments were undertaken and data was summarised using descriptive statistics and narrative synthesis, as appropriate.

RESULTS

Overall, 3924 papers were screened with 41 papers included in the review. Considerable methodological heterogeneity between studies was observed. Most were single-centre (75.6%) prospective observational studies (73.2%) conducted in patients undergoing coronary artery bypass graft (CABG) (n = 51.2%) using a version of the SF-36 (n = 63.4%). Overall, 103 independent predictors (62 pre-operative, five intra-operative and 36 post-operative) were identified, where 34 (33.0%) were reported in more than one study. Potential pre-operative modifiable predictors include alcohol use, BMI/weight, depression, pre-operative quality of life and smoking while in the post-operative period pain and strategies to reduce post-operative complications and intensive care and hospital length of stay are potential therapeutic targets.

CONCLUSION

Despite a lack of consistency across studies, several potentially modifiable predictors were identified that could be targeted in interventions to improve patient or treatment outcomes. This may contribute to delivering more person-centred care involving shared decision-making to improve patient HRQoL after cardiac surgery.

Quality of Cancer Care in Switzerland: Going Beyond Traditional Quality Indicators by Collecting Patient-Reported Experiences of Cancer Care

Background: High-quality cancer care should be effective, safe, accessible, efficient, equitable, and responsive to patients’ needs. In Switzerland, information on the safety and effectiveness of cancer care is available, but not on responsiveness. Systematic and comprehensive reports from patients on cancer care are missing and needed to complete the assessment of the quality of cancer care.

Evidence: Patient-reported experiences of cancer care are key to evaluate responsiveness of care and drive quality improvement initiatives in oncology practice. Studies have found that responsive care leads to more positive experiences of care, which can lead to more effective treatments and health benefits.

Policy Options and Recommendations: Our first recommendation is to develop a position statement on the importance and value of patient-reported experiences of cancer care. Our second recommendation is to systematically collect patients’ experiences of cancer care at the national level, through a dedicated national cancer-specific measurement program or through the integration of patient-reported experiences measures in cancer registries.

Conclusion: The systematic collection of patient-reported experiences of cancer care provides essential information on what matters to patients in addition to traditional clinical information, including patients as partners of the overall assessment of healthcare performance.

Improved 60-day survival but impaired general health in Swedish ICU-COVID patients: An ambidirectional population-based study

Background

Survival among critically ill COVID‐19 patients varies between countries and time periods. Mortality rates up to 60% have been reported in intensive care units (ICUs). Standard‐of‐care has evolved throughout the pandemic. The purpose of the study was to explore management and mortality of COVID‐19 ICU‐patients during the first pandemic wave and assess their post‐ICU health status.

Methods

We conducted an exploratory observational ambidirectional population‐based study of ICU‐patients with COVID‐19 in a Swedish county during 1 March‐30 June 2020. Primary outcome was 60‐day mortality with secondary outcomes including treatments, complications, self‐reported general health and dyspnoea post‐discharge. Patients were consecutively divided into equal tertiles with cut‐offs on April 4 and April 20, 2020, to analyse time trends.

Results

One hundred patients, median age was 63 years, were included, and 60‐day mortality rate was 22%. Ninety‐one percent had moderate/severe ARDS and 88% required mechanical ventilation. In the first tertile of patients 60‐day mortality was 33%, declining to 15% and 18% in the following two. This reduction paralleled increased use of thromboprophylaxis, less steep rise of treated ICU‐patients per day and expanded ICU resources. Four months post‐discharge, 63% of survivors reported self‐assessed decline in general health retrospectively compared to prior COVID‐19.

Conclusions

In this cohort, the initial 60‐day mortality quickly declined, despite continuous admittance of critically ill patients. This was parallel to adaptation to increased workload and more intense thromboembolic prophylaxis. A majority of survivors reported declined general health four months after discharge. Further studies on long‐term health status of ICU‐survivors are indicated.

Diagnostik und Therapie aus der Patientenperspektive - PROMs in der Chirurgie

Die zunehmend an Bedeutung gewinnenden Patient reported Outcome and Experience Measures (PROMs/PREMs) können in allen chirurgischen Disziplinen zusätzlich zu den klassischen harten Endpunkten wie z. B. Überlebenskurven und Implantatestandzeiten wichtige Informationen zu Qualitätsindikatoren oder Entscheidungshilfen zu konkurrierenden Therapieverfahren liefern. Dies gilt ebenso für die Evaluation neuer Therapiekonzepte wie für Vergleiche klassisch offener Zugangswege und minimalinvasiver bzw. endoskopischer Verfahren z. B. im Hinblick auf geringere Zugangsmorbidität und schnellere Rehabilitation vs. höherem Komplikationsrisiko, aber auch der Risiko-Nutzen-Bewertung der Verlängerung der Lebenszeit einerseits auf Kosten einer Beeinträchtigung der Lebensqualität andererseits.

Diesem Zusatznutzen steht ein notwendiger Ressourceneinsatz (Personal- und Sachkosten für Postversand oder für eine Onlineerhebung in Form von Entwicklungs-, Bereitstellungs- oder Lizenz- und Servicekosten) gegenüber, der sich nur bedingt beeinflussen lässt (z. B. Portokosten für eine Vollerhebung vs. repräsentative Stichprobe). Die zentrale Voraussetzung für den erfolgreichen Einsatz von PROMs und PREMs ist jedoch, dass geeignete, sprachlich und inhaltlich validierte Erhebungsinstrumente verfügbar sind oder durch einen Validierungsprozess zur Verfügung gestellt werden können.

Für den Einsatz von PROMs bei konkurrierenden Therapieansätzen findet sich bereits eine Reihe von Beispielen, die wertvolle Unterstützung bieten und sich im Klinikalltag etabliert haben. So können sie bei belastenden Therapieansätze in der chirurgischen Tumortherapie bei Entscheidungen über ein verbessertes Überleben bei starker Belastung vs. dem Erhalt oder sogar Zugewinn an Lebensqualität unterstützen. In der onkologischen Mammachirurgie steht die Lebensqualität bei brusterhaltendem Vorgehen häufig der Überlebenszeit bezogen auf das TU-Stadium bei Ablation gegenüber. Ebenso gilt es bei Prostatakarzinompatienten, immer wieder zwischen invasiver Therapie und Verlaufsbeobachtung (Überleben vs. Inkontinenz und Potenzstörungen) zu entscheiden. In der Orthopädie/Unfallchirurgie gibt es bei einer Reihe von Eingriffen häufig eine Alternative, z. B. Sprunggelenkendoprothesen vs. Arthrodesen oder inverse Schulterprothesen vs. Osteosynthese bei schultergelenknahen Humerusfrakturen.

Aber auch bei der Evaluation neuer Therapiekonzepte (z. B. der subjektive Aspekt einer früheren Wiedererlangung der Selbstständigkeit durch Einführung neuer Nachbehandlungskonzepte/sog. Fast-Track-Reha) sind PROMs und PREMS wichtige Werkzeuge.

Comparison of EQ-5D-3L and 5L versions following operative fixation of closed ankle fractures

Purpose

To undertake the first testing and comparison of measurement properties for the EuroQol EQ-5D-3L and 5L in patients with ankle problems.

Methods

The cross-sectional postal survey of 959 patients aged ≥ 18 years, who underwent surgical treatment (ORIF) for unstable and closed ankle fractures in Eastern Norway. Both the EQ-5D-3L and 5L were included in a postal questionnaire in 2015, 3–6 years post surgery. Missing data, floor and ceiling effects, and response consistency were assessed. Tests of validity included comparisons with scores for the SF-36 and widely used ankle-specific instruments. The 5L version was assessed for test–retest reliability.

Results

There were 567 (59%) respondents; 501 completed both versions and 182 (61%) the 5L retest questionnaire. The 5L outperformed the 3L in tests of data quality and classification efficiency. Correlations with scores for other instruments largely met expectations, those for the 5L being slightly higher. All 5L scores had acceptable levels of reliability. For the 5L index, the smallest detectable differences for group and individual comparisons were 0.02 and 0.20, respectively.

Conclusion

The 5L outperformed the 3L in terms of data quality, number of health states assessed and tests of validity. The 5L is recommended in research and other applications following surgery for ankle fracture but further testing including responsiveness to change is recommended at clinically relevant follow-up periods.

Evaluation of the acceptability of patient-reported outcome measures in women following pelvic floor procedures

PURPOSE

Patient-reported outcome measures (PROMs) are valuable tools in evaluating the outcomes of surgical treatment health-related quality of life (HRQoL) of women with stress urinary incontinence (SUI) and may be incorporated into related clinical quality registries. The aim of this study was to assess the feasibility and acceptability of incorporating PROMs into the Australian Pelvic Floor Procedure Registry (APFPR).

METHODS

Semi-structured qualitative interviews were conducted with women with SUI (N = 12) and their managing clinicians (N = 11) in Victoria, Australia. Interview topics covered content and face validity, appropriateness, and acceptability of three incontinence-specific, two pain, one anxiety and depression, one sexual function and one patient global impression of improvement instruments identified through the literature to determine their suitability and acceptability for the APFPR. We analysed interview data into topics using conventional content analysis.

RESULTS

Study participants agreed that PROMs were needed for the APFPR. Both participant groups suggested that some of the instruments were ambiguous, therefore only three instruments (one incontinence-specific, sexual function and patient global impression of improvement) will be included in the APFPR. Both clinicians and women agreed it would be appropriate to answer PROMs at baseline and then at 6- and 12-month postsurgically. Email, phone call and mail-out of the instruments were the preferred options for administration.

CONCLUSION

Most women and clinicians supported the feasibility of incorporating PROMs in the APFPR. Participants believed the PROMs would demonstrate useful aggregate HRQoL data and have potential for use in individual care.

Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders

PURPOSE OF REVIEW

To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.

Effects of Systemic Enzyme Supplements on Symptoms and Quality of Life in Patients with Pulmonary Fibrosis-A Pilot Study

Current FDA-approved antifibrotic treatments for Idiopathic Pulmonary Fibrosis slow down disease progression but have little impact on symptoms or quality of life in patients. This study was conducted to evaluate the effects of systemic enzymes in relieving symptoms associated with PF and improving quality of life.

METHODS

an open-label, prospective study on subjects with a confirmed diagnosis of PF was conducted as proof-of-concept. The subjects (n = 13) received the oral systemic enzyme supplements Serracor-NK and Serra Rx for 12 weeks and completed Health-Related Quality of Life (HRQL) questionnaires. The effect of this regimen was examined by comparing the end-of-treatment questionnaire scores with baseline values.

RESULTS

significant improvement was seen in 61.5% of subjects, as assessed by the WHO well-being index; an improvement in scores was seen in 84.6% of the subjects, as assessed by the UCSD Shortness of Breath Questionnaire, with 38.4% of the subjects showing minimal clinically important difference; the supplementation was found to be efficacious in 69.2%, 84.6%, 69.2% and 61.5% of the subjects, as assessed by the Saint George's Respiratory Questionnaire total, symptom, activity, and impact scores, respectively.

CONCLUSIONS

Serracor-NK and Serra Rx improve symptoms, as well as mental and physical wellbeing and HRQL in patients with PF.

Digital Patient-Reported Outcome Measures for Monitoring of Patients on Cancer Treatment: Cross-sectional Questionnaire Study

BACKGROUND

Oncology has been facing increasing outpatient activity associated with higher cancer incidence, better survival rates, and more treatment options. Innovative technological solutions could help deal with this increasing demand. Using digital patient-reported outcome measures (PROMs) to identify patients who need a face-to-face (FTF) appointment is a potential approach.

OBJECTIVE

This study aims to assess the feasibility of digital PROM questionnaires to enable remote symptom monitoring for patients undergoing cancer treatment and their ability to highlight the requirement for an FTF appointment.

METHODS

This study was performed at a tertiary oncology center between December 2018 and February 2019. The Common Terminology Criteria for Adverse Events were adapted into patient-friendly language to form the basis of treatment-specific digital questionnaires covering specific cancer drugs and radiotherapy treatments. These treatment-specific digital PROM questionnaires were scored by both patients and their clinicians during FTF appointments. Patients and clinicians did not see each other's scored PROMs. Agreement between patients and clinicians was assessed using descriptive statistics. Patient and staff feedback was also obtained.

RESULTS

In total, 90 patients participated in the study across 10 different treatment pathways. By comparing paired patient and clinician responses, the sensitivity of the patient-completed questionnaires in correctly highlighting the need for FTF review was 94% (44/47), and all patients with severe or grade 3+ symptoms were identified (6/6, 100%). Patient-completed PROMs appropriately revealed that 29% (26/90) of the participating patients did not need FTF review based on their symptoms alone. Certain oncological treatment pathways, such as immunotherapy, were found to have a larger proportion of patients with minimal symptoms than others, such as conventional chemotherapy. Patient and staff feedback showed high approval of digital PROMs and their potential for use in remote monitoring.

CONCLUSIONS

Digital PROM questionnaires can feasibly highlight the need for FTF review in oncology clinics for treatment. Their use with specific treatments could safely reduce the requirement for FTF care, and future work should evaluate their application in the remote monitoring of patients.

The Swedish RAND-36: psychometric characteristics and reference data from the Mid-Swed Health Survey

BACKGROUND

This study aims to evaluate data quality, scaling properties, and reliability of the Swedish RAND-36 in a general population sample and to present reference data for the Swedish population.

METHODS

Testing of data quality, scaling assumptions and reliability followed methods recommended for the International Quality of Life Assessment Project, previously used for psychometric testing of SF-36 and RAND-36. Data were collected via regular mail for a random stratified sample of the general population in a Swedish county. Weighted means for RAND-36 scores were used and differences by sex, age, education, and occupational groups were tested.

RESULTS

The response rate was 42%, and the sample comprised 3432 persons (45% men, 55% women) with a median age of 56.9 years. The internal consistency reliability was satisfactory, with Cronbach's alphas > 0.80 for all eight scales. The percentage of missing items was low, ranging between 1.3% and 3.2%. No floor effects (≥15%) were noted, while ceiling effects were observed for physical functioning, role-functioning/physical, pain, role-functioning/emotional, and social functioning. Item-scale correlations were satisfactory (r ≥ 0.40). Correlations among the physical health scales were strong (range 0.58-0.68) as were the correlations among the mental health scales (range 0.58-0.73). Men reported significantly better health-related quality of life (HRQoL) on all scales, although the gender differences were small. Comparisons among age groups showed approximately equal scores among those 20-29, 30-39, and 40-49 years, while significant decreases in physical health were observed in the older age groups. Substantially worse physical health scores were observed in the oldest age group (80+). Significant differences among age groups were noted also for the mental health scales; however, better energy/fatigue and emotional well-being scores were seen in the older age groups, except for the oldest (80+). Those with university education reported significantly better scores on all scales compared to those with mandatory education.

CONCLUSIONS

The study suggests that the Swedish version of RAND-36 is an acceptable and reliable instrument for measuring HRQoL in the general population. The study provides reference data that can be used for norm-based comparisons.

Acceptability of patient reported outcome measures (PROMs) in a cystic fibrosis data registry

Introduction

Improvements in the treatment of cystic fibrosis (CF) have resulted in longer survival and an increased focus on optimising daily functioning with the condition. Patient-reported outcome measures (PROMs) are valuable tools in evaluating the health-related quality of life of persons with chronic diseases. PROMs may be incorporated into clinical registries to assess and provide feedback regarding the health-related quality of life of the affected population. This study uses qualitative methodology to describe the views of patients with CF, caregivers and clinicians on the usefulness and practicality of incorporating a PROM in the Australian Cystic Fibrosis Data Registry (ACFDR).

Methods

We conducted semistructured interviews with a convenience sample of patients with CF (n=5), caregivers (n=7) and clinicians (n=13) on their opinions on incorporating the Cystic Fibrosis Questionnaire-Revised or the Cystic Fibrosis Quality of Life Questionnaire into the ACFDR. We analysed data into topics and subtopics using conventional content analysis.

Results

Participants believed that PROMs could generate useful aggregate health-related quality of life data to support better understanding of the experiences of the modern CF population. Participants emphasised that implementation must be supported by processes to feedback data to patients and clinicians. Most participants preferred electronic PROMs administration for easy integration into existing systems and the potential to support feedback.

Conclusion

Patients, caregivers and clinicians in this study generally supported the usefulness and practicality of PROM implementation in the ACFDR.

Norwegian population norms for the EQ-5D-5L: results from a general population survey

Purpose

To provide the first Norwegian EQ-5D-5L and EQ VAS population norms for the adult general population.

Methods

Postal survey of a random sample of 12,790 Norwegians identified through the National Registry of the Norwegian Tax Administration. Norms, weighted for Norwegian general population characteristics, are shown for the five EQ-5D-5L dimensions, EQ-5D index, and EQ VAS scores for seven age categories, females, males, and education level.

Results

There were 3200 (25.9%) respondents to 12,263 correctly addressed questionnaires. The EQ-5D-5L dimensions, EQ VAS, and background questions were completed by 3120 (24.6%) respondents. The mean age (SD) was 50.9 (21.7) and range was 18–97 years. The youngest age group of 18–29 years and oldest of 80 years and over had the highest (n = 691) and lowest (n = 239) number of respondents, respectively. Compared to the general population, the respondents comprised a greater number of females, younger and older ages, and had a higher education level. 32% of respondents reported no health problems on the EQ-5D-5L. From the youngest to oldest age groups, there was a general decline in health as assessed by the EQ-5D-5L. The exception was for anxiety/depression, where the youngest age groups had the poorest health. Apart from self-care, women reported poorer health than men, as assessed by the EQ-5D-5L; EQ VAS scores were similar for men and women. Higher levels of health (EQ-5D index, EQ VAS scores) were found with increasing levels of education.

Conclusion

The population norms will improve interpretation of EQ-5D-5L and EQ VAS scores in Norwegian applications including clinical practice, clinical and health services research, and national quality registers where EQ-5D-5L is the most widely used patient-reported instrument.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02938-7.

"Can Someone as Young as You Really Feel That Much Pain?" - A Survey on How People With Fibromyalgia Experience Healthcare in Sweden

Research show that fibromyalgia has low credibility in healthcare, leading to poor treatment, lack of knowledge and disinterest. Therefore, people with fibromyalgia feel frustration, fear, anxiety and disappointment.

Objective: The aim of this study was to explore the experiences of people with fibromyalgia in their encounters with healthcare personnel in Sweden.

Method: A cross-sectional design, where 409 people with fibromyalgia answered an anonymous online patient-reported experience measure, developed specific for the study, with six closed questions and one open-ended question. Descriptive statistics were analysed by response frequencies. Correlation analysis were performed between demographic and clinical variables with the answers from the closed questions. Free-text answers were analysed with content analysis.

Results: A third experienced the treatment as bad (34%) and that they were not being taken seriously (30.5%). Almost half (47%) always or mostly felt fear of seeking healthcare related to fibromyalgia and that the health care personnel did not understand their diagnosis (46%). The majority (54%) experienced that the health care personnel did not understand how fibromyalgia affected them or how they could help them. The findings were confirmed in the free-text answers that were categorized into: Scepticism and disregard, Ignorance and disinterest and Professionalism and empathy. There were positive significant correlations between age and five of the questions (ρ = .105–.181, p < .05–p < .01), indicating that lower age is correlated with a worse experience. Furthermore, the duration of fibromyalgia showed a significant correlation with feeling afraid of seeking healthcare because of fibromyalgia (ρ = .144, p < .01), the shorter duration, the greater was the fear of seeking healthcare.

Conclusion: As a third of patients with fibromyalgia had bad experiences with healthcare, especially younger patients, knowledge about fibromyalgia needs to be increased and the patients should be taken seriously and treated respectfully, as well as given adequate support.

Evaluation of the EQ-5D-3L and 5L versions in low back pain patients

Background

The EuroQol EQ-5D is one of the most widely researched and applied patient-reported outcome measures worldwide. The original EQ-5D-3L and more recent EQ-5D-5L include three and five response categories respectively. Evidence from healthy and sick populations shows that the additional two response categories improve measurement properties but there has not been a concurrent comparison of the two versions in patients with low back pain (LBP).

Methods

LBP patients taking part in a multicenter randomized controlled trial of lumbar total disc replacement and conservative treatment completed the EQ-5D-3L and 5L in an eight-year follow-up questionnaire. The 3L and 5L were assessed for aspects of data quality including missing data, floor and ceiling effects, response consistency, and based on a priori hypotheses, associations with the Oswestry Disability Index (ODI), Pain-Visual Analogue Scales and Hopkins Symptom Checklist (HSCL-25).

Results

At the eight-year follow-up, 151 (87%) patients were available and 146 completed both the 3L and 5L. Levels of missing data were the same for the two versions. Compared to the EQ-5D-5L, the 3L had significantly higher floor (pain discomfort) and ceiling effects (mobility, self-care, pain/discomfort, anxiety/depression). For these patients the EQ-5D-5L described 73 health states compared to 28 for the 3L. Shannon’s indices showed the 5L outperformed the 3L in tests of classification efficiency. Correlations with the ODI, Pain-VAS and HSCL-25 were largely as hypothesized, the 5L having slightly higher correlations than the 3L.

Conclusion

The EQ-5D assesses important aspect of health in LBP patients and the 5L improves upon the 3L in this respect. The EQ-5D-5L is recommended in preference to the 3L version, however, further testing in other back pain populations together with additional measurement properties, including responsiveness to change, is recommended.

Trial registration: retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT01704677.

Recent Trends in Patient Registries for Health Services Research

Background  Patient registries are an established methodology in health services research. Since more than 150 years, registries collect information concerning groups of similar patients to answer research questions. Elaborated recommendations about an appropriate development and an efficient operation of registries are available. However, the scene changes rapidly.

Objectives  The aim of the study is to describe current trends in registry research for health services research.

Methods  Registries developed within a German funding scheme for model registries in health services research were analyzed. The observations were compared with recent recommendations of the Agency for Healthcare Research and Quality (AHRQ) on registries in the 21st century.

Results  Analyzing six registries from the funding scheme revealed the following trends: recruiting healthy individuals, representing familial or other interpersonal relationships, recording of patient-reported experiences or outcomes, accepting participants as study sites, active informing of participants, integrating the registry with other data collections, and transferring data from the registry to electronic patient records. This list partly complies with the issues discussed by the AHRQ. The AHRQ structured its ideas in five chapters, increasing focus on the patient, engaging patients as partners, digital health and patient registries, direct-to-patient registry, and registry networks.

Conclusion  For the near future, it can be said that the concept and the design of a registry should place the patient in the center. Registries will be increasingly linked together and interconnected with other data collections. New challenges arise regarding the management of data quality and the interpretation of results from less controlled settings. Here, further research related to the methodology of registries is needed.

The role of kidney registries in expediting large-scale collection of patient-reported outcome measures for people with chronic kidney disease

In this issue of Clinical Kidney Journal, Van der Willik et al. report findings from a pilot study where they introduced collection of patient-reported outcome measures (PROMs) into routine kidney care in Dutch dialysis centres. It is comparable to a registry-led PROMs initiative in Sweden, published in Clinical Kidney Journal in 2020. Both studies reported low average PROMs response rates with substantial between-centre variation, and both identified suboptimal patient and staff engagement as a key barrier to implementing PROMs in routine care for people with chronic kidney disease (CKD). This suggests that national kidney registries could be well placed to facilitate large-scale collection of PROMs data, but that they may require additional guidance on how to do this successfully. In this editorial, we discuss the current state-of-play of PROMs collection by kidney registries and provide an overview of what is (un)known about the feasibility and effectiveness of PROMs in CKD and other conditions. We anticipate that the fast-growing evidence base on whether, and how, PROMs can be of value in CKD settings will expedite registry-based PROMs collection, which will ultimately lead to more valuable and person-centred services and to enhanced health and well-being of people with CKD.

Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study

BACKGROUND

The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting.

METHODS

In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone  <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction.

RESULTS

From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age  >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital.

CONCLUSIONS

Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.

Adaptation of Coping Effectiveness Training for Patients With Heart Failure and Patient-Reported Experience of the Intervention

Although patients with chronic heart failure (CHF) often experience psychological distress, psychosocial aspects are not an integral part of their treatment and care. The aim is to describe the adaptation of Coping Effectiveness Training for patients with CHF and the participants’ reported experiences. The intervention workbook and manual were translated into Swedish and adapted for patients with CHF. Patient-reported experience from 33 of 35 participants, that had completed the psychosocial intervention, was measured with an evaluation form consisting of closed and open-ended questions. Most participants thought they benefited from the intervention, were pleased with the structure and did not want to add anything to the program. The benefits experienced were learning how to cope with the illness and meeting other people to share and discuss experiences. There was a variation concerning the group process of how much direction should be given during the discussions. Overall, unique data from patient-reported experience measure showed that the participants were satisfied with the psychosocial intervention, applied for the first time to patients with CHF.

First steps in PROMs and PREMs collection in Wales as part of the prudent and value-based healthcare agenda

Purpose

Patients are experts in their own health and should be treated as equal partners in their care. Patient-reported outcome measures (PROMs) are an effective way of gathering patient feedback and can facilitate effectiveness and cost-effectiveness analysis to improve decision making and service improvement. The PROMs, PREMs & Effectiveness Programme was initiated in 2016 and aimed to develop an electronic platform to facilitate collection of PROMs and Patient-reported experience measures (PREMs) from secondary care patients across Wales.

Methods

We worked with all Health Boards in Wales, the NHS Wales Informatics Service (NWIS), and Cedar (a healthcare technology research centre) to identify and meet technical requirements to develop a platform which is fit for purpose. Patient groups were included throughout the development to gather feedback and for extensive testing. Clinical teams helped identify the most appropriate tools, with licences, translations and electronic formatting issues being managed centrally.

Results

The developed platform is integrated with patient administration systems minimising the need for manual input, with processes in place to allow automatic collection triggers according to nationally agreed schedules. We have over 30 nationally agreed PROMs ‘pathways’ with over 110,000 PROMs collected to date. Responses are fed back to clinicians via the electronic patient record and to each health board via feeds to the national data warehouse, making data easily accessible to different teams, maximising use and application.

Discussion

The national platform has provided a co-ordinated approach to PROMs collection in Wales, offering an effective means of communicating with patients outside the traditional clinic visit.

Collection and use of EQ-5D for follow-up, decision-making, and quality improvement in health care - the case of the Swedish National Quality Registries

BACKGROUND

The Swedish National Quality Registries (NQRs) contain individual-level health care data for specific patient populations, or patients receiving specific interventions. Approximately 90% of the 105 Swedish NQRs include any patient-reported outcome measure, with EQ-5D being the most common. As there has been no general overview of EQ-5D data within the NQRs, this study fills a knowledge gap by reporting how the data are collected, presented, and used at different levels of the Swedish health care system.

METHODS

All 46 NQRs with a license for the use of EQ-5D were included. Information was retrieved from the registries' annual reports or from websites, using a template that was subsequently sent to each registry for completion and confirmation. If considered necessary, the contact was followed-up with an interview, either in-person or over the telephone. The uses of EQ-5D were categorised as denoting usage for follow-up, decision-making, or quality improvement in Swedish health care.

RESULTS

In total, 41 of the 46 licensed registries reported collection of EQ-5D data. EQ-5D is most commonly collected within registries related to the musculoskeletal system, but it has a wide application also in other disease areas. Thirty-six registries provide EQ-5D results to patients, clinicians, or other decision-makers. Twenty-two of the registries reported that EQ-5D data are being used for follow-up, decision-making or quality improvement. The registries most commonly reported use of data for assessing interventions, and in quality indicators to follow-up the quality of care at a national level.

CONCLUSION

Collection and use of EQ-5D data vary across the Swedish NQRs, which may partly be accounted for by the different purposes of the registries. The provided examples of use illustrate how EQ-5D data can inform decisions at different levels of the health care system. However, there is potential for improving the use of EQ-5D data.

Routine Health Outcome Measurement: Development, Design, and Implementation of the Hand and Wrist Cohort

Routine measurement of outcome of clinical care is increasingly considered important, but implementation in practice is challenging. This article describes (1) how the authors created and implemented a routine outcome measurement cohort of patients with hand and wrist conditions and (2) how these data are used to improve the quality of care and facilitate scientific research. Starting in 2011, routine outcome measurement was implemented at all practice sites (currently 22) of a specialized treatment center for hand and wrist conditions across The Netherlands. The authors developed five "measurement tracks," including measurements administered at predetermined time points covering all hand and wrist disorders and treatments. An online system automatically distributes measurements among patients, which can be accessed by health care professionals. Using this system, the total number of yearly assigned tracks increased up to over 16,500 in 2018, adding up to 85,000 tracks in 52,000 patients in total. All surgeons, therapists, and other staff have direct access to individual patient data and patients have access to their treatment information using a secure patient portal. The data serve as a basis for studies on, among others, comparative effectiveness, prediction modeling, and clinimetric analyses. In conclusion, the authors present the design and successful implementation of a routine outcome measurement system that was made feasible using a highly automated data collection infrastructure, tightly linked to the patient journey and the workflow of health care professionals. The system serves not only as a tool to improve care but also as a basis for scientific research studies.

Six and eight weeks injection frequencies of bevacizumab are non-inferior to the current four weeks injection frequency for quality of life in neovascular age-related macular degeneration: a randomized controlled trial

Purpose

Patients with neovascular age-related macular degeneration (nARMD) will not deteriorate on visual acuity and retinal thickness when treated with bevacizumab injection frequencies of 6 or 8 weeks compared to 4 weeks. This study aimed to investigate this non-inferiority in quality of life (QoL). We hypothesized that less frequent bevacizumab injections are not inferior regarding patients reported QoL.

Methods

Patients were randomized to bevacizumab every 4 (n = 64), 6 (n = 63), and 8 weeks (n = 64). Patients were at least 65 years old, have a best-corrected visual acuity of 20/200 to 20/20, no previous ARMD treatment and active leakage. Vision-related QoL questionnaire NEI VFQ-39 was used to assess QoL at baseline and after 1 year. General QoL questionnaire SF-36 was included for secondary analysis. Multilevel analyses were performed, correcting for age, gender and baseline.

Results

The 6 (3.68; 95% CI − 0.63 to 8.00) and 8 (2.15; 95% CI − 2.26 to 6.56) weeks bevacizumab regimens resulted in non-inferior QoL differences compared to 4 weeks on the NEI VFQ-39. Also on the SF-36 the differences were well within the non-inferiority limits.

Conclusion

Non-inferiority of the 6 and 8 weeks frequencies was demonstrated compared to 4 weeks on vision-related and general QoL in patients with nARMD. These results are in line with previously published results of lower frequency injections regarding visual acuity and central retinal thickness. Lower injection frequency may reduce burden, side effects, and treatment costs. In consideration of these results, 8 weeks frequency injections of intravitreal bevacizumab could be considered in patients with nARMD.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02580-9) contains supplementary material, which is available to authorized users.

Evaluation of the usefulness of EQ-5D as a patient-reported outcome measure using the Paretian classification of health change among patients with chronic heart failure

PURPOSE

The aim of this study was to evaluate the usefulness of EQ-5D as a patient-reported outcome measure using different analytical methods. Especially we used the Paretian Classification of Health Change, to see if this gave better information compared to measures that are more traditional. For the evaluation we used data from patients with chronic heart failure (HF).

METHODS

We compared results of EQ-5D at baseline and at 1 year's follow up for HF patients with preserved or reduced ejection fraction (EF), HFpEF (EF > 50%, n = 930) and HFrEF (EF < 40%, n = 3831) using individual patient data from the Swedish Heart Failure Registry. Statistical analysis included EQ-5D index and proportions for all five dimensions of the EQ-5D. In addition, we also used the Paretian classification of Health Change to judge overall improvements (improved in at least one dimension and not worsened in any other dimension) or worsening (vice versa) in EQ-5D profiles.

RESULTS

Mean EQ-5D index showed minor changes at the one-year follow-up, likewise in both groups. The proportions reporting moderate, or severe, problems increased for all five dimensions of the EQ-5D in the HFpEF group. In the HFrEF group this was seen only for three dimensions, with no change for "anxiety/depression" and reduction of problems for "usual activities ". The Paretian classification showed that 24% (n = 200) of the HFpEF group and 34% (n = 1059) of the HFrEF group reported overall improvement while 43% (n = 355) and 39% (n = 1212) respectively reported overall worsening. Multiple logistic regressions showed different patterns of determinants e.g. that treatment in a cardiology clinic only affected overall health outcome in the HFrEF group.

CONCLUSION

The usefulness of EQ-5D is dependent on the analytical method used. While the index showed minor differences between groups, analyses of specific dimensions showed different patterns of change in the two groups with better prognosis for the HFrEF group. The Paretian classification of Health Change could further identify subgroups that showed overall improvements or overall worsening. This method can therefore help to identify needs for more tailored interventions in health services.

Elicitation of Norwegian EQ-5D-5L values for hypothetical and experience-based health states based on the EuroQol Valuation Technology (EQ-VT) protocol

INTRODUCTION

Norway is one of several European countries that lacks a national value set and scoring algorithm for the EuroQol five dimensions (EQ-5D). Recent studies have found differences between countries in terms of health values or preferences for health states described by instruments such as the EQ-5D. The project aims to model a national value set for the five level version of the EQ-5D based on values elicited from a representative sample of the Norwegian adult general population in terms of region, age, sex and level of education. Using a sampling strategy supporting the collection of values for both hypothetical and experienced health states, the study will have the additional aim of assessing the feasibility of collecting experience-based values in accordance with the latest EQ-5D valuation study protocol, and comparing values with those given for hypothetical health states.

METHODS AND ANALYSIS

Multistage random sampling and quota-sampling will contribute to representativeness. To increase the number of valuations of experienced health states, those with less than perfect health will be oversampled, increasing the total number of interviews from 1000 to 1300-1500. The most recent EQ-5D valuation protocol will be followed which includes computer assisted face-to-face, one-to-one interviews and use of composite time trade-off and discrete choice experiments.

ETHICS AND DISSEMINATION

The study has been reviewed and found to be outside of the scope of the ethics committee and thus not in need of ethical approval. The study findings will be disseminated through peer-reviewed publications, conference presentations and summaries for key stakeholders and partners in the field. The scoring algorithms will be available for widely used statistical software.

Establishment of a National Hand Surgery Data Registry: An Avenue for Quality Improvement

Considerable variation exists in the practice of hand surgery that may lead to wasteful spending and less than optimal quality of care. Hand surgeons can benefit from a centralized system that tracks process and outcome measures, delivers national benchmarking, and encourages the sharing of knowledge. A national registry can fulfill these needs for hand surgeons and incorporate quality improvement into their daily routine. Leaders in hand surgery should convene to appraise the organization of a national registry for their field and reach consensus on how the registry can be designed and funded.