Patient focused registries can improve health, care, and science

An environmental scan of limb loss rehabilitation centers across Canada

BACKGROUND

The clinical landscape of limb loss rehabilitation across Canada is poorly delineated, lacks standard rehabilitation guidelines, and is without a shared clinical database.

OBJECTIVE

To address these gaps, the objective of the present study was to undertake an environmental scan of the rehabilitation centers across Canada that provide inpatient and/or outpatient services to the limb loss community.

STUDY DESIGN

An environmental scan was conducted to describe the rehabilitation service structure, program services, and outcome measures of sites across Canada.

METHODS

A survey was sent to 36 rehabilitation centers providing care to people with amputations.

RESULTS

Of the 36 centers, 31 completed the survey (11 = Ontario; 8 = Quebec; 6 = British Columbia; 2 = Saskatchewan; 2 = New Brunswick; 1 = Alberta; 1 = Manitoba). Twenty-five provided both inpatient and outpatient services, 1 provided inpatient care only, and 5 provided only outpatient services. Interprofessional services were provided to a wide range of upper extremity amputation and lower extremity amputation patient populations. Range of motion was the most commonly collected outcome for both patients with upper extremity amputation and lower extremity amputation. With regard to prosthetics and orthotics fabrication, 9 of the sites had these services on-site while 15 had off-site fabricators, 6 had both, and 1 provided no response.

CONCLUSIONS

Our findings highlight that limb loss rehabilitation and prosthetic care delivery is variable across Canada with respect to clinical team members, locations of services, and complementary services such as mental health treatments and peer support groups.

Döhmann I, Rüping S, Burkhardt H, Köhm M, Dauth S. Sharing for Caring? A Patients' and Clinicians' View on Handling Personal Medical Data in the Context of Digitization: An Exploratory Study

BACKGROUND

The healthcare sector is currently undergoing a significant transformation, driven by an increased utilization of data. In this evolving landscape, surveys are of pivotal importance to the comprehension of patient needs and preferences. Moreover, the digital affinity of patients and physicians within the healthcare system is reforming the manner in which healthcare services are accessed and delivered. The utilization and donation of data are influencing the future of medical research and treatment, while artificial intelligence (AI) is empowering patients and physicians with knowledge and improving healthcare delivery.

METHODS

In order to evaluate the opinions of patients and physicians regarding the management of personal health data and the functionality of upcoming data management devices in the context of healthcare digitization, we conducted an exploratory study and designed a survey. The survey focused on a number of key areas, including demographics, experience with digitization, data handling, the identification of needs for upcoming digitization, and AI in healthcare.

RESULTS

A total of 40 patients and 15 physicians participated in the survey. The results indicate that data security, timesaving/administrative support, and digital communication are aspects that patients associate with patient-friendly digitization. Based on the responses provided by physicians, it might be concluded that future digital platforms should prioritize usability, time efficacy, data security, and interoperability.

CONCLUSIONS

In terms of expectations for future digital platforms, there is a notable overlap between the needs expressed by patients and those identified by physicians, particularly in relation to usability, time management, data security, and digital communication. This suggests that the requirements of different stakeholders can be combined in a future system, although individual issues may still require attention.

Using Focus Groups to Evaluate a Self-Assessment Approach to Coproduction Value Creation in an International Community of Practice: Phase 2 of the CO-VALUE Study

INTRODUCTION

Coproduction learning health system models clearly define the use of clinical and patient-reported data for system learning and quality improvement, but less is known about how to document formative learning about coproduction value creation over the course of a quality improvement initiative. The authors aimed to 1) assess the feasibility, utility, and acceptability of novel self-assessment tools for coproduction value creation and 2) identify domains of coproduction value creation.

METHODS

The authors conducted 4 focus groups with quality improvement teams from 4 health systems in the United States and Sweden between June 2021 and September 2023. A single analyst coded transcripts and proposed themes, with investigator triangulation validating results.

RESULTS

Participants found the self-assessment tools acceptable and useful. The improvement passport was seen as more feasible for routine use than the full self-assessment guide. Peer learning within the community of practice, diverse multidisciplinary improvement teams, and leadership support facilitated teams' work. Domains of coproduction value creation included communication, self-efficacy, interconnectedness, direct and indirect costs of health care utilization, health professional experience, and access to the right care.

DISCUSSION

Peer learning and camaraderie within the community of practice maintained momentum among participating teams during a challenging time of limited resources and mounting responsibilities in health care settings, suggesting enhanced resiliency through approaching difficult tasks in community.

CONCLUSION

The authors identified themes of coproduction value creation and drivers of engagement. Future research will draw on the measurement domains established in this study to inform the development of measures of coproduction value creation. Those measures could then be incorporated into the data-rich environments of coproduction learning health systems to enhance focus on value from service user and professional perspectives.

A Hybrid Markov-SPC Approach to Assess Cost Differences in Urgent Care Utilization Using Patient-Reported Data in Inflammatory Bowel Disease

BACKGROUND

Cost is a key outcome in quality and value, but it is often difficult to estimate reliably and efficiently for use in real-time improvement efforts. We describe a method using patient-reported outcomes (PROs), Markov modeling, and statistical process control (SPC) analytics in a real-time cost-estimation prototype designed to assess cost differences between usual care and improvement conditions in a national multicenter improvement collaborative-the IBD Qorus Learning Health System (LHS).

METHODS

The IBD Qorus Learning Health System (LHS) collects PRO data, including emergency department utilization and hospitalizations from patients prior to their clinical visits. This data is aggregated monthly at center and collaborative levels, visualized using Statistical Process Control (SPC) analytics, and used to inform improvement efforts. A Markov model was developed by Almario et al to estimate annualized per patient cost differences between usual care (baseline) and improvement (intervention) time periods and then replicated at monthly intervals. We then applied moving average SPC analyses to visualize monthly iterative cost estimations and assess the variation and statistical reliability of these estimates over time.

RESULTS

We have developed a real-time Markov-informed SPC visualization prototype which uses PRO data to analyze and monitor monthly annualized per patient cost savings estimations over time for the IBD Qorus LHS. Validation of this prototype using claims data is currently underway.

CONCLUSION

This new approach using PRO data and hybrid Markov-SPC analysis can analyze and visualize near real-time estimates of cost differences over time. Pending successful validation against a claims data standard, this approach could more comprehensively inform improvement, advocacy, and strategic planning efforts.

A Post-Acute COVID-19 Syndrome (PACS) Clinic in Rural New England

This article explores the demand and utilization of a rural post-acute COVID syndrome clinic. Electronic health records were used to identify referrals between April 2021 and April 2022 and to describe characteristics of referred patients and referrals generated to specialty services. Of the 747 referrals received, 363 (48.6%) met the criteria for an appointment and were seen, the vast majority (89.6%) via Telehealth. Most patients resided in rural communities (63.1%) and were female (75.2%); mean age was 49, and 17% were hospitalized during their acute illness. Nearly half of patients (49%) had at least one pre-existing mental health diagnosis. Referrals to specialty care for further evaluation and/or intervention were most commonly to occupational therapy (27.3%), physical therapy (24.8%), psychiatry (19.8%), and neurology (17%). Telehealth expanded the availability of health care resources. Additional research on how to meet care needs, ameliorate symptoms, and aid recovery in rural communities is warranted.

Implementation of a Co-Design Strategy to Develop a Dashboard to Support Shared Decision Making in Advanced Cancer and Chronic Kidney Disease

Background: Shared decision making (SDM) is the process by which patients and clinicians exchange information and preferences to come to joint healthcare decisions. Clinical dashboards can support SDM by collecting, distilling, and presenting critical information, such as patient-reported outcomes (PROs), to be shared at points of care and in between appointments. We describe the implementation strategies and outcomes of a multistakeholder collaborative process known as "co-design" to develop a PRO-informed clinical dashboard to support SDM for patients with advanced cancer or chronic kidney disease (CKD). Methods: Across 14 sessions, two multidisciplinary teams comprising patients, care partners, clinicians, and other stakeholders iteratively co-designed an SDM dashboard for either advanced cancer (N = 25) or CKD (N = 24). Eligible patients, care partners, and frontline clinicians were identified by six physician champions. The co-design process included four key steps: (1) define "the problem", (2) establish context of use, (3) build a consensus on design, and (4) define and test specifications. We also evaluated our success in implementing the co-design strategy using measures of fidelity, acceptability, adoption, feasibility, and effectiveness which were collected throughout the process. Results: Mean (M) scores across implementation measures of the co-design process were high, including observer-rated fidelity and adoption of co-design practices (M = 19.1 on a 7-21 scale, N = 36 ratings across 9 sessions), as well as acceptability based on the perceived degree of SDM that occurred during the co-design process (M = 10.4 on a 0 to 12 adapted collaboRATE scale). Capturing the feasibility and adoption of convening multistakeholder co-design teams, min-max normalized scores (ranging from 0 to 1) of stakeholder representation demonstrated that, on average, 95% of stakeholder types were represented for cancer sessions (M = 0.95) and 85% for CKD sessions (M = 0.85). The co-design process was rated as either "fully" or "partially" effective by 100% of respondents, in creating a dashboard that met its intended objective. Conclusions: A co-design process was successfully implemented to develop SDM clinical dashboards for advanced cancer and CKD care. We discuss key strategies and learnings from this process that may aid others in the development and uptake of patient-centered healthcare innovations.

The role of registries in improving health and bridging healthcare, research, education, innovation and development: a research department perspective

Health registries are organized systems that collect data on individuals with a particular disease, condition or exposure. The aim of this narrative review was to provide an integrated perspective from the Research Department at the Hospital Italiano de Buenos Aires, Argentina, on how health registries can be used as a bridge between healthcare, research, education, innovation and development while addressing ethical challenges. The review includes a description of the experience of a registry implemented at our institution, which has provided healthcare for 170 years, and is committed to support, education and research. We focus on the potential of health registries to provide better value healthcare by reducing healthcare costs and improving health outcomes and quality of care, and to improve medical knowledge. However, we also acknowledge and discuss the challenges that accompany these achievements, such as that of ethical issues. Through effective collaboration and integration with other healthcare stakeholders, health registries can be a powerful tool to promote better health.

Establishing the Saudi pediatric and youth diabetes registry: initial data and challenges

The Saudi National Diabetes Registry focuses mainly on adult patients. In 2020, the National Guard Health Authority (NGHA) launched the Saudi Pediatric and Youth Diabetes Registry (SPYDR), for children and adolescents with diabetes. This report is about the first data and the challenges we faced during SPYDR initiation. Patients were identified from the electronic medical records of the Saudi NGHA hospitals using the International Classification of Disease (ICD-10). A trained coordinator verified the diagnosis and entered patients' details into the registry and a random sample was validated by experienced endocrinologists. The data were analyzed according to patients' demography, diabetes subtypes, duration, control, and complications. The challenges faced by the team were identified and addressed. At the time of manuscript submission, 2,344 individuals were enrolled. Their mean age at diagnosis was 9.08 (±4.27) years and 1,136 (48.46%) were females. Of these, 91.3% have type 1 (T1D), and 6.4% have type 2 diabetes (T2D). The mean HbA1c was 10.45% (±2.36) and duration of diabetes was 5.31 (±3.05) years. The main challenges included the COVID-19 pandemic, data validation, and centers' participation. However, within 12 months of initiation enrolled subjects matched the expected number. Despite the challenges, the first step of SPYDR was achieved. The initial data confirmed that T1D is the most common form of childhood diabetes, and the frequency of T2D is comparable to regional and international data. SPYDR provides the infrastructure for data sharing and collaborative research with the enrollment of patients from other Saudi healthcare institutes.

Data monitoring roadmap. The experience of the Italian Multiple Sclerosis and Related Disorders Register

INTRODUCTION

Over the years, disease registers have been increasingly considered a source of reliable and valuable population studies. However, the validity and reliability of data from registers may be limited by missing data, selection bias or data quality not adequately evaluated or checked. This study reports the analysis of the consistency and completeness of the data in the Italian Multiple Sclerosis and Related Disorders Register.

METHODS

The Register collects, through a standardized Web-based Application, unique patients. Data are exported bimonthly and evaluated to assess the updating and completeness, and to check the quality and consistency. Eight clinical indicators are evaluated.

RESULTS

The Register counts 77,628 patients registered by 126 centres. The number of centres has increased over time, as their capacity to collect patients. The percentages of updated patients (with at least one visit in the last 24 months) have increased from 33% (enrolment period 2000-2015) to 60% (enrolment period 2016-2022). In the cohort of patients registered after 2016, there were ≥ 75% updated patients in 30% of the small centres (33), in 9% of the medium centres (11), and in all the large centres (2). Clinical indicators show significant improvement for the active patients, expanded disability status scale every 6 months or once every 12 months, visits every 6 months, first visit within 1 year and MRI every 12 months.

CONCLUSIONS

Data from disease registers provide guidance for evidence-based health policies and research, so methods and strategies ensuring their quality and reliability are crucial and have several potential applications.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Examining the National Representativeness of the Axon Registry: A Neurology-Specific Patient Registry

BACKGROUND AND OBJECTIVES

The objective of this study was to determine the external validity of the Axon Registry by comparing the 2019 calendar year data with 2 nationally representative, publicly available data sources, specifically the National Ambulatory Medical Care Survey (NAMCS) and the Medical Expenditure Panel Survey (MEPS). The Axon Registry is the American Academy of Neurology's neurology-focused qualified clinical data registry that reports and analyzes electronic health record data from participating US neurology providers. Its key function is to support quality improvement within ambulatory neurology practices while also promoting high-quality evidence-based care in clinical neurology. We compared demographics of patients who had an outpatient or office visit with a neurologist along with prevalence of selected neurologic conditions and neurologic procedures across the 3 data sets.

METHODS

We performed a cross-sectional, retrospective comparison of 3 data sets: NAMCS (2012-2016), MEPS (2013-2017, 2019), and Axon Registry (2019). We obtained patient demographics (age, birth sex, race, ethnicity), patient neurologic conditions (headache, epilepsy, cerebrovascular disease, multiple sclerosis, parkinsonism, dementia, spinal pain, and polyneuropathy), provider location, and neurologic procedures (neurology visits, MR/CT neuroimaging studies and EEG/EMG neurophysiologic studies). Parameter estimates from the pooled 5-year samples of the 2 public data sets, calculated at the visit level, were compared descriptively with those of the Axon Registry. We calculated Cohen h and performed Wald tests (α = 0.05) to conduct person-level statistical comparisons between MEPS 2019 and Axon Registry 2019 data.

RESULTS

The Axon Registry recorded 1.3 M annual neurology visits (NAMCS, 11 M; MEPS, 22 M) and 645 K people with neurologic conditions (MEPS, 10 M). Compared with the pooled national surveys, the Axon Registry has similar patient demographics, neurologic condition prevalence, neuroimaging and neurophysiologic utilization, and provider location. In direct comparison with MEPS 2019, the Axon Registry 2019 had fewer children (2% vs 7%), more elderly persons (21% vs 16%), fewer non-Black and non-White race persons (5% vs 8%), less number of patients with epilepsy (10% vs 13%), more patients with dementia (8% vs 6%), more patients with cerebrovascular disease (11% vs 8%), and a greater predominance of neurology providers in the Midwest (25% vs 20%). The only difference with a non-negligible effect size was the proportion of people younger than 15 years (Cohen h = 0.25).

DISCUSSION

The Axon Registry demonstrates high concordance with 2 nationally representative surveys. Recruiting more and diverse neurology providers will further improve the volume, representativeness, and value of the Axon Registry.

Digital health solution for monitoring and surveillance of Amyotrophic Lateral Sclerosis in Brazil

Amyotrophic Lateral Sclerosis (ALS) is a complex and rare neurodegenerative disease given its heterogeneity. Despite being known for many years, few countries have accurate information about the characteristics of people diagnosed with ALS, such as data regarding diagnosis and clinical features of the disease. In Brazil, the lack of information about ALS limits data for the research progress and public policy development that benefits people affected by this health condition. In this context, this article aims to show a digital health solution development and application for research, intervention, and strengthening of the response to ALS in the Brazilian Health System. The proposed solution is composed of two platforms: the Brazilian National ALS Registry, responsible for the data collection in a structured way from ALS patients all over Brazil; and the Brazilian National ALS Observatory, responsible for processing the data collected in the National Registry and for providing a monitoring room with indicators on people diagnosed with ALS in Brazil. The development of this solution was supported by the Brazilian Ministry of Health (MoH) and was carried out by a multidisciplinary team with expertise in ALS. This solution represents a tool with great potential for strengthening public policies and stands out for being the only public database on the disease, besides containing innovations that allow data collection by health professionals and/or patients. By using both platforms, it is believed that it will be possible to understand the demographic and epidemiological data of ALS in Brazil, since the data will be able to be analyzed by care teams and also by public health managers, both in the individual and collective monitoring of people living with ALS in Brazil.

Association of ulcerative colitis symptom severity and proctocolectomy with multidimensional patient-reported outcomes: a cross-sectional study

BACKGROUND

The YOu and Ulcerative colitis: Registry and Social network (YOURS) is a large-scale, multicenter, patient-focused registry investigating the effects of lifestyle, psychological factors, and clinical practice patterns on patient-reported outcomes in patients with ulcerative colitis in Japan. In this initial cross-sectional baseline analysis, we comprehensively explored impacts of symptom severity or proctocolectomy on nine patient-reported outcomes.

METHODS

Patients receiving tertiary care at medical institutions were consecutively enrolled in the YOURS registry. The patients completed validated questionnaires on lifestyle, psychosocial factors, and disease-related symptoms. Severity of symptoms was classified with self-graded stool frequency and rectal bleeding scores (categories: remission, active disease [mild, moderate, severe]). The effects of symptom severity or proctocolectomy on nine scales for quality of life, fatigue, anxiety/depression, work productivity, and sleep were assessed by comparing standardized mean differences of the patient-reported outcome scores.

RESULTS

Of the 1971 survey responses analyzed, 1346 (68.3%) patients were in remission, 583 (29.6%) had active disease, and 42 (2.1%) had undergone proctocolectomy. A linear relationship between increasing symptom severity and worsening quality of life, fatigue, anxiety, depression, and work productivity was observed. Patients with even mild symptoms had worse scores than patients in remission. Patients who had undergone proctocolectomy also had worse scores than patients in remission.

CONCLUSIONS

Ulcerative colitis was associated with reduced mood, quality of life, fatigue, and work productivity even in patients with mild symptoms, suggesting that management of active ulcerative colitis may improve patient-reported outcomes irrespective of disease severity. (UMIN Clinical Trials Registry: UMIN000031995, https://www.umin.ac.jp/ctr/index-j.htm ).

The Cystic Fibrosis Learning Network: A mixed methods evaluation of program goals, attributes, and impact

Introduction

The Cystic Fibrosis (CF) Foundation sponsored the design, pilot testing, and implementation of the CF Learning Network (CFLN) to explore how the Foundation's Care Center Network (CCN) could become a learning health system. Six years after the design, the Foundation commissioned a formative mixed methods evaluation of the CFLN to assess: CFLN participants' understanding of program goals, attributes, and perceptions of current and future impact.

Methods

We performed semi-structured interviews with CFLN participants to identify perceived goals, attributes, and impact of the network. Following thematic analyses, we developed and distributed a survey to CFLN members and a matched sample of CCN programs to understand whether the themes were unique to the CFLN.

Results

Interviews with 24 CFLN participants were conducted. Interviewees identified the primary CFLN goal as improving outcomes for people living with CF, with secondary goals of providing training in quality improvement (QI), creating a learning community, engaging all stakeholders in improvement, and spreading best practices to the CCN. Project management, use of data, common QI methods, and the learning community were seen as critical to success. Survey responses were collected from 103 CFLN members and 25 CCN members. The data revealed that CFLN respondents were more likely than CCN respondents to connect with other CF programs, routinely use data for QI, and engage patient and family partners in QI.

Conclusions

Our study suggests that the CFLN provides value beyond that achieved by the CCN. Key questions remain about whether spread of the CFLN could improve outcomes for more people living with CF.

Designing a national pediatric critical care database: a Delphi consensus study

PURPOSE

We sought to describe the processes undertaken for the systematic selection and consensus determination of the common data elements for inclusion in a national pediatric critical care database in Canada.

METHODS

We conducted a multicentre Delphi consensus study of Canadian pediatric intensive care units (PICUs) participating in the creation of a national database. Participants were PICU health care professionals, allied health professionals, caregivers, and other stakeholders. A dedicated panel group created a baseline survey of data elements based on literature, current PICU databases, and expertise in the field. The survey was then used for a Delphi iterative consensus process over three rounds, conducted from March to June 2021.

RESULTS

Of 86 invited participants, 68 (79%) engaged and agreed to participate as part of an expert panel. Panel participants were sent three rounds of the survey with response rates of 62 (91%), 61 (90%) and 55 (81%), respectively. After three rounds, 72 data elements were included from six domains, mostly reflecting clinical status and complex medical interventions received in the PICU. While race, gender, and home region were included by consensus, variables such as minority status, indigenous status, primary language, and ethnicity were not.

CONCLUSION

We present the methodological framework used to select data elements by consensus for a national pediatric critical care database, with participation from a diverse stakeholder group of experts and caregivers from all PICUs in Canada. The selected core data elements will provide standardized and synthesized data for research, benchmarking, and quality improvement initiatives of critically ill children.

Harnessing the Collective Expertise of Patients, Care Partners, Clinical Teams, and Researchers Through a Coproduction Learning Health System: A Case Study of the Dartmouth Health Promise Partnership

The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.

The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry: rationale and study design

INTRODUCTION

Pyruvate kinase (PK) deficiency is a rare, under-recognised, hereditary condition that leads to chronic haemolytic anaemia and potentially serious secondary complications, such as iron overload, cholecystitis, pulmonary hypertension and extramedullary haematopoiesis. It is an autosomal recessive disease caused by homozygous or compound heterozygous mutations in the PKLR gene. Due to its rarity and clinical heterogeneity, information on the natural history and long-term clinical course of PK deficiency is limited, presenting major challenges to patient management, the development of new therapies and establishing disease-specific treatment recommendations. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry is an initiative to address the gaps in the knowledge of PK deficiency. This manuscript describes the objectives, study design and methodology for the Peak Registry.

METHODS AND ANALYSIS

The Peak Registry is an observational, longitudinal, global registry of adult and paediatric patients with a genetically confirmed diagnosis of PK deficiency. The Peak Steering Committee is composed of 11 clinicians and researchers with experience in the diagnosis and management of PK deficiency from 10 countries, a patient representative and representatives from the sponsor (Agios Pharmaceuticals). The registry objective is to foster an understanding of the longitudinal clinical implications of PK deficiency, including its natural history, treatments and outcomes, and variability in clinical care. The aim is to enrol up to 500 participants from approximately 60 study centres across 20 countries over 7 years, with between 2 and 9 years of follow-up. Data will include demographics, diagnosis history, genotyping, transfusion history, relevant clinical events, medications, emergency room visits and hospitalisations.

ETHICS AND DISSEMINATION

Registry protocol and informed consent forms are approved by institutional review boards/independent ethics committees at each study site. The study is being conducted in accordance with the Declaration of Helsinki. Registry data will be published in peer-reviewed journal articles and conference publications.

TRIAL REGISTRATION NUMBER

NCT03481738.

So You Want to Build Your Disease's First Online Patient Registry: An Educational Guide for Patient Organizations Based on US and European Experience

Patient registries fulfill a number of key roles for clinicians, researchers, non-profit organizations, payers, and policy makers. They can help the field understand the natural history of a condition, determine the effectiveness of interventions, measure safety, and audit the quality of care provided. Successful registries in cystic fibrosis, Duchenne's muscular dystrophy, and other rare diseases have become a model for accelerating progress. However, the complex tasks required to develop a modern registry can seem overwhelming, particularly for those who are not from a technical background. In this Education article, a team of co-authors from across patient advocacy, technology, privacy, and commercial perspectives who have worked on a number of such projects offer a "Registry 101" primer to help get started. We will outline the promise and potential of patient registries with worked case examples, identify some of the key technical considerations you will need to consider, describe the type of data you might want to collect, consider privacy risks to protect your users, sketch out some of the paths towards long-term financial sustainability we have observed, and conclude with plans to mitigate some of the challenges that can occur and signpost interested readers to further resources. While rapid growth in the digital health market has presented numerous opportunities to those at the beginning of their journey, it is important to start with the long-term goals in mind and to benefit from the learnings of those who have walked this path before.

Dupilumab-Treated Patients with Asthma in the Real World: The RAPID Global Registry

BACKGROUND

Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key and central drivers of type 2 inflammation. In clinical studies, dupilumab reduced the risk of severe asthma exacerbations, and improved forced expiratory volume in 1 s and quality of life in patients with uncontrolled moderate-to-severe asthma.

OBJECTIVES

The objectives of RAPID (NCT04287621) are to characterize patients with asthma initiating dupilumab in routine clinical practice and to collect information on long-term effectiveness and safety in these patients.

METHODS

RAPID is a global, prospective, observational registry that will enroll approximately 1000 patients (aged ≥ 12 years) with asthma from 150 sites globally. Dupilumab treatment will be initiated in routine clinical practice according to country-specific prescribing information, per physician discretion as part of routine care. Patients will be followed prospectively for up to 3 years, with postbaseline assessments at months 1 and 3, and every 3 months thereafter.

PLANNED OUTCOMES

Baseline data collected will include patient demographics, disease characteristics, and medication history. Patient adherence and persistence will be recorded alongside health-care resource utilization, and effectiveness of dupilumab will be assessed (clinician assessment) as per standard of care. Quality of life, asthma control, type 2 inflammatory comorbidities, work productivity, and physical activity limitation will be assessed. Incidence and severity of adverse events will be recorded.

CONCLUSION

RAPID is the first global registry to characterize patients beginning dupilumab treatment for asthma in clinical practice and will expand on prior clinical studies by providing real-world data.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04287621.

The Italian registry for patients with Prader-Willi syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is a rare and complex genetic disease, with numerous implications on metabolic, endocrine, neuropsychomotor systems, and with behavioural and intellectual disorders. Rare disease patient registries are important scientific tools (1) to collect clinical and epidemiologic data, (2) to assess the clinical management including the diagnostic delay, (3) to improve patients' care and (4) to foster research to identify new therapeutic solutions. The European Union has recommended the implementation and use of registries and databases. The main aims of this paper are to describe the process of setting up the Italian PWS register, and to illustrate our preliminary results.

MATERIALS AND METHODS

The Italian PWS registry was established in 2019 with the aims (1) to describe the natural history of the disease, (2) to determine clinical effectiveness of health care services, (3) to measure and monitor quality of care of patients. Information from six different variables are included and collected into this registry: demographics, diagnosis and genetics, patient status, therapy, quality of life and mortality.

RESULTS

A total of 165 patients (50.3% female vs 49.7% male) were included into Italian PWS registry in 2019-2020 period. Average age at genetic diagnosis was 4.6 years; 45.4% of patients was less than 17 years old aged, while the 54.6% was in adult age (> 18 years old). Sixty-one percent of subjects had interstitial deletion of the proximal long arm of paternal chromosome 15, while 36.4% had uniparental maternal disomy for chromosome 15. Three patients presented an imprinting centre defect and one had a de novo translocation involving chromosome 15. A positive methylation test was demonstrated in the remaining 11 individuals but the underlying genetic defect was not identified. Compulsive food-seeking and hyperphagia was present in 63.6% of patients (prevalently in adults); 54.5% of patients developed morbid obesity. Altered glucose metabolism was present in 33.3% of patients. Central hypothyroidism was reported in 20% of patients; 94.7% of children and adolescents and 13.3% of adult patients is undergoing GH treatment.

CONCLUSIONS

The analyses of these six variables allowed to highlight important clinical aspects and natural history of PWS useful to inform future actions to be taken by national health care services and health professionals.

Enhancing Patient Centricity of Real-World Data Research: An Exploratory Analysis Using the Patient Experience Mapping Toolbox

OBJECTIVES

There is an increasing expectation that medical product development and assessment be guided by patient input captured through patient engagement. Recently published consensus guidelines describe how qualitative patient experience data (PED) can guide the design, conduct, and translation of real-world research that reflects patients' lived experience. The objective of this exploratory analysis is to examine how researchers could leverage PED captured through the Patient Experience Mapping Toolbox (PEMT) to guide real-world data (RWD) research designs.

METHODS

This exploratory analysis included a thematic analysis of interview transcripts collected while pilot testing the PEMT followed by a qualitative analysis of the emerging themes aligned with stages listed in the patient-centered real-world evidence, Real-World Research Design Framework.

RESULTS

PED collected using the PEMT include information about symptomology, interactions with the healthcare system, information-seeking behavior, misdiagnoses, lifestyle changes, treatments, side effects, and comorbidities. This information can be leveraged at key study design decisions, including (1) identifying study cohorts and subgroups, (2) identifying exposures, (3) informing covariates and potential confounders; and (4) refining study periods. Additionally, participants described where they seek information about treatments and diseases, which should inform dissemination strategies.

CONCLUSIONS

We identified opportunities for PED collected using the PEMT to inform RWD study designs. The PED described in this exploratory analysis stem from pilot testing of the PEMT across a variety of conditions. In the next phase of development in this area, researchers should evaluate how data collected using the PEMT can be applied to RWD research for a specific disease.

Mitochondrial disease registries worldwide: A scoping review

BACKGROUND

Mitochondrial diseases are a large group of genetically heterogeneous and clinically diverse disorders. Diagnosis often takes many years for which treatment may not exist. Registries are often used to conduct research, establish natural disease progression, engage the patient community, and develop best disease management practices. In Canada, there are limited centralized registries for mitochondrial disease patients, presenting a challenge for patients and professionals.

OBJECTIVE

To support the creation of such a registry, a systematic scoping review was conducted to map the landscape of mitochondrial disease patient registries worldwide, with a focus on registry design and challenges. Furthermore, it addresses a knowledge gap by providing a narrative synthesis of published literature that describes these registries.

METHODS

Arksey and O'Malley's methodological framework was followed to systematically search English-language literature in PubMed and CINAHL describing the designs of mitochondrial disease patient registries, supplemented by a grey literature search. Data were extracted in Microsoft Excel. Stakeholder consultations were also performed with patient caregivers, advocates, and researchers to provide perspectives beyond those found in the literature. These data were thematically analyzed and were reported in accordance with the PRISMA-ScR reporting guidelines.

RESULTS

A total of 17 articles were identified describing 13 unique registries located in North America, Europe, Australia, and West Asia. These papers described the registries' designs, their strengths, and weaknesses, as well as their tangible outcomes such as facilitating recruitment for research and supporting epidemiological studies.

CONCLUSION

Based on our findings in this review, recommendations were formulated. These include establishing registry objectives, respecting patients and their roles in the registry, adopting international data standards, data evaluations, and considerations to privacy legislation, among others. These recommendations could be used to support designing a future Canadian mitochondrial disease patient registry, and to further research directly engaging these registries worldwide.

Nurses experience increased clinical and organisational competence by working with a medical quality register, RevNatus - a qualitative study

Background

RevNatus is a consent-based, nationwide medical quality register that collects data on patients with inflammatory rheumatic diseases during pregnancy and one year postpartum. The entering of data takes place in outpatient clinics in rheumatology wards in hospitals. The aim of this study is to explore how rheumatology nurses experience organizing and working with the medical quality register RevNatus in addition to their normal clinical patient-care tasks.

Methods

Qualitative focus group interviews and individual in-depth interviews were conducted in 2018 to gain insights into how nurses organize performing quality register work and clinical work simultaneously. Data were analysed using systematic text condensation.

Results

The informants represented seven different rheumatology outpatient clinics in Norway. The analyses showed that working with RevNatus increased the nurses’ knowledge about pregnancy and rheumatic diseases, improved the content of their nurse consultations and found the ‘register form’ as a useful template to structure the nurse consultations. The nurses took the main responsibility for RevNatus, but lack of routines and uncoordinated collaboration with the rheumatologists and secretaries made the nurses spend too much time verifying the accuracy of data or post-registering missing data.

Conclusion

The nurses experienced work with RevNatus as time-consuming, but the register work increased both their clinical and organisational competences. Routines and collaboration within the registry team are important to ensure the data quality and reduce the workload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08595-x.

Patient-Reported Outcome Dashboards Within the Electronic Health Record to Support Shared Decision-making: Protocol for Co-design and Clinical Evaluation With Patients With Advanced Cancer and Chronic Kidney Disease

BACKGROUND

Patient-reported outcomes-symptoms, treatment side effects, and health-related quality of life-are important to consider in chronic illness care. The increasing availability of health IT to collect patient-reported outcomes and integrate results within the electronic health record provides an unprecedented opportunity to support patients' symptom monitoring, shared decision-making, and effective use of the health care system.

OBJECTIVE

The objectives of this study are to co-design a dashboard that displays patient-reported outcomes along with other clinical data (eg, laboratory tests, medications, and appointments) within an electronic health record and conduct a longitudinal demonstration trial to evaluate whether the dashboard is associated with improved shared decision-making and disease management outcomes.

METHODS

Co-design teams comprising study investigators, patients with advanced cancer or chronic kidney disease, their care partners, and their clinicians will collaborate to develop the dashboard. Investigators will work with clinic staff to implement the co-designed dashboard for clinical testing during a demonstration trial. The primary outcome of the demonstration trial is whether the quality of shared decision-making increases from baseline to the 3-month follow-up. Secondary outcomes include longitudinal changes in satisfaction with care, self-efficacy in managing treatments and symptoms, health-related quality of life, and use of costly and potentially avoidable health care services. Implementation outcomes (ie, fidelity, appropriateness, acceptability, feasibility, reach, adoption, and sustainability) during the co-design process and demonstration trial will also be collected and summarized.

RESULTS

The dashboard co-design process was completed in May 2020, and data collection for the demonstration trial is anticipated to be completed by the end of July 2022. The results will be disseminated in at least one manuscript per study objective.

CONCLUSIONS

This protocol combines stakeholder engagement, health care coproduction frameworks, and health IT to develop a clinically feasible model of person-centered care delivery. The results will inform our current understanding of how best to integrate patient-reported outcome measures into clinical workflows to improve outcomes and reduce the burden of chronic disease on patients and health care systems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38461.

The feasibility of collecting the physiotherapy outcomes airway clearance, physical activity and fitness for the Australian Cystic Fibrosis Data Registry

BACKGROUND

Physiotherapy-related data, such as airway clearance techniques (ACTS), physical activity and aerobic fitness are not consistently included in international cystic fibrosis (CF) data registries. This study aimed to pilot the collection of ACTS, physical activity and fitness in a hospital CF clinic, as a step towards informing future national implementation.

METHODS

This study was undertaken in a CF clinic within a major tertiary hospital. Patients and families were invited to participate. Participants completed self-report questionnaires on ACT use and those aged ≥ 10 years completed a physical activity questionnaire (Core Indicators and Measures of Youth Health Survey) and aerobic fitness test (the A-STEP test). Participants also completed a survey to explore the tolerance and acceptability of the fitness test, and the perceived accuracy of the self-reported data collection.

RESULTS

Forty patients agreed to participate in the study (mean age = 9.8, SD = 4.1 years old; 52.5% female). All patients and/or families that were approached agreed to participate and completion rate for the ACTs and physical activity surveys was 98% and 100% (respectively). Completion rate for the fitness test was 55%, due to time constraints. Most participants agreed (≥ 90%) they could accurately provide ACT and physical activity data, and the assessments were tolerable and acceptable.

CONCLUSIONS

Patients with CF and their families are able to and can acceptably provide physiotherapy-related data, and collecting self-report ACTs and physical activity data is highly feasibly during routine CF clinic visits. However, aerobic fitness testing using the A-STEP test may be less feasible in clinic environments, due to time constraints.

Qualitative study measuring the usability of the International Cardiac Rehabilitation Registry

OBJECTIVE

Cardiac rehabilitation (CR) is a comprehensive model of secondary preventive care. There is a wide variety in implementation characteristics globally, and hence quality control is paramount. Thus, the International Council of Cardiovascular Prevention and Rehabilitation was urged to develop a CR registry. The purpose of this study was to test the perceived usability of the International Cardiac Rehabilitation Registry (ICRR) to optimise it.

DESIGN

This was a qualitative study, comprising virtual usability tests using a think-aloud method to elicit feedback on the ICRR, while end-users were entering patient data, followed by semistructured interviews.

SETTING

Ultimately, 12 tests were conducted with CR staff (67% female) in low-resource settings from a variety of disciplines in all regions of the world but Europe before saturation was achieved.

PRIMARY OUTCOME MEASURE

Participants completed the System Usability Scale. Interviews were transcribed verbatim except to preserve anonymity, and coded using NVIVO by two researchers independently. The Unified Theory of Acceptance and Use of Technology 2 informed analysis.

RESULTS

The ICRR was established as easy to use, relevant, efficient, with easy learnability, operability, perceived usefulness, positive perceptions of output quality and high end-user satisfaction. System usability was 83.75, or 'excellent' and rated 'A'. Four major themes were deduced from the interviews: (1) ease of approvals, adoption and implementation; (2) benefits for programmes, (3) variables and their definitions, as well as (4) patient report and follow-up assessment. Based on participant observation and utterances, suggestions for changes to the ICRR were implemented, including to the programme survey, on-boarding processes, navigational instructions, inclusion of programme logos, direction on handling unavailable data and optimising data completeness, as well as policies for authorship and programme certification.

CONCLUSIONS

With usability of the ICRR optimised, pilot testing shall ensue.

Status quo of pain-related patient reported outcomes and perioperative pain management in 10 415 patients from 10 countries: analysis of registry data

BACKGROUND

Postoperative pain is common at the global level, despite considerable attempts for improvement, reflecting the complexity of offering effective pain relief. In this study, clinicians from Mexico, China, and eight European countries evaluated perioperative pain practices and patient-reported outcomes (PROs) in their hospitals as a basis for carrying out quality improvement (QI) projects in each country.

METHODS

PAIN OUT, an international perioperative pain registry, provided standardized methodology for assessing management and multi-dimensional PROs on the first postoperative day, in patients undergoing orthopedic, general surgery, obstetric & gynecology or urological procedures.

RESULTS

Between 2017-2019, data obtained from 10,415 adult patients in 105 wards, qualified for analysis. At the ward level: 50% (median) of patients reported worst pain intensities ≥7/10 NRS, 25% spent ≥50% of the time in severe pain and 20-34% reported severe ratings for pain-related functional and emotional interference. Demographic variables, country and surgical discipline explained a small proportion of the variation in the PROs, leaving about 88% unexplained. Most treatment processes varied considerably between wards. Ward effects accounted for about 7% and 32% of variation in PROs and treatment processes, respectively.

CONCLUSIONS

This comprehensive evaluation demonstrates that many patients in this international cohort reported poor pain-related PROs on the first postoperative day. PROs and treatments varied greatly. Most of the variance of the PROs could not be explained. The findings served as a basis for devising and implementing QI programs in participating hospitals.

The Facilitation of Clinical and Therapeutic Discoveries in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Related Diseases: Protocol for the You + ME Registry Research Platform

BACKGROUND

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, complex, heterogeneous disease that affects millions and lacks both diagnostics and treatments. Big data, or the collection of vast quantities of data that can be mined for information, have transformed the understanding of many complex illnesses, such as cancer and multiple sclerosis, by dissecting heterogeneity, identifying subtypes, and enabling the development of personalized treatments. It is possible that big data can reveal the same for ME/CFS.

OBJECTIVE

This study aims to describe the protocol for the You + ME Registry, present preliminary results related to participant enrollment and satisfaction, and discuss the limitations of the registry as well as next steps.

METHODS

We developed and launched the You + ME Registry to collect longitudinal health data from people with ME/CFS, people with long COVID (LC), and control volunteers using rigorous protocols designed to harmonize with other groups collecting data from similar groups of people.

RESULTS

As of September 30, 2021, the You + ME Registry had over 4200 geographically diverse participants (3033/4339, 69.9%, people with ME/CFS; 833/4339, 19.2%, post-COVID-19 people; and 473/4339, 10.9%, control volunteers), with an average of 72 new people registered every week. It has qualified as "great" using a net promotor score, indicating registrants are likely to recommend the registry to a friend. Analyses of collected data are currently underway, and preliminary findings are expected in the near future.

CONCLUSIONS

The You + ME Registry is an invaluable resource because it integrates with a symptom-tracking app, as well as a biorepository, to provide a robust and rich data set that is available to qualified researchers. Accordingly, it facilitates collaboration that may ultimately uncover causes and help accelerate the development of therapies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04806620; https://clinicaltrials.gov/ct2/show/NCT04806620.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36798.

Prioritizing Measures that Matter Within a Person-Centered Oncology Learning Health System

Background

Despite progress in developing learning health systems (LHS) and associated metrics of success, a gap remains in identifying measures to guide the implementation and assessment of the impact of an oncology LHS. Our aim was to identify a balanced set of measures to guide a person-centered oncology LHS.

Methods

A modified Delphi process and clinical value compass framework were used to prioritize measures for tracking LHS performance. A multidisciplinary group of 77 stakeholders, including people with cancer and family members, participated in 3 rounds of online voting followed by 50-minute discussions. Participants rated metrics on perceived importance to the LHS and discussed priorities.

Results

Voting was completed by 94% of participants and prioritized 22 measures within 8 domains. Patient and caregiver factors included clinical health (Eastern Cooperative Oncology Group Performance Status, survival by cancer type and stage), functional health and quality of life (Patient Reported Outcomes Measurement Information System [PROMIS] Global-10, Distress Thermometer, Modified Caregiver Strain Index), experience of care (advance care planning, collaboRATE, PROMIS Self-Efficacy Scale, access to care, experience of care, end-of-life quality measures), and cost and resource use (avoidance and delay in accessing care and medications, financial hardship, total cost of care). Contextual factors included team well-being (Well-being Index; voluntary staff turnover); learning culture (Improvement Readiness, compliance with Commission on Cancer quality of care measures); scholarly engagement and productivity (institutional commitment and support for research, academic productivity index); and diversity, equity, inclusion, and belonging (screening and follow-up for social determinants of health, inclusivity of staff and patients).

Conclusions

The person-centered LHS value compass provides a balanced set of measures that oncology practices can use to monitor and evaluate improvement across multiple domains.

Demonstrating Benefit-Risk Profiles of Novel Therapeutic Strategies in Kidney Transplantation: Opportunities and Challenges of Real-World Evidence

While great progress has been made in transplantation medicine, long-term graft failure and serious side effects still pose a challenge in kidney transplantation. Effective and safe long-term treatments are needed. Therefore, evidence of the lasting benefit-risk of novel therapies is required. Demonstrating superiority of novel therapies is unlikely via conventional randomized controlled trials, as long-term follow-up in large sample sizes pose statistical and operational challenges. Furthermore, endpoints generally accepted in short-term clinical trials need to be translated to real-world (RW) care settings, enabling robust assessments of novel treatments. Hence, there is an evidence gap that calls for innovative clinical trial designs, with RW evidence (RWE) providing an opportunity to facilitate longitudinal transplant research with timely translation to clinical practice. Nonetheless, the current RWE landscape shows considerable heterogeneity, with few registries capturing detailed data to support the establishment of new endpoints. The main recommendations by leading scientists in the field are increased collaboration between registries for data harmonization and leveraging the development of technology innovations for data sharing under high privacy standards. This will aid the development of clinically meaningful endpoints and data models, enabling future long-term research and ultimately establish optimal long-term outcomes for transplant patients.

Optimizing Outcomes for Children With Phonological Impairment: A Systematic Search and Review of Outcome and Experience Measures Reported in Intervention Research

PURPOSE

Reporting of outcome and experience measures is critical to our understanding of the effect of intervention for speech sound disorders (SSD) in children. There is currently no agreed-upon set of measures for reporting intervention outcomes and experiences. In this article, we introduce the Speech Outcome Reporting Taxonomy (SORT), a tool designed to assist with the classification of outcome and experience measures. In a systematic search and review using the SORT, we explore the type and frequency of these measures reported in intervention research addressing phonological impairment in children. Given the integral relationship between intervention fidelity and intervention outcomes, reporting of fidelity is also examined.

METHOD

Five literature databases were searched to identify articles written or translated into English published between 1975 and 2020. Using the SORT, outcome and experience measures were extracted and categorized. The number of intervention studies reporting fidelity was determined.

RESULTS

A total of 220 articles met inclusion criteria. The most frequently reported outcome domain was broad generalization measures (n = 142, 64.5%), followed by specific measures of generalization of an intervention target (n = 133, 60.5%). Eleven (5.0%) articles reported measures of the impact of the phonological impairment on children's activity, participation, quality of life, or others. Twenty articles (9.1%) reported on parent, child, or clinician experience or child engagement. Fidelity data were reported for 13.4% of studies of interventions.

CONCLUSIONS

The measurement of intervention outcomes is challenging yet important. No single type of measure was reported across all articles. Through using tailored measures closely related to intervention targets in combination with a universal set of measures of intelligibility, the impact of phonological impairment on children's lives, and the experience of receiving and providing intervention, researchers and clinicians could work together to progress insights and innovations in science and practice for children with SSD.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19497803.

Development of Balanced Whole System Value Measures for Inflammatory Bowel Disease Care in the IBD Qorus Collaborative Using a Modified Delphi Process

BACKGROUND

The IBD Qorus Collaborative aims to reduce variation and increase the value of care for the adult inflammatory bowel disease (IBD) community. To evaluate the success of the collaborative, we aimed to develop a balanced set of outcome measures that reflect a multistakeholder view of value in IBD care. To achieve this, we used the Clinical Value Compass framework and engaged a mixed-stakeholder group to conduct a modified Delphi process. The end result was a 10-measure set to assess the value of IBD care.

METHOD

The modified Delphi process included 3 iterative rounds of blinded voting and interactive webinar-style discussion. We recruited 18 participants for the Delphi panel, including clinicians, researchers, patients, Crohn's & Colitis Foundation staff, and payers. Participants first identified constructs to measure, then identified the tools to measure those constructs. A literature review and environmental scan of current measures in 4 domains were performed, and relevant measures were proposed for discussion and voting in each domain. Throughout the process, participants were invited to contribute additional measures.

CONCLUSION

The modified Delphi process led to selection of 10 value measures across 4 domains: (1) patient experience; (2) functional status; (3) clinical status; and (4) health care costs and utilization. We have successfully completed a 3-stage modified Delphi process to develop a balanced set of value measures for adult IBD care. The value measure set expands upon prior efforts that have established quality measures for IBD care by adding cost and experience of care elements. This work positions IBD Qorus to better assess, study, improve, and demonstrate value at individual, system, and population levels and will inform and empower related research, improvement, and implementation efforts.

Learning health systems from an academic perspective: establishing a collaboratory within a school of medicine and health sciences

Learning Health Systems (LHSs) seek continuous improvement through the translation and integration of internally and externally generated knowledge across stakeholders within and external to the organization, yet current approaches are primarily described from the healthcare delivery perspective, leaving teaching and research responsibilities underexposed. Academic medical centers offer a unique perspective on LHSs because their mission includes teaching, research, and healthcare. This introduces an opportunity to enact, educate, and study processes and outcomes of LHSs within a single system. Little information is available to describe these processes and outcomes, resulting in a knowledge gap regarding the role of education and research in the quality improvement cycles and learning of LHSs. To close this knowledge gap, The George Washington University School of Medicine and Health Sciences initiated the Health Research and Education Collaboratory (GW Collaboratory) in 2017. The GW Collaboratory was established to study mechanisms supporting continuous quality improvement and learning in health systems within an academic medical center. We envision the GW Collaboratory as interconnected knowledge nodes facilitating collaboration among clinicians, patients, researchers, and educators to study the knowledge generation, dissemination, application, and evaluation required for continuous quality improvement and learning. We employ a project-based approach to foster communities of learning focused on exploring specific health problems of interest. We propose the GW Collaboratory as one model by which academic medical centers can contribute to the science of LHS.

International, national and local trends in the spread of COVID-19: a geographic view of COVID-19 spread and the role to be played by coproduction

BACKGROUND

COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, emerged in 2019 and led to a worldwide pandemic in 2020. The COVID-19 pandemic has been a massive natural experiment in the formation of mitigation strategies to prevent cases and to provide effective healthcare for those afflicted. Regional differences in the impact of the pandemic on morbidity and mortality have been driven by political and regional differences in the coproduction of public health and social policy. We explored the United States (US) experience of COVID-19 for trends and correlations with other nations and also at the national, regional, state and local levels.

OBJECTIVE

To identify geographic and temporal trends in the spread of COVID-19 in the United States.

METHODS

Population data on COVID-19 cases and mortality were acquired on a daily basis from multiple publicly available databases, including the New York Times and Johns Hopkins University. At each geographic level (national, state and county), geographic entities' reported cases were evaluated for correlations using linear least-squares methods to identify patterns of correlation in the cases independent of scale. We evaluated for two specific characteristics: (i) the nature of the curvature of the line linking across percentile scores, ranging from concave to convex and (ii) the area under this curve, indicating how effectively a selected region (nation, state and county) is linked to its entire containing unit (world, country and state). We used this approach to identify three distinct COVID behavior phenotypes, each of which consisted of a number of states in the USA.

RESULTS

We found that COVID activity in the USA follows a unique trend compared to other countries and that within the USA during the first year of the pandemic, three initial COVID phenotypes emerged: (i) the metropolitan outbreak (early outbreak phenotype); (ii) the regional outbreak (summer peak phenotype) and (iii) trans-regional outbreak (fall/winter peak phenotype), which, taken in sum, represent the overall USA national trend. Each phenotype has specific behavioral characteristics and is composed of a cluster of different states experiencing different conditions.

CONCLUSION

Our findings suggest a new opportunity for public health strategy in the pandemic, namely to apply targeted public health approaches to address the specific needs of each phenotype. In the future, we should create databases that capture key health and hardship data elements at the smallest geographic level possible and use these to track trends, predict the future and apply targeted coproduction approaches to more effectively and efficiently safeguard population health, economic vitality and social well-being.

Harmonization of the ICHOM Quality Measures to Enable Health Outcomes Measurement in Multimorbid Patients

Objectives: To update the sets of patient-centric outcomes measures (“standard-sets”) developed by the not-for-profit organization ICHOM to become more readily applicable in patients with multimorbidity and to facilitate their implementation in health information systems. To that end we set out to (i) harmonize measures previously defined separately for different conditions, (ii) create clinical information models from the measures, and (iii) restructure the annotation to make the sets machine-readable.

Materials and Methods: First, we harmonized the semantic meaning of individual measures across all the 28 standard-sets published to date, in a harmonized measure repository. Second, measures corresponding to four conditions (Breast cancer, Cataracts, Inflammatory bowel disease and Heart failure) were expressed as logical models and mapped to reference terminologies in a pilot study.

Results: The harmonization of semantic meaning resulted in a consolidation of measures used across the standard-sets by 15%, from 3,178 to 2,712. These were all converted into a machine-readable format. 61% of the measures in the 4 pilot sets were bound to existing concepts in either SNOMED CT or LOINC.

Discussion: The harmonization of ICHOM measures across conditions is expected to increase the applicability of ICHOM standard-sets to multi-morbid patients, as well as facilitate their implementation in health information systems.

Conclusion: Harmonizing the ICHOM measures and making them machine-readable is expected to expedite the global adoption of systematic and interoperable outcomes measurement. In turn, we hope that the improved transparency on health outcomes that follows will let health systems across the globe learn from each other to the ultimate benefit of patients.

A model for building a national, patient-driven database to track contraceptive use in women with rare diseases

Data on the safety and effectiveness of contraception among women with rare diseases are critical and sorely lacking. To fill this gap, we propose a national, patient-driven database that tracks contraceptive safety and effectiveness among women with rare diseases. We built a pilot database focusing on women with cystic fibrosis in 3 phases: (1) database design input from patients and experts, (2) merging of contraceptive survey data with relevant clinical outcomes from the Cystic Fibrosis Foundation Patient Registry (CFFPR), and (3) forming a data guide to facilitate accessible output data. We successfully linked 62 contraceptive survey variables with 362 relevant clinical outcome variables for 150 patients. This pilot represents a breakthrough in linking contraceptive data to disease-specific outcomes and informs how to build a national, patient-driven contraceptive database for women with rare diseases.

Elosulfase alfa in the treatment of mucopolysaccharidosis type IVA: insights from the first managed access agreement

Managed access agreements provide a crucial mechanism whereby real-world data can be collected systematically to reduce uncertainty around available clinical and economic data, whilst providing the opportunity to identify patient sub-populations who are most likely to benefit from a new treatment. This manuscript aims to share learnings from the first managed access agreement, which was initiated following positive conditional approval in 2015 from the National Institute for Health and Care Excellence (NICE) for elosulfase alfa, an enzyme replacement therapy for the treatment of mucopolysaccharidosis type IVA (MPS IVA). This managed access agreement enabled the collection of comprehensive real-world data for patients with MPS IVA, with results demonstrating that patients starting elosulfase alfa treatment showed gains similar to those seen in the pivotal trial for outcomes including endurance, respiratory and cardiac function, pain, quality of life measures and urinary keratan sulfate levels. In addition, former trial patients continued to see benefits in both clinical assessments and quality of life/activities of daily living nine years after beginning treatment. Key strengths of the process included recruitment of a high proportion of MPS IVA patients treated in England (72/89 known eligible patients) with a wide range of ages (2-58 years). Participation of a patient organisation (the MPS society) ensured that the patient voice was present throughout the process, whilst a contract research organisation (Rare Disease Research Partners) ensured that patients were represented when interpreting agreement criteria and during patient assessment meetings. Longer-term follow-up will be required for several MPS IVA outcomes (e.g. skeletal measures) to further reduce uncertainty, and continued follow-up of patients who had stopped treatment was found to be challenging. The burden associated with this managed access agreement was found to be high for patients, physicians, patient organisations, NHS England and the manufacturer, therefore costs and benefits of future agreements should be considered carefully before initiation. Through evaluation of the strengths and limitations of this process, it is hoped that learnings from this managed access agreement can be used to inform future agreements.

Contextual Factors Affecting Implementation of In-hospital Pediatric CPR Quality Improvement Interventions in a Resuscitation Collaborative

Supplemental Digital Content is available in the text.

Introduction:

Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative.

Methods:

A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide.

Results:

All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6–124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff.

Conclusions:

Using mixed methods, we identified an association between the local QI team’s strength and the successful implementation of the QI interventions.

An initial analysis of the UK Medical Cannabis Registry: Outcomes analysis of first 129 patients

AIM

Cannabis-based medicinal products (CBMPs) are prescribed with increased frequency, despite a paucity of high-quality randomized controlled trials. The aim of this study is to analyze the early outcomes of the first series of patients prescribed CBMPs in the UK with respect to effects on health-related quality of life and clinical safety.

METHODS

A prospective case series was performed using the UK Medical Cannabis Registry. Primary outcomes were change in patient-reported outcomes measures (EQ-5D-5L, General Anxiety Disorder-7 (GAD-7) and Single-Item Sleep Quality Scale (SQS)) at 1 and 3 months from baseline. The secondary outcome was the incidence of adverse events. Statistical significance was defined by a P-value <.050.

RESULTS

There were 129 patients included in the final analysis with a mean age of 46.23 (±14.51) years. The most common indication was chronic pain of undefined etiology (n = 48; 37.2%). The median initial cannabidiol and (-)-trans-Δ⁹-tetrahydrocannabinol daily dose was 20.0 mg (Range: 0.0-768.0 mg) and 3.9 mg (Range: 0.0-660.0 mg), respectively. Statistically significant improvements in health-related quality of life were demonstrated at 1 and 3 months in GAD-7, SQS, EQ-5D-5L pain and discomfort subscale, EQ-5D-5L anxiety and depression subscale, EQ-VAS and EQ-5D-5L index values(P < .050). There were 31 (24.03%) total reported adverse events.

CONCLUSION

This study suggests that CBMP therapy may be associated with an improvement in health-related quality-of-life outcomes as self-reported by patients. CBMPs are also demonstrated to be relatively safe in the short to medium-term. These findings must be treated with caution given the limited scope of this initial analysis, with no placebo or an active comparator, with further research required.

The use of electronic PROMs provides same outcomes as paper version in a spine surgery registry. Results from a prospective cohort study

BACKGROUND AND PURPOSE

Patient-Reported Measured Outcomes (PROMs) are essential to gain a full understanding of a patient's condition, and in spine surgery, these questionnaires are of help when tailoring a surgical strategy. Electronic registries allow for a systematic collection and storage of PROMs, making them readily available for clinical and research purposes. This study aimed to investigate the reliability between the electronic and paper form of ODI (Oswestry Disability Index), SF-36 (Short Form Health Survey 36) and COMI-back (Core Outcome Measures Index for the back) questionnaires.

METHODS

A prospective analysis was performed of ODI, SF-36 and COMI-back questionnaires collected in paper and electronic format in two patients' groups: Pre-Operatively (PO) or at follow-up (FU). All patients, in both groups, completed the three questionnaires in paper and electronic form. The correlation between both methods was assessed with the Intraclass Correlation Coefficients (ICC).

RESULTS

The data from 100 non-consecutive, volunteer patients with a mean age of 55.6 ± 15.0 years were analysed. For all of the three PROMs, the reliability between paper and electronic questionnaires results was excellent (ICC: ODI = 0.96; COMI = 0.98; SF36-MCS = 0.98; SF36-PCS = 0.98. For all p < 0.001).

CONCLUSIONS

This study proved an excellent reliability between the electronic and paper versions of ODI, SF-36 and COMI-back questionnaires collected using a spine registry. This validation paves the way for stronger widespread use of electronic PROMs. They offer numerous advantages in terms of accessibility, storage, and data analysis compared to paper questionnaires.

Assessing Shared Decision-Making in Cystic Fibrosis Care Using collaboRATE: A Cross-Sectional Study of 159 Programs

There are numerous opportunities for shared decision-making (SDM) in cystic fibrosis (CF) care, yet little is known about patients’ SDM experiences. This study evaluated SDM across 159 CF care programs (4024 participants) in the United States. Shared decision-making was assessed using the patient-reported collaboRATE measure, which was included in the CF Foundation’s Patient and Family Experience of Care Survey over 18 months. Overall, 69% of respondents reported experiencing SDM. Respondents at pediatric programs were more likely to experience SDM than those at adult programs (72% vs 67%, P < .001). Multivariable logistic regression analyses showed a relationship between SDM and patient age, whereby SDM was less likely to occur with patients aged 18 to 24 years, compared to some younger and older age groups (P = .02-<.001). Shared decision-making was more likely to occur at pediatric programs when patients had better general health (P = .02-<.01), and at pediatric and adult programs when patients had better mental health (P = .02-<.001). Disparities in SDM experiences highlight a need to improve decision-making processes in CF care. Interventions tailored for improving SDM among specific patient populations may be particularly advantageous.

The ACIRA Registry: A Regional Tool to Improve the Healthcare Pathway for Patients Undergoing Percutaneous Coronary Interventions and Coronary Angiographies in the French Aquitaine Region: Study Design and First Results

BACKGROUND

In France, there is a lack of information about practices and pathways of coronary angiographies and percutaneous coronary interventions (PCI). We present the design and the first results of the ACIRA registry, the goal of which is to answer questions about quality, security, appropriateness, efficiency of, and access to interventional cardiology (IC) healthcare pathway in the French Aquitaine region.

METHODS

The ACIRA registry is an on-going, multicenter, prospective, exhaustive, scalable, and nominative cohort study of patients who undergo coronary angiographies or percutaneous coronary intervention in any of the catheterization laboratories. The data related to hospitalizations and procedures are directly extracted from hospital information systems. In-hospital mortality, readmissions, and cardiovascular morbidity are collected from the French hospital medical information system database. An identity management system has been implemented to create the patient health care pathway.

RESULTS

From January 1, 2012, to June 30, 2018, 147,136 procedures performed on 106,005 patients have been included in the ACIRA registry.

CONCLUSIONS

ACIRA has shown its ability to study the patient IC healthcare pathway, up to 1 year after the procedure. Nominative data enable the linkage between clinical and medico-administrative databases and possible supplementary data collection. The use of existing databases allowed us to limit patients lost to follow-up, prevent the double entry of data, improve data quality, and reduce the operating costs. The prospect of linkage with the French National Health Data System may offer promising opportunities for future medical research projects and for developing collaboration and benchmarking with other IC registries abroad.

Hidden labour: the skilful work of clinical audit data collection and its implications for secondary use of data via integrated health IT

Background

Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits.

Methods

Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in ‘back offices’ and meetings (102 h). Findings were analysed thematically and synthesised in narratives.

Results

Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements.

Conclusions

If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations.

System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative

Multiple sclerosis (MS) is a "3C" (complex, chronic, costly) condition that is a common and disabling neurological illness affecting approximately 1 million adults in the United States. MS has been studied at the basic science, individual, and population levels, but not at the system level to assess small-area variation effects on MS population health outcomes. System-level effects have been observed in other 3C conditions including cystic fibrosis, rheumatoid arthritis, and inflammatory bowel disease. The authors report here on system-level variation findings from the baseline period during the first year of the Multiple Sclerosis Continuous Quality Improvement (MS-CQI) study. Stepwise binary logistic regression analyses were conducted to investigate system-level (small-area variation) effects on MS relapses (exacerbations), disease-modifying therapy (DMT) utilization, and brain MRI utilization, controlling for demographics (age and sex) and other potential confounders. Significant differences were observed in people with MS (PwMS) between centers for a number of demographic and disease characteristics, including sex, age, and MS subtype. Controlling for these factors, significant system-level effects were observed on outcomes, including DMT utilization, MRI utilization, and relapses. Significant relationships also were observed between outcomes and urgent care utilization, including emergency department visits and hospitalizations. This initial study provides evidence establishing the presence of system-level variation effects on MS outcomes in a multicenter population study - where PwMS get their care can influence their outcomes. Results support continued systems-level research and improvement initiatives to optimize MS population health outcomes in this challenging and costly complex chronic condition.

Designing and Implementing an IT Architecture for a Digital Multicenter Dementia Registry: digiDEM Bayern

Background  Registries are an essential research tool to investigate the long-term course of diseases and their impact on the affected. The project digiDEM Bayern will set up a prospective dementia registry to collect long-term data of people with dementia and their caregivers in Bavaria (Germany) supported by more than 300 research partners.

Objective  The objective of this article is to outline an information technology (IT) architecture for the integration of a registry and comprehensive participant management in a dementia study. Measures to ensure high data quality, study governance, along with data privacy, and security are to be included in the architecture.

Methods  The architecture was developed based on an iterative, stakeholder-oriented process. The development was inspired by the Twin Peaks Model that focuses on the codevelopment of requirements and architecture. We gradually moved from a general to a detailed understanding of both the requirements and design through a series of iterations. The experience learned from the pilot phase was integrated into a further iterative process of continuous improvement of the architecture.

Results  The infrastructure provides a standardized workflow to support the electronic data collection and trace each participant's study process. Therefore, the implementation consists of three systems: (1) electronic data capture system for Web-based or offline app-based data collection; (2) participant management system for the administration of the identity data of participants and research partners as well as of the overall study governance process; and (3) videoconferencing software for conducting interviews online. First experiences in the pilot phase have proven the feasibility of the framework.

Conclusion  This article outlines an IT architecture to integrate a registry and participant management in a dementia research project. The framework was discussed and developed with the involvement of numerous stakeholders. Due to its adaptability of used software systems, a transfer to other projects should be easily possible.

Editorial: Registries and Population Databases in Clinical Research and Practice

Patient registries include data on patient diagnosis, demographics, treatment, and outcomes and are now fundamental to the provision of successful global health systems. Patient registries include mainly local, regional, and national patient data on general or specific patient groups. Global registries currently exist mainly for rare diseases. Some of the most studied registries include the national Surveillance, Epidemiology, and End Results (SEER) program and the hospital-based Medical Information Mart for Intensive Care (MIMIC-III) dataset. The limitations of registry databases have included lack of feedback from clinical studies to the clinical center, the lack of patient involvement, and limited findings on patient-reported outcomes (PROs). In September 2020, the European Medicines Agency (EMA) published its draft guidelines on registry-based clinical studies. Guidelines for the development and analysis of registry data will improve the quality and registry-based studies and increase the role of registry data to support clinical trials. This Editorial aims to present the current status of registries and population databases in clinical research and practice.

Predictors for incomplete response to ursodeoxycholic acid in primary biliary cholangitis. Data from a national registry of liver disease

Background

The current standard of treatment in primary biliary cholangitis (PBC) is ursodeoxycholic acid (UDCA), although a considerable proportion of patients show incomplete response resulting in disease progression.

Objective

This study aimed to assess the prevalence of incomplete response to UDCA and determine associated patients' characteristics.

Methods

Patients with PBC as main diagnosis were included from a national multicentric patient registry—Liver.pt. Main endpoints included incomplete response to UDCA treatment according to Barcelona, Paris I and Paris II criteria, Globe and UK PBC scores and the association between baseline characteristics and incomplete response according to Paris II criteria.

Results

A total of 434 PBC patients were identified, with a mean age of 55 years and 89.2% females. Nearly half of patients were asymptomatic at diagnosis and 93.2% had positive anti‐mitochondrial antibodies. Almost all patients (95.6%) had been prescribed at least one drug for PBC treatment. At the last follow‐up visit, 93.3% were under treatment of which 99.8% received UDCA. Incomplete response to UDCA was observed in 30.7%, 35.3%, 53.7% and 36.4% of patients according to Barcelona, Paris I, Paris II criteria and Globe score, respectively. After adjusting for age and sex, and accordingly to Paris II criteria, the risk for incomplete biochemical response was 25% higher for patients with cirrhosis at diagnosis (odds ratio [OR] = 1.25; 95% confidence interval [95%CI]: 1.02–1.54; p = 0.033) and 35% (95%CI:1.06–1.72; p = 0.016) and 5% (OR = 1.05; 95%CI:1.01–1.10; p = 0.013) for those with elevated gamma‐glutamyl transferase (GGT) and alkaline phosphatase (ALP).

Conclusion

A considerable proportion of patients showed incomplete biochemical response to UDCA treatment according to Paris II criteria. Cirrhosis, elevated GGT and ALP at diagnosis were identified as associated risk factors for incomplete response. Early identification of patients at risk of incomplete response could improve treatment care and guide clinical decision to a more careful patient monitorization.

Summarise the established knowledge on this subject

Primary biliary cholangitis is a liver disease that can progress to end‐stage liver disease, with premature death or need for liver transplantation.

Treatment with ursodeoxycholic acid (UDCA) significantly increases liver transplant‐free survival. However, incomplete response to UDCA reduces this beneficial effect.

What are the significant and/or new findings of this study?

By evaluating prevalence and risk factors for UDCA incomplete response through a large multicentric national registry it was found that 53.7% of patients were incomplete responders, according to Paris II criteria, with cirrhosis, elevated gamma‐glutamyl transferase and alkaline phosphatase at diagnosis as the main risk factors.

These findings suggest that patients diagnosed at an advanced stage should be closely monitored and might benefit from novel therapies to improve outcomes if incomplete response is present.

Patient-reported outcomes after hip and knee arthroplasty : results from a large national registry

AIMS

This study aims to describe the pre- and postoperative self-reported health and quality of life from a national cohort of patients undergoing elective total conventional hip arthroplasty (THA) and total knee arthroplasty (TKA) in Australia. For context, these data will be compared with patient-reported outcome measures (PROMs) data from other international nation-wide registries.

METHODS

Between 2018 to 2020, and nested within a nationwide arthroplasty registry, preoperative and six-month postoperative PROMs were electronically collected from patients before and after elective THA and TKA. There were 5,228 THA and 8,299 TKA preoperative procedures as well as 3,215 THA and 4,982 TKA postoperative procedures available for analysis. Validated PROMs included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L; range 0 to 100; scored worst-best health), Oxford Hip/Knee Scores (OHS/OKS; range 0 to 48; scored worst-best hip/knee function) and the 12-item Hip/Knee disability and Osteoarthritis Outcome Score (HOOS-12/KOOS-12; range 0 to 100; scored best-worst hip/knee health). Additional items included preoperative expectations, patient-perceived improvement, and postoperative satisfaction. Descriptive analyses were undertaken.

RESULTS

For THA and TKA patients respectively, the patient profile was 2,850 (54.5%) and 4,684 (56.4%) female, mean age 66.8 years (SD 10.6) and 67.5 (SD 8.8), and mean BMI 29.9 kg/m2 (SD 7.7) and 32.5 kg/m2 (SD 7.0). The proportion of THA and TKA patients who reported their joint as 'much better' was 2,946 (92.6%) and 4,020 (81.6%) respectively, and the majority of patients were 'satisfied' or 'very satisfied' with their procedure (2,754 (86.5%) and 3,981 (80.8%)). There were 311 (9.7%) of THA patients and 516 (10.5%) of TKA patients who reported 'dissatisfied' or 'very dissatisfied' with their surgery.

CONCLUSION

Large improvements in pain, function, and overall health were evident following primary THA and TKA. Approximately 10% of patients reported dissatisfaction with their surgery. Future analyses will focus on factors contributing to dissatisfaction after arthroplasty. Cite this article: Bone Jt Open 2021;2(6):422-432.

The voice of patients in Israel's general hospitals

PURPOSE

The purpose of this study is to capture the variety of issues that concern patients and to examine the extent to which personal characteristics of patients, such as education, ethnicity, age, gender and conditions of hospitalisation, influence the tendency to "express (negative) voice" and raise "critical views".

DESIGN/METHODOLOGY/APPROACH

Using data obtained from the 2014 Survey of Health Satisfaction in Israel, the study focuses on patients' responses to an open-ended question regarding the medical care experience in hospitals.

FINDINGS

The analysis reveals that "the voice of patients" spreads across a wide variety of issues, including the physical condition of the hospital and caregiver behaviour. Multivariate regression models show that subgroups with greater access to social and economic resources (i.e. in Israel, individuals who are Jewish), academics, women and younger patients are more likely to express critical voice regarding the hospitalisation experience. Likewise, inferior hospitalisation conditions are likely to increase expression of negative "voice" and criticism.

ORIGINALITY/VALUE

The findings underscore the importance and value of open-ended questions in evaluating healthcare satisfaction, suggesting that the likelihood of expressing critical voice is higher among patients of high socio-economic status - perhaps because they are more likely to expect, demand and feel entitled to high-quality care. Likewise, inferior hospitalisation conditions increase the critical voice.