The Use of Patient-Reported Outcome Measures: Secondary School Athletic Trainers' Perceptions, Practices, and Barriers

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation

PURPOSE

To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks.

MATERIALS AND METHODS

A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised.

RESULTS

Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support.

CONCLUSIONS

Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Comparing the Primary Concerns of Injured Collegiate Athletes With the Content of Patient-Reported Outcome Measures

CONTEXT

Patient-reported outcome measures (PROMs) have been endorsed for providing patient-centered care. However, PROMs must represent their target populations.

OBJECTIVE

To identify the primary concerns of collegiate athletes experiencing injury and compare those with the content of established PROMs.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

Collegiate athletes experiencing injury (N = 149).

MAIN OUTCOME MEASURE(S)

Open-ended responses to the Measure Yourself Medical Outcome Profile were used to identify primary concerns, which were linked to International Classification of Functioning, Disability and Health taxonomy codes. Items of the Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; Lower Extremity Functional Scale; Knee injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee Subjective Knee Form (IKDC); Foot and Ankle Ability Measure; Disabilities of the Arm, Shoulder, and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire were linked to International Classification of Functioning, Disability and Health codes. We calculated χ2 single-sample goodness-of-fit tests to determine if 70% of the content was shared between PROMs and participant-generated codes.

RESULTS

Participant-generated concerns were primarily related to sport participation (16%) and pain (23%). Chi-square tests showed that the Lower Extremity Functional Scale and Foot and Ankle Ability Measure presented significant content differences, with common participant-generated lower extremity responses at all levels. The Patient-Reported Outcomes Measurement Information System; modified Disablement of the Physically Active Scale; KOOS; IKDC; Disabilities of the Arm, Shoulder and Hand; Functional Arm Scale for Throwers; and Kerlan-Jobe Orthopaedic Clinic questionnaire did not have significant content differences for level 2 codes; still, significant differences were present for level 3 analyses except for the KOOS and IKDC (P < .001). All measures except the IKDC contained significant superfluous content (P < .05).

CONCLUSIONS

The presence of significant content differences supports clinician-perceived barriers regarding the relevance of established PROMs. However, the IKDC was a relevant and efficient PROM for evaluating the primary concerns of collegiate athletes experiencing lower extremity injury. Clinicians should consider using patient-generated measures to support coverage of patient-specific concerns in care.

Validation of a Script to Facilitate Social Determinant of Health Conversations with Adolescent Patients

Current social determinants of health (SDOH) tools exist to assess patient exposure; however, healthcare providers for the adolescent population are unsure of how to integrate SDOH knowledge into clinical practice. The purpose of this study was to validate a focused history script designed to facilitate SDOH conversations between clinicians and adolescents through the use of the Delphi method. Six individuals (1 clinician, 5 educators/researchers) participated as expert panelists. Panelists provided critical feedback on the script for rounds 1 and 2. For rounds 3-7, panelists received an electronic questionnaire asking them to indicate agreement on a 6-point Likert scale (1 = strongly disagree, 6 = strongly agree). We defined consensus as mean item agreement ≥ 5.0 and percent agreement ≥ 80%. In round 7, panelists rated overall script level of agreement. After seven rounds of feedback, the focused history script achieved content validity with 100% of panelists agreeing on the final 40-item script. A focused history script for the SDOH was content validated to aid conversations between healthcare providers and adolescent patients on factors that affect their life, school, and play. Addressing social determinants of health with adolescent patients will improve cultural proficiency and family-centered care delivered by school healthcare professionals.

Patient Outcomes After Treatment by Athletic Therapy Students

CONTEXT

Patient-reported outcome measures (PROMs) should be used in athletic training and athletic therapy but are rarely incorporated in internships. Student-run clinics are common in other health professions and provide effective treatment and valuable learning environments. To our knowledge, no one has evaluated rehabilitation outcomes in patients treated by athletic therapy students (ATSs).

OBJECTIVE

To measure the improvement in function in injured patients seeking treatment at an ATS clinic.

DESIGN

Cohort study.

SETTING

An ATS clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 59 patients (32 women, age = 33.9 ± 14.7 years; 27 men, age = 38 ± 14.4 years) from the community with a variety of low back, lower extremity, and upper extremity injuries participated.

MAIN OUTCOME MEASURE(S)

At baseline and 6-week follow-up, all patients completed 1 of 3 scales (depending on their injury location) to assess their injured level of function. Scales were the Oswestry Disability Index for low back injuries; Lower Extremity Functional Scale for lower extremity injuries; and Disabilities of the Arm, Shoulder and Hand for upper extremity injuries.

RESULTS

On average, patients received 4.7 ± 1.8 treatments across 48.8 ± 16.1 days. They experienced an increase in function between baseline and follow-up assessments (18.8% ± 20.3%; P < .001, Cohen d = 1.06). Moreover, the amount of functional improvement was clinically meaningful, as it was greater than the minimal clinically important difference for each scale. The efficacy of treatments did not differ according to the internship experiences of the ATSs.

CONCLUSIONS

Function improved in patients after treatment delivered by an ATS. Patient-reported outcome measures were useful for the students in monitoring patient improvement, but more research is needed regarding effective treatments for patients with chronic pain. Our results suggested that ATS clinics provide effective treatments for patients, service to the community, and a learning opportunity for students.

Concussion Knowledge and Clinical Experience Among Athletic Trainers: Implications for Concussion Health Care Practices

CONTEXT

Athletic trainers (ATs) are heavily involved in concussion assessment and return-to-play (RTP) decision making. Despite ATs' crucial role, few researchers have directly examined ATs' knowledge of concussions or whether concussion knowledge or clinical experience affects clinical concussion-management practices.

OBJECTIVE

To determine the overall concussion knowledge of ATs and whether concussion knowledge and clinical experience affect concussion-assessment and -management practices.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Random convenience sample of 8725 (15.0% response rate [1307/8725]; certified, 14.8 ± 10.6 years) ATs surveyed from the National Athletic Trainers' Association membership.

MAIN OUTCOME MEASURE(S)

The survey collected demographics, concussion-assessment and -management tools used, and concussion knowledge (patient-clinician scenarios, signs and symptoms recognition). We used multiple logistic regression models to determine the odds ratios (ORs) for using assessment and management tools based on signs and symptoms recognition and years of clinical experience.

RESULTS

The ATs correctly identified 78.0% ± 15.1% of concussion signs and symptoms. Approximately 46% (357/770) of ATs indicated an athlete could RTP if the athlete stated he or she had a "bell rung." Every additional year of clinical experience decreased the odds of using standardized sideline-assessment tools by 3% (OR = 0.97, 95% Confidence Interval [CI] = 0.95, 0.99). The odds of using standardized sideline tools (OR = 0.98, 95% CI = 0.96, 0.99) and symptom checklists (OR = 0.98, 95% CI = 0.97, 0.99) for RTP assessment were significantly decreased for each additional year of clinical experience. No other tools used for RTP assessment were influenced by signs and symptoms recognition (P ≥ .136) or clinical experience (P ≥ .158).

CONCLUSIONS

The ATs with greater clinical experience had lower odds of using concussion-assessment and -management tools. Athletic trainers should frequently review and implement current consensus guidelines into clinical practice to improve concussion recognition and prevent improper management.

Implementing Patient-Reported Outcome Measures in Outpatient Rehabilitation Settings: A Systematic Review of Facilitators and Barriers Using the Consolidated Framework for Implementation Research

OBJECTIVE

This systematic review examines the facilitators and barriers to the use of patient-reported outcome measures (PROMs) in outpatient rehabilitation settings and provides strategies to improve care to maximize patient outcomes.

DATA SOURCES

Eleven databases were systematically searched from November 2018 to May 2019.

STUDY SELECTION

Two reviewers independently assessed articles based on the following inclusion criteria: English text, evaluate barriers and facilitators, include PROMs, and occur in an outpatient rehabilitation setting (physical therapy, occupational therapy, speech language pathology, or athletic training). Of the 10,164 articles initially screened, 15 articles were included in this study.

DATA EXTRACTION

Data were extracted from the selected articles by 2 independent reviewers and put into an extraction template and into the Consolidated Framework for Implementation Research (CFIR) model. The Appraisal Tool for Cross-Sectional Studies (AXIS) was conducted on each study to assess study design, risk of bias, and reporting quality of the eligible studies.

DATA SYNTHESIS

Ten studies were identified as high quality, according to the AXIS. Based on the CFIR model, the top barriers identified focused on clinician training and time in the implementation process, lack of recognized value and knowledge at the individual level, lack of access and support in the inner setting, and inability of patients to complete PROMs in the intervention process. Facilitators were identified as education in the implementation process, support and availability of PROMs in the inner setting, and recognized value at the individual level.

CONCLUSIONS

More barriers than facilitators have been identified, which is consistent with PROM underuse. Clinicians and administrators should find opportunities to overcome the barriers identified and leverage the facilitators to improve routine PROM use and maximize patient outcomes.

Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers

BACKGROUND

Despite the importance of assessing patient outcomes during patient care, current evidence suggests relatively limited use of patient-reported outcome measures (PROMs) by athletic trainers (ATs). Major barriers to PROM use include lack of knowledge, navigating the intricate process of assessing a wide variety of PROMs, and selecting the most appropriate PROM to use for care. A concise resource for ATs to consult when selecting and implementing PROMs may help facilitate the use of PROMs in athletic health care.

OBJECTIVE

To review the instrument essentials and clinical utility of PROMs used by ATs.

METHODS

We studied 11 lower extremity region-specific, 10 upper extremity region-specific, 6 generic, and 3 single-item PROMs based on the endorsement of at least 10% of ATs who use PROMs, as reported in a recent investigation of PROM use in athletic training. A literature search was conducted for each included PROM that focused on identifying and extracting components of the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and clinical utility (ie, acceptability, feasibility, and appropriateness). Through independent review and group consensus, we also classified each PROM question by International Classification of Functioning, Disability and Health domain and health-related quality-of-life dimensions.

KEY FINDINGS

The PROMs contained in this report generally possessed appropriate instrument essentials and clinical utility. Moreover, the PROMs generally emphasized body structure and function as well as the physical functioning of the patient. Athletic trainers aiming to assess patients via a whole-person approach may benefit from combining different PROMs for use in patient care to ensure broader attention to disablement health domains and health-related quality-of-life dimensions.

Post-concussion driving management among athletic trainers

Primary objective: To describe and compare athletic trainer (AT) post-concussion driving management practices and opinions.Research design: Cross-sectional.Methods & procedures: A survey was sent via email to 8,723 ATs (10.8% response rate[945/8723]) to capture demographics, management practices, and opinions (agreement on a seven-point Likert scale). We used Kruskal-Wallis tests to compare the percentage of patients instructed to refrain from driving across the highest earned a degree, setting, and years certified (alpha = 0.05).Main outcomes & results: When asked whether they recommended patients with concussion refrain from driving, 58.5%(n = 553/945) of ATs responded "sometimes", 37.9%(n = 358/945) responded "always", and 3.6%(n = 34/945) responded "never". ATs responding "sometimes" or "always" estimated that they instruct 57.6 ± 37.6% of patients with concussion to refrain from driving. ATs most commonly: recommended that patients refrain from driving until symptom resolution(44.7%,n = 399/892); utilized their clinical exam (patient interview/history) to determine when a patient could resume driving(64.9%,n = 579/892); and provided instructions verbally(94.2%,n = 840/892). High school(60.5 ± 37.6%) and clinical ATs(66.5 ± 31.2%) trended toward higher percentages of patients they instruct to refrain from driving relative to college(52.3 ± 38.2%; χ²(2) = 5.92,p = .052).Conclusions: ATs recommend driving restrictions to some, but not all, patients with concussion. Overall, ATs recognize post-concussion driving dangers, but do not strongly endorse refraining from driving after a concussion. High school and clinical ATs may manage more adolescent novice drivers and, therefore, act more conservatively.