Use of a patient reported outcome measure with acute adult in-patients receiving physiotherapy

Purpose

The use of outcome measures is well evidenced and documented. Despite prevalent use of various clinician reported outcome measures (CROMs), patient reported outcome measures (PROMs) are often in the form of detailed quality of life questionnaires, which are not appropriate in acute, fast paced environments. A new PROM tool (called thera-PROM) was devised and used with the aim of measuring the effect of goal-focused physiotherapy interventions in an acute adult in-patient setting. Process and data evaluation aims to identify standards and guidelines for future use to support service evaluation and quality measurement.

The small scale project was carried out as a starter to implement an appropriate PROM tool for the clinical area where there was not previously any PROM tool used as it had not been possible to identify an existing PROM tool that was fit for purpose.  The findings may be useful to share with other therapists for wider use or consideration when implementing a PROM tool.

Approach

The PROM tool was devised using a development framework based on a literature review of PROM tools. This was carried out as a separate project and has been reported in poster format by the author separately.

The tool uses treatment focused questions selected for the patient population. The patient rates their response to the question using an 11 point verbal rating scale (0-10) on initial assessment and final treatment interventions. Improvement scores were calculated by subtracting the initial score from the end score. The tool was used for a three-month pilot study with patients who had had a general surgical procedure. Data was collected prospectively, analysed and evaluated. The initial three-month period was extended indefinitely. Cognitively impaired and non-English speaking patients were exempt from using the PROM tool.

Outcomes

Between June and August 2017 the number of complete data sets collected almost doubled (where n increased from 11 to 21). Initial scores collected which resulted in a complete data set increased from 55% to 81%. The mean improvement scores of 4.00 demonstrates an improvement score of 36.36%. The number of complete datasets stabilised between September 2017 and February 2018 (range n= 12-26 ) however, a diminishing trend for mean improvement scores (a drop from 3.38 to 2.06) was identified.

The patient population changed; Patients with acute medical conditions were out-lied to the surgical wards. Elective surgery was cancelled. The patients with medical conditions were frequently discharged to tertiary units for continuation of physiotherapy thus the end scores reported were not representative of completed treatment. Also, the questions used as part of the tool were not appropriate for the altered patient population; consequently the data lacked validity.

Cost and savings

There was no cost associated with the project / service evaluation.

The findings are useful in providing feedback to the treating therapist in evaluation of service / treatment given to patinets on an individual basis which may contribute to treatment modification and therefore effectiveness and efficiency.

Collection of more data and psychometric analysis in the future will determine if thera-PROM can be reliably used as a valid OM for evaluating treatment effectiveness as part of a larger data set when evaluating services.

Implications

The increasing number of datasets suggests that the PROM tool was effectively embedding into practice with a small patient population. Key points for future work are highlighted: · Exploring and refining operational use ensuring datasets represent patient caseload. · Psychometric analysis of the tool: validity, reliability and minimally important clinical difference. · Setting local standards and guidelines for PROMs. For example, a percentage target for identified patient populations.

The findings of this highlight that a simple, context specific tool can be implemented for routine PROM data collection in a small patient population. Using PROMs in conjunction with CROMs and Patient Reported Experience Measures creates an outcome measure "bundle" facilitating service evaluation. The tool has flexibility to be patient focused, yet treatment specific. Evaluation of improvement scores may inform practice and treatment selection and identify changes in patient care needs. The potential use for other clinical settings and professions demands future exploration.

Top three learning points

  1. That it is possible to implement a simple, context specific PROM for use by physiotherapists and therapy support workers which contributes to a “bundle” of outcome measures with potential for service evaluation purposes.
  2. The thera-PROM tool questions were specifically designed and structured for the intended patient population and are not transferable to other patient populations; however, the design of the tool and the verbal rating scale may be transferable.
  3. Measuring a PROM score pre and post treatment provides timely feedback to the treating clinician and enables treatment planning and modification as well as a basis for enhancing patient-therapist communication to identify the patients treatment goals. Whilst improved scores potentially demonstrate effective treatment delivery it also highlighted the need for psychometric analysis and assessment of the PTOM tool value.

Fund acknowledgements

This service evaluation was generated from preliminary work that was carried out as part of a Masters of science degree which was funded by "Learning Beyond Recognition" Leicester, Leicestershire and Rutland. The dissertation module of which was funded by the Chartered Society of Physiotherapy charitable funds.

Additional notes

This work was presented at Physiotherapy UK 2018.

For further information about this work contact: ruth.johnson@uhl-tr.nhs.uk