Despite the increasing availability of multidimensional health status and outcome measures of the patient's physical and emotional functioning, and a number of national initiatives to promote their use, little is known about the attitudes and behaviour of general practitioners (GPs) and practice nurses (PNs) regarding their use in evaluating the effectiveness of health care. What evidence there is remains largely anecdotal but supports the view that health outcome data is currently not used in the routine management of the patient.To investigate the attitudes and behaviour of GPs and PNs regarding the use of health outcome data in the routine care of patients with diabetes.A questionnaire comprising 20 attitudinal and behavioural statements covering the use and benefits of health outcome data in the routine care of patients with diabetes were sent to 156 GPs and 114 PNs in the Doncaster area together with a covering letter and two examples of multidimensional health outcome measures.Completed questionnaires were received from 90 (58%) GPs and 49 (50% corrected for out of scope) nurses. Median response scores showed that both GPs and nurses expressed a positive overall attitude towards health outcome measurement giving responses favourable to it in 15 (75%) and 18 (90%) of the statements respectively. A key finding was that 48% and 46% of GPs and PNs were unclear as to how they would use health outcome data.While our findings reflect a favourable view towards the use of health outcome data for the routine management of the patient with diabetes in a general practice setting, a number of important barriers to their implementation have been identified. These include insufficient knowledge on their use, the need for easily interpretable data, and a lack of resources.
The objective of this article is to illustrate the importance of the role philosophy and its tools play in the designing and undertaking of nursing research and its importance to be understood by the practicing researcher to ensure the selected methodology and the tools used provide the framework for obtaining reliable and valid answers to their research questions. The article discusses the three major paradigms (Positivism, Interpretivism, and Pragmatism) which have characterized much of health-related research together with a set of essential and practical tools with no metaphysical assumptions that will hopefully provide an explicit framework and a nomenclature which can be applied as we proceed through the research process.
Objectives: It is important to know what patient reported outcome measure (PROM) scores relate to a meaningful change in health status across time. The aim of this study was to investigate the minimally important difference (MID) of the Diabetes Health Profile (DHP-18), EQ-5D and SF-6D in a Type 1 and Type 2 diabetes patient sample. Methods: A longitudinal dataset including a UK community sample of people with Type 1 and Type 2 diabetes was used for the analysis. A combination of anchor and distribution methods was used to investigate the MID. For the anchor based method, a global health change indicator was used if it correlated with the PROM scores at baseline and follow up. To calculate the anchor based MID, the change in PROM score for those reporting no change on the anchor was subtracted from those reporting small change. For the distribution based estimation, the 1 Standard Error of Measurement, 0.5 and 0.33 standard deviation methods were used. Results: The anchor was not correlated with the DHP-18 dimensions so was only used to estimate MID values for the EQ-5D and SF-6D. For the DHP-18, MID estimates for the Psychological Distress domain range from 6.99 to 10.59, the Barriers to Activity domain range from 6.48 to 9.89, and the Disinhibited Eating domain range from 7.52 to 11.39. The EQ-5D estimations range from 0.058 to 0.158, and the SF-6D estimations range from 0.038 to 0.081. The 0.5 SD and 1SEM estimations are of a similar magnitude across the three measures. Conclusions:This study has derived a range of values for each measure that may correspond to an important change in health status. The MID values may guide researchers who are using the measures as part of their assessment of both Type 1 and Type 2 patients with diabetes mellitus.
Multiple choice questionnaires (MCQs) capable of being marked manually or by a newly developed optical mark reader, or by use of an inexpensive inter‐active microcomputer system have been developed for the separate assessment of insulin‐dependent and non‐insulin‐dependent patient knowledge. Forty‐six insulin‐related and non‐insulin‐related multiple choice questions covering six main areas of knowledge were constructed for inclusion into draft questionnaires. From the responses of a total of 180 completed questionnaires, piloted in 18 randomly selected clinics in 14 Regional Health Authorities in England, psychometric analysis was performed to determine reliability, discrimination coefficients, and facility indices. Seventy‐three per cent of insulin‐dependent diabetic patients (IDDM) and 92% of non‐insulin‐dependent diabetic patients (NIDDM) MCQ correct options had facility indices within the acceptable range of 30 to 90%. 82% IDDM and 93% NIDDM correct options had discrimination coefficients exceeding 0.2. Questionnaire reliability (internal consistency) using the Kudor‐Richardson (KR20) formula was IDDM 0.87 and NIDDM 0.82. Evidence in support of the IDDM questionnaire's criterion validity was based on significant differences ( p <0.05) identified between a number of knowledge area scores stratified according to HbA 1 levels. Prescriptive correction for screen display and automatic hard copy feedback was designed for both incorrect and omitted question options, providing both educational (patient) and analytical (clinic) documentation. Both technical and psychometric properties of these knowledge assessment instruments should be acceptable for diabetic knowledge evaluation and instruction.
Interest in the measurement of health related quality of life and psychosocial functioning from the patient’s perspective in diabetes mellitus has grown in recent years. The aim of this study is to investigate the psychometric performance of and agreement between the generic EQ-5D and SF-6D and diabetes specific DHP-18 in Type 2 diabetes. This will support the future use of the measures by providing further evidence regarding their psychometric properties and the conceptual overlap between the instruments. The results will inform whether the measures can be used with confidence alongside each other to provide a more holistic profile of people with Type 2 diabetes. A large longitudinal dataset (n = 1,184) of people with Type 2 diabetes was used for the analysis. Convergent validity was tested by examining correlations between the measures. Known group validity was tested across a range of clinical and diabetes severity indicators using ANOVA and effect size statistics. Agreement was examined using Bland-Altman plots. Responsiveness was tested by examining floor and ceiling effects and standardised response means. Correlations between the measures indicates that there is overlap in the constructs assessed (with correlations between 0.1 and 0.7 reported), but there is some level of divergence between the generic and condition specific instruments. Known group validity was generally good but was not consistent across all indicators included (with effect sizes from 0 to 0.74 reported). The EQ-5D and SF-6D displayed a high level of agreement, but there was some disagreement between the generic measures and the DHP-18 dimensions across the severity range. Responsiveness was higher in those who self-reported change in health (SRMs between 0.06 and 0.25). The psychometric assessment of the relationship between the EQ-5D, SF-6D and DHP-18 shows that all have a level of validity for use in Type 2 diabetes. This suggests that the measures can be used alongside each other to provide a more holistic assessment of with the quality of life impacts of Type 2 diabetes.
The prevalence of diabetes mellitus (DM) is increasing dramatically, placing considerable financial burden on the healthcare budget of each country. Patient self-management is crucial for the control of blood glucose, which largely determines the chances of developing diabetes-related complications. Self-management interventions vary widely, and a method is required for assessing the impact of self-management. This paper describes the development of a questionnaire intended for use to measure the impact of self-management in diabetes. An iterative development process was undertaken to identify the attributes of self-management using 5 steps. First, a literature review was undertaken to identify and understand themes relating to self-management of DM to inform a topic guide. Second, the topic guide was further refined following consultation with a Patient and Public Involvement group. Third, the topic guide was used to inform semi-structured interviews with patients with Type 1 DM (T1DM) and Type 2 DM (T2DM) to identify how self-management of DM affects individuals. Fourth, the research team considered potential attributes alongside health attributes from an existing measure (Diabetes Health Profile, DHP) to produce an instrument reflecting both health and self-management outcomes simultaneously. Finally, a draft instrument was tested in a focus group to determine the wording and acceptability. Semi-structured interviews were carried out with 32 patients with T1DM and T2DM. Eight potential attributes were identified: fear/worry/anxiety, guilt, stress, stigma, hassle, control, freedom, and feeling supported. Four of these self-management attributes were selected with four health attributes (mood, worry about hypos (hypoglycaemic episodes), vitality and social limitations) to produce the Health and Self-Management in Diabetes (HASMIDv1) questionnaire. HASMIDv1 is a short questionnaire that contains eight items each with four response levels to measure the impact of self-management in diabetes for both T1DM and T2DM. The measure was developed using a mixed-methods approach that involved semi-structured interviews with people with diabetes. The measure has high face validity. Ongoing research is being undertaken to assess the validity of this questionnaire for measuring the impact of self-management interventions in economic evaluation.
s for plenary sessionsP1 Using Patient Reported Outcome Measures (PROMs) in cancer careGalina VelikovaLeeds Institute of Cancer & Pathology, University of Leeds and Leeds Teaching Hospitals, Leeds, UKMonitoring of patients' physical and psychological problems during and after cancer treatment is essential in modern oncology practice. Traditional clinical methods can be supplemented by Patient-Reported Outcomes Measures (PROMs) measures. The potential role of PROMs is recognised and endorsed by national and international practice guidelines. The introduction of formal measurement of PROMs in clinical practice is a complex health care innovation requiring careful planning, design and successful implementation of a number of essential components, such as choosing the patient questionnaire(s), a convenient affordable electronic method for reporting and display in hospital records and engaging clinicians to use and act on the reports. There is mounting research evidence that using PROMs in individual patient care in oncology is beneficial to patients, but this approach has not found a place in routine clinical practice. A brief overview of this evidence will be provided. Following this, the presentation will focus on examples of incorporating PROMs and eHealth interventions into routine patient care during and after cancer treatment, drawing on 20 years' experience in Leeds of using electronic systems for capturing patient reported data in oncology settings. Examples will be given of: 1) Monitoring toxicity during systemic cancer treatment using online PROMs integrated with Electronic Patient Records (randomized trial part of NIHR eRAPID programme); 2) Service development project - Remote follow-up of testicular cancer patients using online PROMs plus community-based investigations. Examples of other online PROMs systems will be presented. The values and challenges of PROMs integration in routine oncology practice will be discussed.P2 The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS): a view from the UKJose M Valderas1,2 1Health Services & Policy Research Group, University of Exeter Medical School, Exeter UK; 2Exeter Collaboration for Academic Primary Care (APEx), Exeter, UKThe Patient-Reported Outcomes Measurement Information System (PROMIS) is a system for the measurement of patient reported outcomes whose development was funded by the US National Institute for Health. Its methodological rigor, scope, ambition and flexibility (including both standardized short forms and computerized adaptive administration) has turned it into one of the standards of PROMs measurement, although its use is still very limited outside the US. The presentation will provide an overview of the rationale for the development of the system, the methods employed in its development and the resulting scales and short forms and key characteristics, including Assessment Centre, the online platform supporting the use of PROMIs scales. Current applications and use of PROMIS in the UK will be reviewed and the potential for its application to support the management of patients in the NHS will be considered.
Measuring symptom specific health outcome is complex, but the methodologies now exist to develop measures with the appropriate properties.As one element of a major programme to develop muldo health outcome measures for chronic disease, a symptom based measure for asthma care has been developed for use in general practice and outpatient departments.This article outlines the development process, which used a framework recently described in the theoretical literature to show the constraints that scientific criteria place on the development of outcome measures and the means of overcoming such limiting factors.Although substantial effort is required to undertake a rigorous process of development, useful tools are the result.Two five item, symptom based outcome measures for adult asthma are described.
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