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Background The use of Patient Reported Outcome Measures (PROMS) in clinical practice has the potential to promote patient-centred care and improve patients’ quality of life. Individualized PROMs may be particularly helpful in identifying, prioritizing and monitoring health problems of patients with multimorbidity. We aimed to develop an intervention centred around PROMs feedback as part of Primary Care annual reviews for patients with multimorbidity and evaluate its feasibility and acceptability. Methods We developed a nurse-oriented intervention including (a) training of nurses on PROMs; (b) administration to patients with multimorbidity of individualized and standardized PROMS; and (c) feedback to both patients and nurses of PROMs scores and interpretation guidance. We then tailored the intervention to patients with two or more highly prevalent conditions (asthma, COPD, diabetes, heart failure, depression, and hip/knee osteoarthritis) and designed a non-controlled feasibility and acceptability evaluation in a convenience sample of primary care practices (5). PROMs were administered and scores fed back immediately ahead of scheduled annual reviews with nurses. Patients and nurses rated the acceptability of the intervention using with a brief survey including optional free comments. Thematic analysis of qualitative interviews with a sample of participating patients (10) and nurses (4) and of survey free comments was conducted for further in-depth evaluation of acceptability. Feasibility was estimated based on rates of participation and completion. Results Out of 68 recruited patients (mean age 70; 47% female), 68 completed the PROMs (100%), received feedback (100%) and confirmed nurse awareness of their scores (100%). Most patients (83%) “agreed”/”strongly agreed” that the PROMs feedback had been useful, a view supported by nurses in 89% of reviews. Thematic analysis of rich qualitative data on PROMS administration, feedback and role in annual reviews indicated that both patients and nurses perceived the intervention as acceptable and promising, emphasizing its comprehensiveness and patient-centredness. Conclusions We have developed and tested an intervention focusing on routine PROM assessment of patients with multimorbidity in Primary Care. Preliminary findings support its feasibility and a high degree of acceptability from both patients and nurses. The next step is to conduct a full-scale trial for evaluating the effectiveness of the proposed intervention.

Background The National Health Service in England pledged >£365 million to improve access to mental healthcare services via Community Perinatal Mental Health Teams (CPMHTs) and reduce the rate of perinatal relapse in women with severe mental illness. This study aimed to explore changes in service use patterns following the implementation of CPMHTs in pregnant women with a history of specialist mental healthcare in England, and conduct a cost-analysis on these changes. Methods This study used a longitudinal cohort design based on existing routine administrative data. The study population was all women residing in England with an onset of pregnancy on or after 1st April 2016 and who gave birth on or before 31st March 2018 with pre-existing mental illness ( N  = 70,323). Resource use and costs were compared before and after the implementation of CPMHTs. The economic perspective was limited to secondary mental health services, and the time horizon was the perinatal period (from the start of pregnancy to 1-year post-birth, ~ 21 months). Results The percentage of women using community mental healthcare services over the perinatal period was higher for areas with CPMHTs (30.96%, n=9,653) compared to areas without CPMHTs (24.72%, n=9,615). The overall percentage of women using acute care services (inpatient and crisis resolution teams) over the perinatal period was lower for areas with CPMHTs (4.94%, n=1,540 vs. 5.58%, n=2,171), comprising reduced crisis resolution team contacts (4.41%, n=1,375 vs. 5.23%, n=2,035) but increased psychiatric admissions (1.43%, n=445 vs. 1.13%, n=441). Total mental healthcare costs over the perinatal period were significantly higher for areas with CPMHTs (fully adjusted incremental cost £111, 95% CI £29 to £192, p -value 0.008). Conclusions Following implementation of CPMHTs, the percentage of women using acute care decreased while the percentage of women using community care increased. However, the greater use of inpatient admissions alongside greater use of community care resulted in a significantly higher mean cost of secondary mental health service use for women in the CPMHT group compared with no CPMHT. Increased costs must be considered with caution as no data was available on relevant outcomes such as quality of life or satisfaction with services.

Objectives To determine the extent to which practice level scores mask variation in individual performance between doctors within a practice.Design Analysis of postal survey of patients’ experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices. Setting Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey.Participants 7721 of 15 172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013.Main outcome measure Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models.Results After control for differences in patients’ age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores.Conclusions Aggregating patients’ ratings of doctors’ communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to “screen” for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners.

Background Lateral elbow tendinopathy (LET) is a common condition affecting adults. Although a lack of treatment consensus continues to prompt numerous effectiveness studies, there is a paucity of clear guidance on the choice of outcome measure. Our aim was to undertake a standardised evaluation of the available clinical rating systems that report patient-centred outcomes in LET. Methods A systematic review of studies reporting the development, assessment of metric properties and/or use of instruments aiming to quantify LET-specific patient-centred outcome measures was conducted in MEDLINE, Embase and CINAHL (inception-2017) adhering to PRISMA guidance. The evidence for each instrument was independently assessed by two reviewers using the standardised evaluating measures of patient-reported outcomes (EMPRO) method evaluating overall and attribute-specific instrument performance (metric properties and usability). EMPRO scores > 50/100 were considered indicative of high performance. Results Out of 7261 references, we identified 105 articles reporting on 15 instruments for EMPRO analysis. Median performance score was 41.6 (range 21.6–72.5), with four instruments meeting high-performance criteria: quick Disabilities of the Arm Shoulder and Hand score (qDASH) (72.5), DASH (66.9), Oxford Elbow Score (OES) (66.6) and Patient-Rated Tennis Elbow Evaluation (PRTEE) (57.0). One hundred seventy-nine articles reported instrument use internationally with DASH as the most frequent (29.7% articles) followed by PRTEE (25.6%), MEPS (15.1%) and qDASH (8.1%). The correlation between frequency of use and performance was r  = 0.35 (95%CI − 0.11; 0.83). Conclusions This is the first study to provide standardised guidance on the choice of measures for LET. A large number of clinical rating systems are both available and being used for patients with LETs. Robust evidence is available for four measures, the DASH, QDASH, PRTEE and OES. The use of instruments in the literature is only in part explained by instrument performance.

Background Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation. Methods An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed. Results Eight out of twenty teams were recruited and randomised . Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI − 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI − 1.4 to 10.2; N = 17) at 8 months. Discussion While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions. Trial registration ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).

Purpose The validity and reliability of various items on the GP Patient Survey (GPPS) survey have been reported, however stability of patient responses over time has not been tested. The purpose of this study was to determine the test–retest reliability of the core items from the GPPS. Methods Patients who had recently consulted participating GPs in five general practices across the South West England were sent a postal questionnaire comprising of 54 items concerning their experience of their consultation and the care they received from the GP practice. Patients returning the questionnaire within 3 weeks of mail-out were sent a second identical (retest) questionnaire. Stability of responses was assessed by raw agreement rates and Cohen’s kappa (for categorical response items) and intraclass correlation coefficients and means (for ordinal response items). Results 348 of 597 Patients returned a retest questionnaire (58.3 % response rate). In comparison to the test phase, patients responding to the retest phase were older and more likely to have white British ethnicity. Raw agreement rates for the 33 categorical items ranged from 66 to 100 % (mean 88 %) while the kappa coefficients ranged from 0.00 to 1.00 (mean 0.53). Intraclass correlation coefficients for the 21 ordinal items averaged 0.67 (range 0.44–0.77). Conclusions Formal testing of items from the national GP patient survey examining patient experience in primary care highlighted their acceptable temporal stability several weeks following a GP consultation.

The use of Patient Reported Outcome Measures (PROMS) in clinical practice has the potential to promote patient-centred care and improve patients' quality of life. Individualized PROMs may be particularly helpful in identifying, prioritizing and monitoring health problems of patients with multimorbidity. We aimed to develop an intervention centred around PROMs feedback as part of Primary Care annual reviews for patients with multimorbidity and evaluate its feasibility and acceptability. We developed a nurse-oriented intervention including (a) training of nurses on PROMs; (b) administration to patients with multimorbidity of individualized and standardized PROMS; and (c) feedback to both patients and nurses of PROMs scores and interpretation guidance. We then tailored the intervention to patients with two or more highly prevalent conditions (asthma, COPD, diabetes, heart failure, depression, and hip/knee osteoarthritis) and designed a non-controlled feasibility and acceptability evaluation in a convenience sample of primary care practices (5). PROMs were administered and scores fed back immediately ahead of scheduled annual reviews with nurses. Patients and nurses rated the acceptability of the intervention using with a brief survey including optional free comments. Thematic analysis of qualitative interviews with a sample of participating patients (10) and nurses (4) and of survey free comments was conducted for further in-depth evaluation of acceptability. Feasibility was estimated based on rates of participation and completion. Out of 68 recruited patients (mean age 70; 47% female), 68 completed the PROMs (100%), received feedback (100%) and confirmed nurse awareness of their scores (100%). Most patients (83%) \"agreed\"/\"strongly agreed\" that the PROMs feedback had been useful, a view supported by nurses in 89% of reviews. Thematic analysis of rich qualitative data on PROMS administration, feedback and role in annual reviews indicated that both patients and nurses perceived the intervention as acceptable and promising, emphasizing its comprehensiveness and patient-centredness. We have developed and tested an intervention focusing on routine PROM assessment of patients with multimorbidity in Primary Care. Preliminary findings support its feasibility and a high degree of acceptability from both patients and nurses. The next step is to conduct a full-scale trial for evaluating the effectiveness of the proposed intervention.

Background: Patient reported outcome measures (PROMs) are regularly used in research, and increasingly in clinical practice for individuals with chronic conditions, to gather patients’ perspective on their experience of health. Whereas research applications have focused on the use of aggregate PROMs information, biological rhythms and other intraindividual cycles have potential implications for how patients report on their health using PROMs, and ultimately the scores that are produced, with potentially important implications for the use of PROMs at the individual level. Research on this issue is, however, sparse and results in a lack of understanding of the key concepts, methods and associated phenomena associated with individual cyclical variation in PROMs scores.Aim: The aim of this thesis is to explore the cyclical variation in patient reported outcome measurements (PROMs) in patients with chronic conditions. Specific objectives included: a) the development of a conceptual model for researching cyclical variation of PROMs, b) the elicitation of patient perspectives on cyclical variation in PROMs, and c) the mapping, selection and use of best methods for the statistical modelling of cyclical variation.Method: This thesis comprised of three sequential studies which informed each other to address the aims and objectives of the thesis. A mixed methods scoping review, considering both quantitative and qualitative research, was conducted to map out the knowledge on cyclical variation of patient reported outcome measurements in patients with chronic conditions. Findings from this scoping review informed the development of a conceptual model building up on established outcomes models. A longitudinal mixed methods study was conducted to understand the factors that were important in the cyclical variation of PROMs from the patients’ perspective, to test the concepts within the conceptual model and to refine it. Sixteen individuals recruited with varying combinations of asthma, depression and osteoarthritis and conducted a total of 3 interviews with each participant over a 9-month period, in order to account for seasonal changes. Finally, variation in outcome scores for a range of symptoms (aural fullness, tinnitus, dizziness, and hearing loss) in Meniere’s disease was modelled by applying Fourier transformation using quantitative longitudinal data on Meniere’s symptoms captured across time.Results: The scoping review identified 33 articles which provided empirical evidence for cyclical variation in PROMs, in respiratory, musculoskeletal, mental health and neurological conditions. The hypotheses and findings in the documents were used to develop a conceptual model of cyclical variation of PROMs in chronic conditions which included the following concepts: determinants (biorhythms, timing and type of healthcare interventions), variation in outcomes (health conditions, outcomes, and time-period), a mediator (psychological health status), moderators (individual and environmental factors), and variation in scores (cognition, integration, measurement, recall and interpretation). Patient interviews confirmed both cyclical variations in outcomes as experienced by patients themselves as well as the relevance of the concepts included in the conceptual model and supported the inclusion of additional ones (sleep, partners interpretation of outcomes and salience of recent episodes and/or flare ups). Fourier analysis of the Meniere’s disease data showed that the severity of symptoms was reported differently across a 24-hour period. Individuals reported the morning to be the worst time of the day for hearing loss and dizziness, tinnitus, and aural fullness peaking around 1/2pm. However, all four symptoms presented a decline in symptom severity by the evening.

Background There is growing interest in real‐time feedback (RTF), which involves collecting and summarizing information about patient experience at the point of care with the aim of informing service improvement. Objective To investigate the feasibility and acceptability of RTF in UK general practice. Design Exploratory randomized trial. Setting/Participants Ten general practices in south‐west England and Cambridgeshire. All patients attending surgeries were eligible to provide RTF. Intervention Touch screens were installed in waiting areas for 12 weeks with practice staff responsible for encouraging patients to provide RTF. All practices received fortnightly feedback summaries. Four teams attended a facilitated reflection session. Outcomes RTF ‘response rates’ among consulting patients were estimated, and the representativeness of touch screen users were assessed. The frequency of staff–patient interactions about RTF (direct observation) and patient views of RTF (exit survey) were summarized. Associated costs were collated. Results About 2.5% consulting patients provided RTF (range 0.7–8.0% across practices), representing a mean of 194 responses per practice. Patients aged above 65 were under‐represented among touch screen users. Receptionists rarely encouraged RTF but, when this did occur, 60% patients participated. Patients were largely positive about RTF but identified some barriers. Costs per practice for the twelve‐week period ranged from £1125 (unfacilitated team‐level feedback) to £1887 (facilitated team ± practitioner‐level feedback). The main cost was the provision of touch screens. Conclusions Response rates for RTF were lower than those of other survey modes, although the numbers of patients providing feedback to each practice were comparable to those achieved in the English national GP patient survey. More patients might engage with RTF if the opportunity were consistently highlighted to them.

ObjectiveTo examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care.DesignMixed methods study integrating data from patient questionnaires completed immediately after a video-recorded face-to-face consultation with a general practitioner (GP) and subsequent interviews with the same patients which included playback of the recording.Setting12 general practices in rural, urban and inner city locations in six areas in England.Participants50 patients (66% female, aged 19–96 years) consulting face-to-face with 32 participating GPs.Main outcome measuresPositive responses to interpersonal skills items in a postconsultation questionnaire (‘good’ and ‘very good’) were compared with experiences reported during subsequent video elicitation interview (categorised as positive, negative or neutral by independent clinical raters) when reviewing that aspect of care.ResultsWe extracted 230 textual statements from 50 interview transcripts which related to the evaluation of GPs' interpersonal skills. Raters classified 70.9% (n=163) of these statements as positive, 19.6% (n=45) neutral and 9.6% (n=22) negative. Comments made by individual patients during interviews did not always express the same sentiment as their responses to the questionnaire. Where questionnaire responses indicated that interpersonal skills were ‘very good’, 84.6% of interview statements concerning that item were classified as positive. However, where patients rated interpersonal skills as ‘good’, only 41.9% of interview statements were classified as positive, and 18.9% as negative.ConclusionsPositive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of ‘good’ feedback. Relative scores are more easily interpretable when used to compare the performance of providers.