Clinician's Checklist for Reading and Using an Article About Patient-Reported Outcomes

Clinicians need evidence-based medicine to help them make clinical decisions with their patients. For many health problems, the goal of treatment is to help the patient to function and feel better. To measure patient functioning, well-being, and symptoms, questionnaires referred to as patient-reported outcome (PRO) measures are often used. Clinicians are generally not trained in survey design, scale development, and questionnaire administration, making it difficult for them to interpret and effectively use PROs as clinical evidence. It is increasingly important that clinicians be able to understand and use outcomes measured from both the clinical and patient perspectives to inform their practice. We aim to provide a “Clinician's Checklist” to help practicing clinicians understand clinical research articles that include PROs so that the information can be used for decision making. This checklist provides an itemization of important areas for the reader to consider in evaluating research articles. We propose that clinicians consider 5 elements when reading a study using PROs: study design and PRO assessment strategy, PRO measure performance, validity of results, context of the findings, and generalizability to their own patient population. Patient-reported outcomes play an increasingly prominent role in clinical research and practice, and this trend has the potential to improve the patient-centeredness of care. Clinicians will need to understand how to use PROs to partner with patients and help them function and feel better. The proposed Clinician's Checklist can help clinicians systematically evaluate PRO studies by determining whether the study design was appropriate and whether the measurement approach was adequate and properly executed as well as by assisting in the interpretation and application of the results to a specific patient population.     

Benefits to Patients and Clinicians of Discussing Explanatory Images During Uterine Fibroid Consultations

This study of an interventional radiology practice's uterine fibroid embolization (UFE) consultations explains how patient-clinician discussion of images produces communication patterns that benefit patients and clinicians. The examples analyzed here show how inconsultation discussion of images aids patients' treatment decisions by enhancing their understanding and recall of information about causes of uterine fibroid tumor symptoms and the UFE procedure. The data also show that such interaction affects clinicians' understandings of patients' particular information needs and concerns. Discussion of images prompts patients to present information about their current medical conditions and treatments, which they did not reveal earlier during standard history taking. Both patients and clinicians mentioned that inconsultation discussion of explanatory images led to patients' satisfaction with their consultations.     

Technologic advances in psychiatric nursing

This is an exciting time to be involved with the care of patients with mental illness. More and more information about what is happening in the brain when mental illness develops is becoming available. Even more important, however, clinicians need not be seduced by the secrets of the brain being discovered. Psychiatric nurses must remember that patients have real and frightening experiences. They alone must learn to adapt and function with their symptoms of mental illness. To the degree that clinicians become enamored of the science and technology, they may lose their empathy with the human experience of mental illness [11]. Nurses, who help people respond to their illnesses, must engage the science with curiosity and engage the person with empathy.     

Communicating good care: A qualitative study of what people with urological cancer value in interactions with health care providers

PurposeCommunication with health care providers is important to help meet cancer patients' information and support needs. It can significantly affect the extent to which patients feel cared for, respected and involved, and it can influence a range of cancer care processes and outcomes. This paper presents findings from a study which explored urological cancer patients' experiences of care, focussing on insights into what they appeared to value in their interactions with health care providers and why.MethodIn-depth interviews were undertaken with 20 men and 6 women with different types of urological cancer at a range of times since diagnosis. Interviews were audio-recorded, transcribed and thematically analysed using an established interpretive approach.ResultsPatients valued being treated as someone who mattered and was worthy of care; being recognised and responded to as an individual; and experiencing support for autonomy/agency. Reasons for their valuations related to the implications of communicative interactions for the ways patients thought health professionals related to them ‘as persons’. Our findings highlight the value of relational aspects of communication for: indicating to patients what clinicians think of their worth; facilitating individualised care; and enabling patients to contribute to their own care.ConclusionsEfforts to improve health care provider-patient communication should attend not only to the transfer of information about the condition and its management but to the range of features of interactions that can signal to people how health care providers relate to them as persons.     

Clinical outcomes assessment for the management of sport-related concussion

PATIENT SCENARIO: An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life. CLINICAL OUTCOMES ASSESSMENT: Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms. CLINICAL DECISION MAKING: The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete's symptoms. CLINICAL BOTTOM LINE: Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.     

Uncertainties in real‐world decisions on medical technologies

Patients, clinicians, payers and policy makers face substantial uncertainties in their respective healthcare decisions as they attempt to achieve maximum value, or the greatest level of benefit possible at a given cost. Uncertainties largely come from incomplete information at the time that decisions must be made. This is true in all areas of medicine because evidence from clinical trials is often incongruent with real‐world patient care. This article highlights key uncertainties around the (comparative) benefits and harms of medical technologies. Initiatives and strategies such as comparative effectiveness research and coverage with evidence development may help to generate reliable and relevant evidence for decisions on coverage and treatment. These efforts could result in better decisions that improve patient outcomes and better use of scarce medical resources.     

What information on quality specifications should be communicated to clinicians, and how?

BACKGROUND: Quality specifications, the level of performance required to facilitate clinical decision-making, not only have a central role in quality management in the laboratory but are also essential for assuring the interpretation and utilization of laboratory data by physicians. Consensus has been reached on the hierarchy of criteria for quality specifications. However, the information on quality specifications that should be communicated to clinicians, and the way in which this information should be given, is still widely debated. METHODS: Laboratory tests have been grouped into four categories including uni-modal, and bi-modal distributions, tests used in patients monitoring and in evaluating the response to therapy (serial measurements), and, finally, tests that require interpretive comments. The most suitable and informative ways to communicate quality specifications to clinicians have been proposed for each category. RESULTS: For tests with a uni-modal distribution, the decision limits should replace traditional reference values in the report. For tests with a bi-modal distribution, in addition to traditional reference values, some flags based on the uncertainty (i.e., analytical and biological variability) of laboratory data, can be included to help clinicians interpret laboratory data. For tests used in monitoring patients and in evaluating the response to therapy (serial measurements), the reference change value or the most effective threshold of the difference between two consecutive results should be indicated. For tests/test batteries that require interpretive comments, these should be added to the report and discussed in multidisciplinary meetings and interpretive rounds to promote knowledge of a more objective evaluation of laboratory data. CONCLUSIONS: A proposal has been made to improve the way laboratory results are communicated to clinicians, with practical information derived from quality specifications. By providing clinicians with information on quality characteristics and the degree of uncertainty, a more objective interpretation of laboratory data may be possible, and data may be more appropriately utilized for diagnosis and monitoring.     

A New and Inclusive Intake Form for Diagnostic Imaging Departments

IntroductionThe gender landscape is changing. For professionals in health care, particularly diagnostic imaging (DI), we need better communication tools to obtain personal information from this gender diverse community. We need more specific information from patients because we are performing examinations in which radiation is involved. It is our professional duty to protect a patient's reproductive organs whenever possible, but we must know where those organs are located. In addition, we must determine if a patient could be pregnant or not. Compliance to the professional duty must also extend to transgender and nonbinary patients. Transgender patients do not express or identify the same as their sex assigned at birth; therefore, we may shield inappropriately and expose their reproductive organs unintentionally. Nonbinary patients do not identify as either male or female, and therefore, their expression does not indicate reproductive organ location.MethodThere are currently no specific forms in DI that ask the questions we need to know to protect the public from unnecessary radiation exposure to reproductive organs. In developing the new form, we began looking at current practices in DI departments to better understand where the communication gap was and what important information would be required in the new form.ResultThe authors have created a new intake form that accommodates all patients—regardless of age or gender. The result is the SIGE (Sex, Identity, Gender, Expression) form.DisscussionThe SIGE form is inclusive and asks the necessary questions medical radiation technologists need to know in a respectful and professional manner so that we can shield gonadal tissue from ionizing radiation. In addition, the intention of the form is to help the gender diverse community to feel safe and respected in our department.     

How important is the opinion of significant others to cancer patients’ adjuvant chemotherapy decision-making?

GOALS: Decisions regarding adjuvant chemotherapy are difficult, since value tradeoffs are involved. Little is known about the importance of the significant others in patients' decision-making regarding adjuvant treatment. We surveyed patients with breast and colorectal cancer about the importance they assigned to the opinions of their significant others and assessed correlates of these importance scores. MATERIALS AND METHODS: One hundred and twenty-three patients rated on a five-point scale how much they cared about the opinion of six significant others. MAIN RESULTS: Most important was the opinion of their treating specialist, followed by that of their partner, children, other family, friends, and colleagues. Women assigned higher scores to the opinion of their children, younger patients to that of their specialist, and patients who were about to undergo chemotherapy to that of their family. Patients with breast cancer and patients without paid employment assigned slightly more importance to the opinion of their partner. CONCLUSIONS: Information on the influence of significant others may help clinicians when involving patients in treatment decision-making and discussing patients' treatment preferences.     

Effects of patient deaths by suicide on clinicians working in mental health: A survey

In the UK, at least a quarter of suicides occurs in patients whilst under the care of mental health services. This study investigated the effects of such deaths on non-medical mental health clinicians. An online survey was conducted within a single NHS mental health Trust to elicit both quantitative and qualitative responses from staff across a range of professions. The survey focused on personal and professional impacts and available support. Participants reported significant negative emotional and professional effects that were long-lasting for some. These included mental health difficulties, loss of confidence regarding clinical responsibilities, and actual or contemplated career change. However, there was also some evidence of positive effects and professional growth. Support from colleagues and line managers is clearly important following deaths of patients by suicide. Clinicians' experiences of the support they had received in the workplace were polarized, suggesting that there is no single nor ideal approach that will meet everyone's needs. Participants made recommendations for the types of support that may be helpful. Most commonly, clinicians desired opportunities for focused reflection and support and help with the formal processes following the death. Sensitivity around how clinicians are notified about the death was highlighted as being particularly important. Conclusions are drawn as to how training institutions and employers can help staff to be better prepared for the potential occurrence of patient suicides and the formal processes that follow, with a view to mitigating risks of more serious harm to staff and hence indirectly to patients, and potential loss of highly trained clinicians to the workforce.     

Injuries in The Netherlands: results of surveillance-based public health research.

Public health is the scientific field which aims to study, preserve and improve the health of populations. Its primary diagnostic tool is public health surveillance. In this paper the methodology and results are presented of three surveillance-based studies on injury patients in The Netherlands. With the help of national registration data the economic burden of injury was assessed, and both time trends and regional differences in injury mortality were analysed. The results show that the societal burden of injury is high on the one hand, but that there seems large potential for reducing health damage by prevention and improved emergency care on the other. It was also shown that surveillance-based studies may reveal differences in patient outcome by time period or geographic region. In this way they provide valuable information for an assessment of the quality of individual patient care, including the care by emergency clinicians. A basic condition, however, is the availability of valid surveillance data. A central issue is the recording of information on the injury diagnosis, including information on injury severity. This can only be obtained if clinicians are willing to collect data. Public health surveillance therefore highly relies on the co-operation of clinicians.     

Tracheostomy in the acute setting: Patient experience and information needs

Purpose

The placement of a tracheostomy tube is a common hospital procedure used to clear secretions or bypass upper airway obstruction. However, little is known about patients' experiences of tracheostomy or the adequacy of the information provided to them.

Methods

This pilot qualitative study used semistructured interviews with 8 patients to gain a deeper understanding of their experiences. They were recruited from and interviewed in a large teaching hospital in the South of England.

Results

Four main themes were identified: physical sensations, understanding, information, and experiences after removal of the tracheostomy tube.

Conclusions

This research suggests that the experience of tracheostomy is a complex mix of physical sensations and emotions. Despite being a relatively routine procedure for clinicians, it can be very distressing to patients both during and after removal. Information needs to be more comprehensive, and it should be tailored to suit individual patient needs.     

CPR policies and the patient's best interests

Standard hospital CPR policies in many countries require CPR to be attempted on all patients having a cardiac arrest unless a Not-for-CPR order is in place. It has recently been shown that this approach is legally inappropriate in New Zealand. It appears that this argument may also potentially apply in other common law countries given the role that ‘best interests’ has in these jurisdictions in providing treatment to patients lacking decision-making capacity. Not-for-CPR orders provide an important and transparent mechanism for making advanced decisions regarding resuscitation. However, advanced planning is not always possible and it is legally inappropriate to require CPR to be performed when it is not in the patient's best interests. Notwithstanding the difficult practical balance that exists at the time of arrest between initiating CPR without delay or interruption for it to be effective for those whom CPR is in their best interests, and recognising as quickly as possible those patients for who CPR is not appropriate, it is argued that policies should be modified to allow clinicians to consider whether CPR is appropriate at time of arrest. Such a change may require ALS training to include a stronger emphasis on early recognition of patients for whom CPR is not in their best interests.     

How should we make the admission decision in community-acquired pneumonia?

The spectrum of pneumonia patients ranges from only slightly compromised patients to patients who require life-sustaining measures. Admission decision support algorithms usually are not required for patients at either end of the spectrum. For patients presenting with intermediate severity of illness, decision support algorithms have shown that they can support clinicians in the admission decision and complement the clinicians' experience and clinical judgment with an objective tool. Clinical information systems may help overcome the existing obstacles to successful implementation. Successful guideline implementation in a clinical setting includes strategies that target not only the disease, but also include other forces that significantly influence the admission decision. Shared decision making and better managing of patients' expectations about treatment and prognosis need to be incorporated in the overall admission decision. The availability of improved outpatient management, such as outpatient intravenous antibiotic treatment and home health care, and a change in physicians' perspectives and patients' expectations may help to increase the proportion of outpatient management without compromising the quality of care. Decision support tools for pneumonia are available and show promising results. Further studies are needed, however, that show the successful dissemination and clinical implementation during routine patient care. Studies are needed that assess the impact of guidelines and prediction rules on patient outcomes. As the example of the PSI shows, the development, implementation, and dissemination of admission decision support systems is not a revolutionary, but a stepwise, evolutionary process that requires many years of research.     

In the system: the lived experience of chronic back pain from the perspectives of those seeking help from pain clinics

Narrative accounts of their lived experiences were collected from twenty back pain patients who were seeking help from two pain clinics in the UK. Following analysis using a phenomenological approach, five themes emerged which tell a typical story of back pain. One prominent emergent theme, ‘in the system', is reported in which participants tell how they became entrapped within the medical, social security and legal systems. These systems, designed to treat or support those who are ill or disabled, effectively rendered participants powerless, helpless and angry. It is suggested that these accounts may help clinicians and researchers to gain a better understanding of the origins and nature of the negative attitudes exhibited by many back pain patients who seek help from pain treatment centres.