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Patient Reported Experience Measure

Patient Reported Experience Measure. Dr. Mahesh D Kumar Consultant Anaesthetist Trafford General Hospital 22 nd March 2012. Introduction. Valid, Reliable and Responsive measure VAS PONV impact scale Nine Item Questionaire 40 item Questionaire

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Patient Reported Experience Measure

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  1. Patient Reported Experience Measure Dr. Mahesh D Kumar Consultant Anaesthetist Trafford General Hospital 22nd March 2012

  2. Introduction • Valid, Reliable and Responsive measure • VAS • PONV impact scale • Nine Item Questionaire • 40 item Questionaire • Myles, P.S. BJA 2000 Myles, P.S. BJA 2012

  3. Quality of outcome • Patient’s perception of their outcome of care • Eberhart, L.H.Anaesthesist 2002 Gill, T.M. JAMA 1994 Guyatt, G.H. JAMA 1994 • Traditional Factors • Time to awakening • Duration of stay • Pain, emesis and confusion • Lee, A. Anaesth Intensive Care 1996

  4. Consequences of Traditional factors • Transient events: negative recollection of recovery from surgery • Poor quality recovery- prolongs duration of stay • Delays discharge from hospital- Resource utilisation • Moerman. ACTA Anaesthesiol Scan 1992 Tong, D. Anesthesiology 1997

  5. Quality in Anaesthesia • Quality of recovery- An important dimension of the patient’s experience and related to the quality of care • Quality of recovery- related to patient satisfaction • Data collected on over 10000 patients • Myles, P.S. Minerva Anestesiol 2001

  6. Nine item questionaire • Psychometric evaluation • Moderate validity and reliability (coefficients 0.5-0.61) • Acceptable for group measurements

  7. 40 item questionaire • Ethics committee approval • Men and Women >18yrs (n=160) • Exclusion criteria: • Poor English comprehension • Psychiatric disturbance • Known history of alcohol/drug dependence • Severe pre-existing medical condition limiting objective assessment

  8. Methods • Base line data collected and patients asked to complete two questionaires • 1stquestionaire has nine items (3-point scale) • 2ndquestionaire has 50 items (5-point Likert scale, 1=None of the time, 5= all of the time) • Type of surgery, duration of recovery room stay and total hospital stay

  9. Methods • On the morning after surgery • Pts asked to rate overall recovery using VAS (poor recovery to excellent recovery) • Complete QoR score • 50-item questionaire • Inpatients post in an internal mail envelope • Day cases instructed to complete and return in a self-addressed envelope provided • Time taken to complete QoR score and 50 item questionaire <10 min

  10. QoR-40 • 10 items removed from 50 item questionaire- Not correlated with quality of recovery, identified by Pearson correlation coefficient<0.3 • Emotional state (n=9) • Physical comfort (n=12) • Psychological support (n=7) • Physical independence (n=5) • Pain (n=7)

  11. QoR-40 • Emotional state • Feeling comfortable • Having general feeling of well-being • Feeling in control • Bad dreams • Feeling anxious • Feeling angry • Feeling depressed • Feeling alone • Difficulty falling asleep

  12. QoR-40 • Physical comfort: • Able to breathe easy • Having a good sleep • Being able to enjoy food • Feeling rested • Nausea • Vomiting • Dry retching • Feeling restless • Shaking or twitching • Shivering • Feeling too cold • Feeling dizzy

  13. QoR-40 • Psychological support • Able to communicate with hospital staff • Able to communicate with family or friends • Getting support from hospital doctors • Getting support from hospital nurses • Having support from family or friends • Able to understand instructions or advice • Feeling confused

  14. QoR-40 • Physical independence • Able to return to work or usual home activities • Able to write • Having a normal speech • Able to wash, brush teeth or shave • Able to look after own appearance

  15. QoR-40 • Pain • Moderate pain • Severe pain • Headache • Muscle pains • Backache • Sore throat • Sore mouth

  16. Validity testing • Convergent validity: comparing QoR 40 with VAS- measure inter-item correlations • Construct validity: • QoR 40 between men and women- Women are expected to have poorer QoR but emerge faster from GA than men- Buchanan, F.F. BJA 2011 • QoR 40 and time for completion of questionaire, duration of stay in recovery and duration of hospital stay

  17. Reliability • A measure of consistency • Test-retest reliablility- Pts completed same questionaires on a second occasion, later on the same post-op day • Internal consistency of the QoR-40 • Split-half reliability

  18. Statistical analysis • Associations measured using Pearson correlation coefficients (r), Spearman rank correlation (rho) or Cronbach’s alpha (α), test-retest reliability (concordance) was measured using the intra-class correlation coefficient (ri) • Repeatability calculated within subjects based on the Bland-Altman method • Guyatt, J. Chronic Dis 1987 Katz, J.N. Med Care 1992

  19. Patient demographics Extent of surgery: • Day surgery 25 (16%) • Minor 78 (49%) • Major 57 (36%) Type of surgery • General 48(30%), Gyn 33(21%), Ortho 25(16%), ENT 22(14%), Urol 15(9%) Duration of surgery (min) 70 [45-120] Recovery room stay (min) 60 [45-84]

  20. Results • Good convergent validity between QoR 40 and VAS (r=0.68, p<0.001) • Construct validity supported by negative correlation with duration of stay (rho=-0.24, p<0.001) • Lower mean QoR-40 score in women (162 (sd 26) compared with men (173(17) p=0.002 • Good test-retest reliability (intra-class ri=0.92, P<0.001), internal consistency (Cronbach’s α=0.93, P<0.001) and Split-half coefficient (α=0.83, P<0.0001)

  21. Discussion • Validity, reliability and clinical acceptability of the score was excellent • Pts able to complete 40-item questionaire in <10 min • Women have worse post-op recovery • Negative association between QoR-40 and duration of hospital stay

  22. Recommendations • Scores would have been lower if pts were interviewed at an earlier time after surgery to detect greater changes in health status and responsiveness • Pts priorities may differ from anaesthetists and surgeons • Relevant to measure PtsQoR, and satisfaction with care.

  23. Regional audit data • Pain is dynamic- interferes with rehabilitation • 70% in pain after open shoulder surgery5 • QoR- Dimension of patient experience- related to the quality of patient care

  24. Methods • Prospective audit conducted on patients undergoing arthroscopic and open shoulder procedures under a few designated consultant anaesthetists • During pre-operative assessment, patients were explained about the audit and verbal consent obtained to participate

  25. Methods • All patients had asleep interscalene brachial plexus block using combined ultrasound and peripheral nerve stimulator technique • Patients were followed up in the recovery areas monitoring their vital signs (BP/ HR), consciousness, PONV, Pain, Temp, Surgical bleeding every 5 min intervals and scored on a scale of 0-2 and discharged from the recovery only after their total score was at least 11/12.

  26. Methods • Patients were asked to comment in their own words on the quality of recovery score (QoR 9) form on the ward, 4-6 hrs after discharge from the recovery area • Follow up 24 hrs & 10 days following discharge from the hospital done over the phone to evaluate their post-operative pain relief and signs of any residual effects from the nerve block.

  27. RECOVERY DATA (provider centred): please mention the management if score is <2 e.g Vital signs score 1, IV Gelofusine started or Temp score 1, Bair hugger started Patient Discharged at:…………………………………………………………………... Reasons for Delay (>15mins ) ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

  28. The Quality of recovery score (QoR Score)- patient centred

  29. Results • 52 patients underwent ambulatory surgeries eg. SLAP, ASAD, RCR, Excision of AC joint • 17 patients underwent in-patient surgeries eg. Open shoulder, TSR, TER, TSH, Open Bankart repair

  30. Recovery score following ambulatory surgery Recovery score Blue- 11/12 Red- 9/10 Green-<8 No of Patients Minutes to recover from Anaesthesia

  31. Recovery score following in-patient surgery Recovery score Blue-11/12 Red-9-10 Green<8 No of patients Minutes to recover from anaesthesia

  32. QOR9 –Audit Results from Upper Limb ambulatory Surgery

  33. QOR9 –Ambulatory surgery Results continued

  34. QOR9 – In-patient surgery

  35. QOR9 –In-patients result

  36. Comparison of QoR9 • Our audit showed most patients expressed satisfaction with anaesthesia care • Ambulatory patients have higher QoR 9 score (16.79) compared to in-patients (15.05) • These figures are in-accordance with the results of P. Myles group (5672 patients analysed) in Anesthesia and intensive care 2000- (16.6 Vs 14.6)

  37. Conclusion • An important component of improving the quality of healthcare is that relevant patient information, including patient preferences and expectations, are incorporated into clinical care decisions. • We advocate the widespread introduction of reporting systems for patient feedback on our clinical service ECONOMICS AND HEALTH SYSTEMS RESEARCH MACARIO ET AL PATIENT PREFERENCES FOR ANESTHESIA OUTCOMES ANESTH ANALG,1999;89:652–8

  38. THANK YOU

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