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The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature |
Valderas J M, Kotzeva A, Espallargues M, Guyatt G, Ferrans C E, Halyard M Y, Revicki D A, Symonds T, Parada A, Alonso J |
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CRD summary The authors concluded that the strength of inference about the impact of providing patient-reported outcome information to clinicians was limited by methodological concerns in the identified studies; results suggested great heterogeneity of impact and the need for further research. This was generally a well-conducted and clearly reported review and the authors’ conclusions were likely to be reliable. Authors' objectives To evaluate the effects of routine patient-reported outcomes (PRO) in daily primary and secondary health care. Searching The review included studies in a previous systematic review (search dates 1966 to 1997, see Other Publications of Related Interest, no. 1). MEDLINE and The Cochrane Library (including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and DARE) were searched from 1998 to September 2007. A broad outline of the search strategy was reported. In addition, reference lists of eligible studies and reviews were screened and authors and experts were contacted for details of further published and unpublished studies. Studies were included if they were published in English, French, German, Italian, Russian or Spanish. Study selection Randomised controlled trials (RCTs) that compared replicable interventions involving the administration of standardised patient-reported outcomes questionnaires to patients plus feedback to clinicians with routine clinical practice were eligible for inclusion. Studies could randomly allocate individual physicians, groups of physicians or patients. Patients had to be attending a health practitioner’s office, outpatient clinic, emergency room or hospital. Studies had to assess at least one of mortality, morbidity, health-related quality of life and related measures, clinician behaviour, clinician impressions, patient satisfaction and costs.
Most of the included studies were conducted in the United States. Most were set in primary care. About half only included fully trained physicians. Most involved adults, often from restricted patient groups (geriatric, mental health or a specified condition). Studies varied with respect to intervention, type and content of information provided to clinicians, interval between questionnaire administration and feedback, co-interventions and outcomes. Most studies used well-known and validated outcome measures. The selection of review outcomes was based on the stage of care assessed and the frequency of their use. Thus, the review assessed process of care, outcomes of care and satisfaction of care. Two reviewers independently selected studies and resolved disagreements by consensus with the aid of a third reviewer if required. Assessment of study quality Two reviewers independently assessed validity using a modified version of the Jadad criteria that assessed statistical analysis appropriate for unit of randomisation, blinding and losses to follow-up. Disagreements were resolved by discussion. The maximum possible quality score was 7. The use of sample size calculation was also assessed. Data extraction Two reviewers independently extracted data onto a standardised form. Disagreements were resolved by discussion. Methods of synthesis The characteristics of the included studies were summarised in the text of the review and tables. Studies were grouped by outcome and combined in a narrative synthesis. Results of the review Twenty-eight RCTs were included (studying a total of at least 968 clinicians and 16,766 patients).
The mean quality score was 3.41 out of 7 (range 2.0 to 5.0). Only five studies reported use of a sample size calculation. The most common methodological flaws were data analysis not consistent with unit of randomisation and assessment of multiple outcomes.
Process of care (23 studies): patient-reported outcomes were associated with at least one statistically significant difference in outcome measures in 15 (65 per cent) of the 23 studies assessing any process of care measure, three (43 per cent) of seven studies assessing advice, education or counselling and seven (50 per cent) of 14 studies assessing referrals or consultations.
Outcomes of care (17 studies): patient-reported outcomes were associated with at least one statistically significant difference in outcome measures in eight (47 per cent) of the 17 studies assessing any outcome of care and three (50 per cent) of six studies assessing general functional status.
Satisfaction with care (12 studies): patient-reported outcomes were associated with at least one statistically significant difference in outcome measures in five (42 per cent) of the 12 studies assessing any measure of satisfaction with care. Authors' conclusions The strength of inference about the impact of providing patient-reported outcomes information to clinicians was limited by methodological concerns in the identified studies. Results suggest great heterogeneity of impact and the need for further research. CRD commentary The review question was clearly stated and appropriate inclusion criteria were specified. The authors acknowledged that there may have been limitations resulting from restricting the updated search to two databases. Some attempts were made to minimise language bias and attempts were made to identify unpublished studies. Appropriate methods were used to minimise reviewer error and bias during the review process. Validity was assessed using specified criteria and major flaws in the included studies were discussed. Adequate information was provided about the included studies. In view of the differences between studies, a narrative synthesis with a focus on study characteristics was appropriate. This was generally a well-conducted and clearly reported review and the authors’ conclusions were likely to be reliable. Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that well-designed and well-conducted RCTs were required to evaluate the impact of feedback from patient-reported outcomes in clinical practice. Studies should use appropriate statistical methods that take account of the unit of randomisation and the multiplicity of outcome measures and adhere to current reporting guidelines. Funding Ministerio de Educacion, Cultura y Deporte (SAB 2001-0088); the Spanish Public Health Network (RCESP) “Investigacion en Epidemiologia y Salud Publica: Determinantes, Mecanismos, Metodos y Politicas” (Exp. C03/09); Instituto de Salud Carlos III: Red de Investigacion Cooperativa IRYSS (Exp. G03/202); Ayudas para contratos de Profesionales Post MIR (Exp. CM0300118). Bibliographic details Valderas J M, Kotzeva A, Espallargues M, Guyatt G, Ferrans C E, Halyard M Y, Revicki D A, Symonds T, Parada A, Alonso J. The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Quality of Life Research 2008; 17(2): 179-193 Other publications of related interest Espallargues M, Valderas JM, Alonso J. Provision of feedback on perceived health status to health care professionals: A systematic review of its impact. Medical Care 2000;38:175-1865 Indexing Status Subject indexing assigned by NLM MeSH Feedback; Health Status Indicators; Humans; Patient Satisfaction; Quality of Life; Randomized Controlled Trials as Topic AccessionNumber 12008103445 Date bibliographic record published 23/12/2008 Date abstract record published 01/07/2009 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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