Xuejing (Jennifer) Jin, Fatima Al Sayah, Arto Ohinmaa, Deborah A. Marshall, Christopher Smith, Jeffrey A. Johnson

Clinical Orthopaedics and Related Research (CORR) July 2019, 477:1632-1644.

The EQ-5D has been widely using in measuring health-related quality of life (HRQL) of patients following joint arthroplasty, especially in registry programs. Previous studies indicated that the ceiling effect of the three-level EQ-5D (EQ-5D-3L) limits its application in joint arthroplasty. The five-level EQ-5D (EQ-5D-5L) was developed by adding two response levels to each dimension to improve measurement properties of the instrument; however, in joint arthroplasty field, evidence that supports the EQ-5D-5L is superior to the 3L version is limited.

In this study, Jin and colleagues examined and compared the performance of the EQ-5D-3L and EQ-5D-5L among patients awaiting total hip (THA) or knee (TKA) arthroplasty using data from the Alberta Bone and Joint Health Data Repository, which recorded information on all patients receiving elective hip or knee replacements in Alberta since 2010.

The study showed that, compared to the 3L version, the EQ-5D-5L had better measurement properties in terms of response distribution, construct validity, and ability to discriminate between patients with different severity levels of health problems, especially in mobility (a key health aspect or outcome in these patients).

Jin concluded, “the EQ-5D-5L is more appropriate for measuring HRQL of patients awaiting THA and TKA than the EQ-5D-3L.” The findings “support the use of the EQ-5D-5L for more accurate measurement of HRQL in clinical research and routine application among these patients.”

You can read the full article here.

Following the publication, the Clinical Orthopaedics and Related Research journal published a commentary that summarized the importance and limitations of collecting patient-reported outcome measures (PROMs) in hip and knee replacement. The commentary endorsed the application of the EQ-5D in economic evaluations of hip and knee interventions, and highlighted the demand of minimally important difference (MID) in this field. Additionally, it recommended establishing public searchable databases, and exploring the use of pre-surgery PROMs to screen patients or predict prognosis.

You can read the full commentary here.

For any questions or comments, please do not hesitate to contact us at apersu@ualberta.ca.

Fatima Al Sayah, Arto Ohinmaa, Jeffrey A. Johnson

MDM Policy and Practice 2018 (in press)

Anxiety and depressive symptoms are highly prevalent in chronic disease patients, including those with type 2 diabetes. These symptoms, often undiagnosed and untreated, adversely impact diabetes management and outcomes.

In this study, Al Sayah and colleagues examined the performance of two of the most commonly used patient-reported outcome (PRO)measures of health-related quality of life (EQ-5D-5L and the SF-12 v.2) in screening for anxiety and depressive symptoms in type 2 diabetes patients in primary care setting in Alberta. The researchers opted to explore these measures given their increasing use in the healthcare system in routine outcome measurement.

The researchers found that the EQ-5D-5L and the SF-12 to be suitable tools for screening for anxiety and depressive symptoms in adults with type 2 diabetes. The anxiety/depression dimension of the EQ-5D and the MCS score of the SF-12 had the best performance in screening for these symptoms.

Al Sayah stated “These tools present a unique opportunity for a standardized approach for routine mental health screening in primary care settings within the context of routine outcome measurement initiatives, particularly for patients with chronic diseases”. And added “Users should consider all pros and cons of each measure while selecting a PRO measure that would also serve as a screener for mental health”.

You can read the full article here: https://journals.sagepub.com/doi/full/10.1177/2381468318799361

For any questions or comments, please do not hesitate to contact us at apersu@ualberta.ca

Kara Schick-Makaroff, Lisa A. Wozniak, Hilary Short, Sara N. Davison, Scott Klarenbach, Robert Buzinski, Michael Walsh & Jeffrey A. Johnson

This research project, conducted in Northern Alberta, Canada, explored two critical aspects of hemodialysis care: we studied the burden and management of mental health symptoms and the effectiveness of patient-reported outcome measures (PROMs) in improving patient-clinician communication.

Study 1: Mental health burden in hemodialysis patients

Burden of mental health symptoms and perceptions of their management in in-centre hemodialysis care: a mixed methods study

This study examined the prevalence of mental health symptoms among adults received in-centre hemodialysis. Mental health symptoms were screened and measured using the PHQ-2 for depressive symptoms and the GAD-2 for anxiety. Additionally, patients and nurses were interviewed to explore their perceptions of managing these symptoms.

Prevalence of mental health symptoms:

-              29% screened positive for depressive symptoms.

-              21% screened positive for anxiety symptoms.

-              16% screened positive for both depression and anxiety.

Mental health management findings:

-              PROMs had the potential to identify and prompt management of mental health symptoms.

-              There were varying opinions within and between patients and nurses whether mental health is within the scope of dialysis care.

-              Identifying mental health issues through PROM use was problematic because there were inadequate mental health resources in in-centre hemodialysis. Three resources were identified as missing: 1) access to mental health providers and services; 2) knowledge to address mental health concerns; 3) privacy to discuss mental health issues.

Mental health symptoms were substantially higher than those in the general population, highlighting the need for integrated mental health care in dialysis settings. Additional research is needed to determine how routine use of self-reported mental health concerns through PROMs may be best addressed to meet patients’ needs.

To access the full article, click here.

Study 2: Impact of PROMs on patient-clinician communication

How the routine use of patient-reported outcome measures for hemodialysis care influences patient-clinician communication: A mixed-methods study

This study investigated how the routine use of PROMs in in-centre hemodialysis units influenced patient-clinician communication, assessed using a modified Communication Assessment Tool (CAT). In addition, we explored perceptions of communication using PROMs through patient and nurse interviews, on-site observations, and analysis of patient responses to two survey questions. 

Key findings include:

- Only a small positive change in mean total CAT scores from baseline to 12 months in units using PROMs compared to control units that did not use PROMs.

- PROMs were not implemented as intended across units with considerable variation in how PROMs were used in care.

- PROMs assessments were viewed as redundant to usual care, and there was a lack of understanding of the purpose of PROMs assessments.

- Many nurses conflated PROMs assessments with their clinical assessments, and patients were uncertain of what might happen with their PROM responses.

Our findings highlight the need for research into validation processes to articulate what core mechanisms are needed for PROM use to enhance patient-clinician communication within the context of hemodialysis.

To access the full article, click here.

Overall, this project highlights the need for further research into the appropriate use of PROMs to improve patient outcomes and experience in renal care.

Johnson, J.A., Itiola, A., Rahman, S., Smith, C., Soprovich, A., Wozniak, L.A., & Marshall, D.A.

BMC Musculoskeletal Disorders (2024)

This study examines patient perspectives on the visualization of individualized EQ-5D-5L data within a decision aid for individuals considering treatment options for knee osteoarthritis in Alberta, Canada. The research focuses on understanding the clarity of different EQ-5D-5L data visualization formats showing individuals how they compare to other people like them (age, sex, and BMI) in pre-surgery status and probable post-surgery outcomes. Two versions of the EQ-5D-5L visualizations were tested for both pre- and post-surgery: Version 1 used an icon array presentation, while Version 2 employed a waffle or grid display. The versions were evaluated for comprehension, usefulness, and visual appeal.

**Pre-Surgery Insights:**

- Most participants (95.8%) found the instructions clear and about half found the information useful. However, opinions varied on the simplicity of the instructions, with some suggesting simpler terms. Participants appreciated the comparison information, which helped them understand how they compared to others undergoing similar procedures. Some questioned the rationale behind comparing themselves to others, indicating a preference for making decisions based on personal experiences and discussions with their doctors.

**Post-Surgery Insights:**

Most participants (92%) found Version 2 more informative, as it included the pre-surgery information; however, some participants found the additional information unnecessary. Approximately 60% of participants rated the post-surgery information as very useful. For both pre- and post-surgery versions, some participants viewed the information as interesting but not necessarily impactful on their decision-making process.

Overall, the visual appeal was rated highly for both versions for both pre- and post-surgery; however, suggestions for improvement included larger fonts and better color contrast for readability.

The study highlights the importance of clear and simple data visualization in decision aids for patients considering treatment options for knee osteoarthritis. While patients valued being able to compare their status and probably outcomes relative to other people like them, the perceived useful of this information for treatment decisions was mixed. Participants suggested improvements to enhance comprehension and visual appeal, underscoring the need for patient-centered design in healthcare tools.

This research contributes to the ongoing efforts to improve data visualization, emphasizing the need to balance detailed information with simplicity and clarity to support decision-making in clinical settings.

You can read the full article here: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-024-07304-5/tables/3

For any questions or comments, please do not hesitate to contact us at apersu@ualberta.ca

Bonsel, J.M., Itiola, A.J., Huberts, A.S., Bonsel, G.J., & Penton, H.

Health and Quality of Life Outcomes (2024)

This systematic review critically examines the impact of patient-reported outcome measures (PROMs) on improving patient-related outcomes across micro- (patient), meso- (organization), and macro-level (system) healthcare settings. Drawing on 76 studies from five databases, we evaluate quantitative evidence and interrogate the mechanisms that may drive or hinder PROM effectiveness.

At the micro-level, findings indicate that PROMs have matured as a clinical tool, especially when tied directly to care pathways. While only 43% of studies that ‘simply’ fed PROMs back to patients or providers showed improved outcomes, effectiveness rose markedly to nearly 70% when PROMs were used for monitoring treatments or screening for symptoms. In these instances (monitoring and screening), the PROMs were typically linked to a clinical action. These interventions were particularly successful in symptom-driven conditions such as cancer, depression, and gastrointestinal diseases. This highlights the importance of aligning PROMs with clinical decision-making and treatment algorithms. Interestingly, even the simple act of collecting PROMs or embedding them into decision aids improved patient engagement and decision quality, suggesting value beyond traditional metrics for effectiveness.

At the meso- and macro levels, PROMs remain underutilized. Benchmarking applications of PROMs failed to improve outcomes, likely due to their indirect linkage to care decisions. However, modest gains were observed when PROMs were used for internal performance analyses or integrated into quality improvement cycles such as Plan-Do-Study-Act (PDSA). The review also found that disease-specific PROMs tend to outperform generic tools, underlining the need to tailor implementation to specific clinical context. Yet, the overall evidence base is limited by moderate to weak study quality, raising questions about the validity of findings and the need for more rigorously designed studies to assess  the impact of PROM interventions. 

In sum, while PROMs play an advanced role in enhancing patient care at the micro level, particularly when embedded in actionable workflows, their system-level potential is still developing and requires more robust, strategically aligned research.

You can read the full article here: https://hqlo.biomedcentral.com/articles/10.1186/s12955-024-02312-4

For any questions or comments, please do not hesitate to contact us at apersu@ualberta.ca