A protocol for the formative evaluation of the implementation of patient-reported outcome measures in child and adolescent mental health services as part of a learning health system.

BACKGROUND: Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of most children and youth. Learning health systems are an approach to enhancing services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures provide a key data source for learning health systems. They have also been shown to improve outcomes for patients when integrated into routine clinical care. However, implementing these measures into health systems is a challenging process. This paper describes a protocol for a formative evaluation of the implementation of patient-reported measures in a newly operational child and adolescent mental health centre in Calgary, Canada. The purpose is to optimize the collection and use of patient-reported outcome measures. Our specific objectives are to assess the implementation progress, identify barriers and facilitators to implementation, and explore patient, caregivers and clinician experiences of using these measures in routine clinical care. METHODS: This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. Participants include patients and caregivers who have used the centre's services, as well as leadership, clinical and support staff at the centre. Focus groups and semi-structured interviews will be conducted to assess barriers and facilitators to the implementation and sustainability of the use of patient-reported outcome measures, as well as individuals' experiences with using these measures within clinical care. The data generated by the patient-reported measures over the first five months of the centre's operation will be analyzed to understand implementation progress, as well as validity of the chosen measures for the centres' population. DISCUSSION: The findings of this evaluation will help to identify and address the factors that are affecting the successful implementation of patient-reported measures at the centre. They will inform the co-design of strategies to improve implementation with key stakeholders, which include patients, clinical staff, and leadership at the centre. To our knowledge, this is the first study of the implementation of patient-reported outcome measures in child and adolescent mental health services and our findings can be used to enhance future implementation efforts in similar settings.

Early Identification of Family Physicians Using Qualitative Admissions Data.

BACKGROUND AND OBJECTIVES: The medical community has been concerned about the shortage of family physicians for decades. Identification of likely family medicine (FM) student matches early in medical school is an efficient recruitment tool. The objective of this study was to analyze qualitative data from medical school applications to establish themes that differentiate future family physicians from their non-FM counterparts. METHODS: We conducted a qualitative analysis of admissions essays from two groups of 2010-2019 medical school graduates: a study group of students who matched to FM (n=135) and a random sample comparison group of non-FM matches (n=136). We utilized a natural language modeling platform to recognize semantic patterns in the data. This platform generated keywords for each sample, which then guided a more traditional content analysis of the qualitative data for themes. RESULTS: The two groups shared two themes: emotions and science/academics, but with some differences in thematic emphasis. The study group tended toward more positive emotions and the comparison group tended to utilize more specialized scientific language. The study group exhibited two unique themes: special interests in service and community/people. A secondary theme of religious faith was evident in the FM study group. The comparison group exhibited two unique themes: lab/clinical research and career aspirations. CONCLUSIONS: Aided by machine learning, a novel analytical approach revealed key differences between FM and non-FM student application materials. Findings suggest qualitative application data may contain identifiable thematic differences when comparing students who eventually match into FM residency programs to those who match into other specialties. Assessing student potential for FM could help guide recruitment and mentorship activities.

Factors affecting implementation of patient-reported outcome and experience measures in a pediatric health system.

BACKGROUND: The use of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) in pediatric clinical practice can enhance clinical care and bring children and families' perspectives into evaluations of healthcare services. Implementing these measures is complex and requires a thorough assessment of the context of implementation The purpose of this study is to describe the barriers and facilitators to PROMs and PREMs implementation and to recommend strategies for implementing these measures in a pediatric health system. METHODS: We used a qualitative descriptive approach to analyse data from interviews to understand the experiences of PROMs and PREMs users across different pediatric settings in a single Canadian healthcare system. RESULTS: There were 23 participants representing a variety of roles within the healthcare system and pediatric populations. We found five main factors that affected implementation of PROMs and PREMs in pediatric settings: 1) Characteristics of PROMs and PREMs; 2) Individual's beliefs; 3) Administering PROMs and PREMs; 4) Designing clinical workflows; and 5) Incentives for using PROMs and PREMs. Thirteen recommendations for integrating PROMs and PREMs in pediatric health settings are provided. CONCLUSIONS: Implementing and sustaining the use of PROMs and PREMs in pediatric health settings presents several challenges. The information presented will be useful for individuals who are planning or evaluating the implementation of PROMs and PREMs in pediatric settings.

Developing a triage predictive model for access to a spinal surgeon using clinical variables and natural language processing of radiology reports.

PURPOSE: To utilize natural language processing (NLP) of MRI reports and various clinical variables to develop a preliminary model predictive of the need for surgery in patients with low back and neck pain. Such a model would be beneficial for informing clinical practice decisions and help reduce the number of unnecessary surgical referrals, streamlining the surgical process. METHODS: A historical cohort study was conducted using de-identified data from patients referred to a spine assessment clinic. Various demographic, clinical, and radiological variables were included as potential predictors. Full-text radiology reports of patients' MRI findings were vectorized using NLP before applying machine learning algorithms to develop models predicting who underwent surgery. Outputs from these models were then entered into a logistic regression model with clinical variables to develop a preliminary model predictive of surgical recommendations. RESULTS: Of the 398 patients assessed, 71 underwent spine surgery. NLP variables were significant predictors in univariate analysis but did not remain in the final logistic regression model. An outcome of receiving surgery was predicted by a primary symptom of low back and leg pain (adjusted odds ratio 2.81), distal pain indicated by a pain diagram (adjusted odds ratio 2.49) and self-reported difficulties walking (adjusted odds ratio 2.73). CONCLUSION: A logistic regression model was created to predict which patients may require spine surgery. Simple clinical variables appeared more predictive than variables created using NLP. However, additional research with more data samples is needed to validate this model and fully evaluate the usefulness of NLP for this task.

Patient-reported outcome measures used to improve youth mental health services: a systematic review.

BACKGROUND: Patient-reported outcome measures (PROMs) are standardized and validated self-administered questionnaires that assess whether healthcare interventions and practices improve patients' health and quality of life. PROMs are commonly implemented in children and youth mental health services, as they increasingly emphasize patient-centered care. The objective of this study was to identify and describe the PROMs that are currently in use with children and youth living with mental health conditions (MHCs). METHODS: Three databases (MEDLINE, EMBASE, and PsycINFO) were systematically searched that used PROMs with children and youth < 18 years of age living with at least one diagnosed MHC. All methods were noted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis. Four independent reviewers extracted data, which included study characteristics (country, year), setting, the type of MHC under investigation, how the PROMs were used, type of respondent, number of items, domain descriptors, and the psychometric properties. RESULTS: Of the 5004 articles returned by the electronic search, 34 full-texts were included in this review. This review identified both generic and disease-specific PROMs, and of the 28 measures identified, 13 were generic, two were generic preference-based, and 13 were disease-specific. CONCLUSION: This review shows there is a diverse array of PROMs used in children and youth living with MHCs. Integrating PROMs into the routine clinical care of youth living with MHCs could improve the mental health of youth. Further research on how relevant these PROMs are children and youth with mental health conditions will help establish more uniformity in the use of PROMs for this population.

Youth engagement in mental health research: A systematic review.

INTRODUCTION: Patient engagement in youth mental health research has the potential to inform research on the interventions, services and policies that will benefit youth. At present, there is little evidence to guide mental health researchers on youth engagement. This systematic review aims to describe the impacts of youth engagement on mental health research and to summarize youth engagement in mental health research. METHODS: We searched the following databases: MEDLINE, EMBASE and PsycINFO, using a combination of subject headings, keywords and synonyms for the concepts 'patient engagement', 'youth' and 'mental health'. Articles that described engaging youth in mental health research were included. Two reviewers performed the study selection. Study characteristics, research activities performed by youth, impacts of youth engagement, challenges, and facilitators to engagement and recommendations for youth engagement described by authors were extracted. Quality appraisal involved determining the level of engagement of youth and the stage(s) of research where youth were involved. RESULTS: The database search returned 2836 citations, 151 full-text articles were screened and 16 articles, representing 14 studies, were selected for inclusion. Youth were involved at nearly all stages of the research cycle, in either advisory or co-production roles. Youth engagement impacts included enhancing relevant research findings, data collection and analysis and dissemination to academic and stakeholder audiences. Both youth and academic researchers reported personal development across many domains. One negative impact reported was the increase in funding and resources needed for engagement. We produced a list of 35 recommendations under the headings of training, youth researcher composition, strategy, expectations, relationships, meeting approaches and engagement conditions. CONCLUSIONS: This study provides an understanding of the impacts and recommendations of youth engagement in mental health research. The findings from this study may encourage researchers to engage youth in their mental health research and support youth engagement in funding applications. PATIENT AND PUBLIC CONTRIBUTION: We consulted three youths with experience being engaged in mental health research about the review findings and the discussion. One youth designed a visual representation of the results and provided feedback on the manuscript. All youth's input informed the way the findings were presented and the focus of the discussion.

An integrative review of the qualities of a 'good' physiotherapist.

INTRODUCTION: Qualities of a physiotherapist may influence the therapeutic alliance and physiotherapy outcomes. Understanding what qualities constitute a 'good' physiotherapist has yet to be systematically reviewed notwithstanding potentially profound implications for the future practice of physiotherapy. PURPOSE: The primary purpose of this review was to critically examine how physiotherapists and their patients describe the qualities of a 'good' musculoskeletal physiotherapist as depicted in peer-reviewed literature. The secondary aim was to synthesize qualities represented in the literature, and to compare patient and physiotherapist perspectives. METHODS: An integrative review methodology was used to undertake a comprehensive literature search, quality appraisal of studies, and thematic analysis of findings. An electronic search of CINAHL, EMBASE, Nursing and Allied Health, PsycINFO, PubMed, and Scopus databases was conducted within a time range from database inception to June 14, 2019. RESULTS: Twenty-seven studies met the inclusion criteria. Six qualities of a 'good' musculoskeletal physiotherapist were identified as: responsive, ethical, communicative, caring, competent, and collaborative. CONCLUSIONS: The qualities of a 'good' physiotherapist identified in the review emphasize the human interaction between physiotherapists and patients and point to the centrality of balancing technical competence with a relational way of being.

Measuring therapeutic relationship in physiotherapy: conceptual foundations.

The "therapeutic relationship" in physiotherapy refers to the beneficial or healing relationship between the patient and physiotherapist. Interest in researching therapeutic relationships in physiotherapy is growing and there is a need for a measure of therapeutic relationship with a strong conceptual foundation. Body of paper:We begin with a general discussion of the state of therapeutic relationship measurement in physiotherapy research - notably, how current research is based on measures borrowed and adapted from psychotherapy. Then, we introduce Miciak's physiotherapy therapeutic relationship framework, discuss why it offers a solid foundation for measurement development, and describe the key concepts in the framework. We then discuss various approaches to measuring therapeutic relationship, illustrating how Miciak's framework could be used to inform their development. We end by discussing current challenges in measuring therapeutic relationship and how these could be addressed.

Developing clinical practice guidelines for physiotherapists working with people with inherited bleeding disorders.

INTRODUCTION: Several bleeding disorders are characterized by haemorrhage into joints and muscles. These conditions are best managed by interdisciplinary teams that include physiotherapists. In 1997, physiotherapists from haemophilia treatment centres in Canada formed the Canadian Physiotherapists in Hemophilia Care (CPHC). The guiding principles of the CPHC reflect a commitment to evidence-based practice, education and collaboration. AIM: To describe the process used by CPHC to develop evidence-based clinical practice guidelines to inform best practice, guide decision-making and help educate physiotherapists, students, and other team members about the physiotherapy management of people with bleeding disorders. METHODS: We followed the procedures outlined in the American Physical Therapy Association's Clinical Practice Guideline Process Manual (2018). Namely, we selected a working group, determined the scope of the guidelines, performed a literature search, selected and appraised the evidence, drafted the guidelines as practice statements, assigned a strength of recommendation to each practice statement and disseminated the guidelines. RESULTS: Thirty-nine practice statements were developed in nine practice areas. Strength of evidence was strong for two statements, moderate for one and weak for three. The remainder were graded as theoretical or best practice. CONCLUSION: To our knowledge, these are the first evidence-based clinical practice guidelines that cover all aspects of physiotherapy management of people with bleeding disorders. Some areas, such as exercise and manual therapy, have been well investigated. However, the overall low levels of evidence and low strengths of recommendations highlight the need for more rigorous research with this population.

Measuring therapeutic relationship in the care of patients with haemophilia: A scoping review.

OBJECTIVE: We conducted a scoping review of the tools used to measure therapeutic relationship in patients with haemophilia. BACKGROUND: Haemophilia is an inherited bleeding disorder caused by a deficiency of a clotting factor in the blood. Therapeutic relationship is foundational to the management of patients with chronic diseases like haemophilia. A reliable and valid measurement tool for assessing therapeutic relationship is needed to evaluate the quality of care received by these patients, and to rigorously study the association between therapeutic relationship and the outcomes of treatment. METHODS: We adopted the Arksey and O'Malley framework for scoping studies. The following electronic databases were searched for studies that measured a construct related to therapeutic relationships in haemophilia care: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus. We inventoried these studies, identified the measurement tools used, and described each tool by purpose, content, measurement properties and target population. We identified gaps in the current evidence and directions for future research. RESULTS: There were 253 unique records retrieved in the search, and twenty studies were deemed relevant. Ten measurement tools were identified. None of the tools measured therapeutic relationship as a single entity; however, six tools measured constructs considered part of patient-provider relationship (eg trust, communication, working alliance). There has been little validation testing of these tools in haemophilia patient populations. CONCLUSIONS: There is a need for a validated tool for measuring therapeutic relationship in the care of patients with haemophilia. This review provides a foundation for future research in this area.

Procedures to develop a computerized adaptive test to assess patient-reported physical functioning.

PURPOSE: The purpose of this paper is to demonstrate the procedures to develop and implement a computerized adaptive patient-reported outcome (PRO) measure using secondary analysis of a dataset and items from fixed-format legacy measures. METHODS: We conducted secondary analysis of a dataset of responses from 1429 persons with work-related lower extremity impairment. We calibrated three measures of physical functioning on the same metric, based on item response theory (IRT). We evaluated efficiency and measurement precision of various computerized adaptive test (CAT) designs using computer simulations. RESULTS: IRT and confirmatory factor analyses support combining the items from the three scales for a CAT item bank of 31 items. The item parameters for IRT were calculated using the generalized partial credit model. CAT simulations show that reducing the test length from the full 31 items to a maximum test length of 8 items, or 20 items is possible without a significant loss of information (95, 99% correlation with legacy measure scores). CONCLUSIONS: We demonstrated feasibility and efficiency of using CAT for PRO measurement of physical functioning. The procedures we outlined are straightforward, and can be applied to other PRO measures. Additionally, we have included all the information necessary to implement the CAT of physical functioning in the electronic supplementary material of this paper.

Advancements in anti-inflammatory therapy for dry eye syndrome.

PURPOSE: The goal of this literature review is to discuss recent discoveries in the pathophysiology of dry eye and the subsequent evolution of diagnostic and management techniques. The mechanisms of various anti-inflammatory treatments are reviewed, and the efficacy of common pharmacologic agents is assessed. Anti-inflammatory therapy is evaluated in terms of its primary indications, target population, and utility within a clinical setting. METHODS: The Medline PubMed database and the World Wide Web were searched for current information regarding dry eye prevalence, pathogenesis, diagnosis, and management. After an analysis of the literature, major concepts were integrated to generate an updated portrayal of the status of dry eye syndrome. RESULTS: Inflammation appears to play a key role in perpetuating and sustaining dry eye. Discoveries of inflammatory markers found within the corneal and conjunctival epithelium of dry eye patients have triggered recent advancements in therapy. Pharmacologic anti-inflammatory therapy for dry eye includes 2 major categories: corticosteroids and immunomodulatory agents. Fatty acid and androgen supplementation and oral antibiotics have also shown promise in dry eye therapy because of their anti-inflammatory effects. CONCLUSIONS: Anti-inflammatory pharmacologic agents have shown great success in patients with moderate to severe dry eye when compared with alternative treatment modalities. A deeper understanding of the link between inflammation and dry eye validates the utilization of anti-inflammatory therapy in everyday optometric practice.