Exploring the Patient Experience with Patient-Reported Outcomes: A Qualitative, Multistakeholder Study.

OBJECTIVES: Although the literature provides guidance regarding patient-reported outcome (PRO) implementation barriers, patients' perspectives are underreported. This study aimed to improve the understanding of patient experiences with PRO tools through examining perceptions of and attitudes toward PROs and expectations of data use after collection. METHODS: Ethnographic human-centered design approaches were used to conduct free-form interviews. Two case studies of existing PRO use in clinics also were examined. Unstructured thematic analyses were performed using notes taken during these interviews. RESULTS: Patients generally reported a good understanding of the need for PRO collection, both for research and clinical use. Many expected that results would be acted upon by the clinicians promptly. Thematic analyses identified the following patient perception topics: transparency, individualization to patient needs, timely response, different "identities" while accessing care locally compared with at a destination center, and preference for brief PROs. CONCLUSIONS: Design and implementation of PRO assessments into patient care should include the patients as key end users. Transparency of the purpose for data collection is critical for broader patient adoption. Ensuring that only necessary and sufficient data are collected for clinical action, and associated research may help minimize burden and maximize patient participation.

Opioid Use in Fibromyalgia Continues Despite Guidelines That Do Not Support Its Efficacy or Risk.

BACKGROUND/OBJECTIVE: The aim of this cross-sectional study is to determine the prevalence of opioid use in a large sample of fibromyalgia (FM) patients and examine the factors associated with opioid prescription/use despite multiple clinical guidelines that do not recommend opioid use in this population. METHODS: Data were collected from a convenience sample of 698 patients admitted from August 2017 to May 2019 into an intensive 2-day Fibromyalgia Treatment Program at a tertiary medical center in the United States after FM diagnosis. Patients were administered the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Study of Depression Scale, and the Pain Catastrophizing Scale upon admission to the program. Demographic information and opioid use were self-reported. Logistic regression analysis was utilized to determine associations between patient-related variables and opioid use in this prospective study. RESULTS: Of 698 patients, 27.1% (n = 189) were taking opioids at intake. Extended duration of symptoms (>3 years), increased age, higher degree of functional impairment, and increased pain catastrophizing were significantly associated with opioid use. CONCLUSIONS: Opioids are not recommended for the treatment of FM under current guidelines. Greater burden of illness appeared to be associated with the prescription and use of opioids in this population. These findings suggest that some providers may not be aware of current recommendations that have been found to be effective in the management of FM that are contained in guidelines. Alternative approaches to the management of FM that do not involve opioids are reviewed in an effort to improve care.

Feasibility Study of Three-Phase Implementation of International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in an Outpatient Consultation-Liaison Psychiatry Practice.

OBJECTIVE: We describe a three-phase implementation of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in a Consultation-Liaison Psychiatry practice. METHODS: During the preintervention phase, we reviewed patient-reported outcome tools and engaged stakeholders and leadership. During phase 1, the standard set was converted into an electronic previsit intake assessment that was implemented in a physician champion's practice. Patients completed the intake on a tablet, and computer adaptive testing was used to reduce response burden. Physician-facing data display facilitated use during subsequent in-person visits. An electronic version of the follow-up standard set was used during follow-up visits. During phase 2, a second physician tested scalability and the intervention was disseminated department wide in phase 3. RESULTS: During phase 1, 186 intakes and 67 follow-up electronic patient-reported outcome sets were completed. Average patient age was 54 years, and 44% were male. On average, patients ranked the tool 4.4 out of 5 and spent 22 minutes completing the intake. Time-driven activity-based costing found the new process to be cost-effective. During phase 2, 386 patients completed electronic patient-reported outcome sets, with 315 follow-up visits. Patients ranked the tool as 4.0 out of 5 and spent 26 minutes completing the questions. During phase 3, 2166 patients completed intake electronic patient-reported outcome sets and 1249 follow-up visits. Patients ranked the tool 4.3 out of 5 and spent 26 minutes on it. Scores and completion time did not differ greatly between phases. CONCLUSIONS: Integration of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set is feasible. Future research comparing International Consortium for Health Outcomes Measurement set with other approaches and in different settings is needed.

Patients seeking stem cell therapies-a prospective qualitative analysis from a Regenerative Medicine Consult Service.

Despite patient demand for stem cell therapies (SCTs) for musculoskeletal conditions, there remains limited research on why patients seek SCTs or their sources of information. We employ three questions into a consult intake form: (1) Why are you interested in stem cell treatment for your condition? (2) How did you find out about stem cell treatment for your condition? (3) Have you contacted a stem cell clinic? Responses analyzed, using a qualitative content analysis approach to identify themes reveal many patients seek SCTs to treat pain or delay surgery which may align with some current clinical evidence while other patients express motivations as expected outcomes (e.g., SCTs are better than standard of care or can regenerate tissue) which are not supported by current medical evidence. These differences suggests that patient-centered counseling may help patients by addressing misconceptions and increasing health literacy about expected outcomes of SCTs for treating musculoskeletal conditions.

Subarachnoid Hemorrhage "Fast Track": A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge.

OBJECTIVE: To determine whether earlier hospital discharge is feasible and safe in selected patients with subarachnoid hemorrhage (SAH) using an outpatient "fast-track" protocol. PATIENTS AND METHODS: We conducted a prospective quality improvement cohort study with the primary feasibility end point of patients with SAH deemed safe for discharge by treating team consensus. All patients received detailed education and outpatient transcranial Doppler monitoring; caregivers could contact the on-call team 24-7. Primary safety end points were adverse events after discharge and hospital readmission. RESULTS: From January 1, 2010, to January 1, 2015, our center had 377 SAH diagnoses, of which 200 were included in the final cohort, 36 qualifying for fast-track early discharge. The 30-day readmission rate for fast-track patients was 11.0% (4 of 36) compared with 11.4% (18 of 164) for non-fast-track patients. The rate of delayed cerebral ischemia and stroke was 3% (1 of 36) in the fast-track group vs 25.0% (41 of 164) for the non-fast-track group. Adverse events occurred in 11.0% (4 of 36) of the fast-track group compared with 26.0% (43 of 164) in the non-fast-track group. The mean length of stay was reduced 60% from 15 days to 6.6 days in the fast-track group. CONCLUSION: Although our fast-track group was relatively small, data suggested early feasibility and safety in a carefully selected group of patients with SAH. Direct and indirect financial benefits of early discharge over a 5-year period were an estimated savings at least $864,000 in overall costs. A comparative effectiveness study is planned to replicate and validate these results using a larger multicenter design.

Qualitative study of implementation of patient self-reported measures in a consultation-liaison psychiatry practice.

RATIONAL, AIMS, AND OBJECTIVES: Understanding of barriers and successes associated with the implementation of electronic patient self-reported measures (ePSRMs) within clinical settings are limited and have not been pursued utilizing implementation science frameworks. This qualitative study is designed to assess staff perceptions of an ePSRM implementation. METHODS: The study took place in an academic hospital's Consultation Liaison Psychiatry practice. Qualitative interviews were conducted with the staff and clinicians from the practice. Participants were directly involved with the implementation and use of the ePSRM system within the Psychiatry practice. Interviews were structured around the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS: Participants reported increased patient engagement as well as efficiency and time savings. The intervention was perceived to be more challenging for older patients. Facilitators include communicating the ePSRM to patients prior to the care visit, having enough trained staff or super-users who can assist with technical problems, and having a shorter questionnaire. CONCLUSIONS: Overall, assessment of the ePSRM implementation was positive. Staff and clinicians indicated benefits in time, effectiveness, and improvements in patient treatment. Results indicate that defining how the system would fit within the clinical workflow was key, as was a flexible and user-friendly technology platform. The ePSRM implementation was dependent upon clinical involvement and interest in adoption, while barriers were associated with technical challenges as well as some patient difficulties, such as cognitive impairment. The use of the RE-AIM framework is valuable as it allows for systematic assessment of the implementation and identifies areas in that implementation has succeeded or is lacking.

Patient portal use and hospital outcomes.

Objectives: To determine whether use of a patient portal during hospitalization is associated with improvement in hospital outcomes, 30-day readmissions, inpatient mortality, and 30-day mortality. Materials and Methods: We performed a retrospective propensity score-matched study that included all adult patients admitted to Mayo Clinic Hospital in Jacksonville, Florida, from August 1, 2012, to July 31, 2014, who had signed up for a patient portal account prior to hospitalization (N = 7538). Results: Out of the admitted patients with a portal account, 1566 (20.8%) accessed the portal while in the hospital. Compared to patients who did not access the portal, patients who accessed the portal were younger (58.8 years vs 62.3 years), had fewer elective admissions (54.2% vs 64.1%), were more frequently admitted to medical services (45.8% vs 35.2%), and were more likely to have liver disease (21.9% vs 12.9%) and higher disease severity scores (0.653 vs 0.456). After propensity score matching, there was no statistically significant difference between the 2 cohorts with respect to 30-day readmission (P = .13), inpatient mortality (P = .82), or 30-day mortality (P = .082). Conclusion: Use of the patient portal in the inpatient setting may not improve hospital outcomes. Future research should examine the association of portal use with more immediate inpatient health outcomes such as patient experience, patient engagement, medication reconciliation, and prevention of adverse events.