Patient Reported Experience Measure

Dr. Mahesh D KumarConsultant AnaesthetistTrafford General Hospital

22nd March 2012

IntroductionValid, Reliable and Responsive measure

VASPONV impact scaleNine Item Questionaire40 item Questionaire

Myles, P.S. BJA 2000 Myles, P.S. BJA 2012

Quality of outcome

Patient’s perception of their outcome of careEberhart, L.H. Anaesthesist 2002 Gill, T.M. JAMA 1994 Guyatt, G.H. JAMA 1994

Traditional FactorsTime to awakeningDuration of stayPain, emesis and confusion

Lee, A. Anaesth Intensive Care 1996

Consequences of Traditional factorsTransient 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

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

Nine item questionaire

Psychometric evaluationModerate validity and reliability (coefficients 0.5-0.61)

Acceptable for group measurements

40 item questionaire

Ethics committee approval

Men and Women >18yrs (n=160)

Exclusion criteria:Poor English comprehensionPsychiatric disturbanceKnown history of alcohol/drug dependenceSevere pre-existing medical condition limiting objective assessment

MethodsBase line data collected and patients asked to complete two questionaires

1st questionaire has nine items (3-point scale)

2nd questionaire 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

MethodsOn the morning after surgery

Pts asked to rate overall recovery using VAS (poor recovery to excellent recovery)Complete QoR score50-item questionaireInpatients post in an internal mail envelopeDay cases instructed to complete and return in a self-addressed envelope provided

Time taken to complete QoR score and 50 item questionaire <10 min

QoR-4010 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)

QoR-40Emotional state

Feeling comfortableHaving general feeling of well-beingFeeling in controlBad dreamsFeeling anxiousFeeling angryFeeling depressedFeeling aloneDifficulty falling asleep

QoR-40Physical comfort:

Able to breathe easyHaving a good sleepBeing able to enjoy foodFeeling restedNauseaVomitingDry retchingFeeling restlessShaking or twitchingShiveringFeeling too coldFeeling dizzy

QoR-40Psychological support

Able to communicate with hospital staffAble to communicate with family or friendsGetting support from hospital doctorsGetting support from hospital nursesHaving support from family or friendsAble to understand instructions or adviceFeeling confused

QoR-40Physical independence

Able to return to work or usual home activitiesAble to writeHaving a normal speechAble to wash, brush teeth or shaveAble to look after own appearance

QoR-40Pain

Moderate painSevere painHeadacheMuscle painsBackacheSore throatSore mouth

Validity testingConvergent 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 2011QoR 40 and time for completion of questionaire, duration of stay in recovery and duration of hospital stay

ReliabilityA 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

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

Patient demographicsExtent 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]

ResultsGood 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)

DiscussionValidity, 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

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 Pts QoR, and satisfaction with care.

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

MethodsProspective 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

MethodsAll patients had asleep interscalene brachial plexus block using combined ultrasound and peripheral nerve stimulator techniquePatients 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.

MethodsPatients 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.

On admission 5 mins 10 mins 15 mins 20 mins 30 mins Fit for Discharge (Score of 11/12)

Time Vital signs: BP2 = normal1 = low BP and high/ low HR managed with fluids

0 = low BP and high / low HR requiring IV medications

CONSCIOUSNESS2 = fully awake1 = rousable on command and maintaining airway

0 = not responding and requiring airway support

PONV2 = no PONV/ minimal PONV treated with PO medications

1 = moderate: treated with IM/IV medications

0 = continuesPAIN2 = non / well controlled1 = acceptable to patient0 = not acceptable requiring IV analgesics

TEMP2= NORMAL TEMP 1= 35.5 - 36.00 = <35 OR >37SURGICAL BLEEDING2 = non / minimal no dressing change required

1 = moderate upto 2 dressing changes required

0 = severe > 3 dressing change and blood transfusion needed

SCORES

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 startedPatient Discharged at:…………………………………………………………………...Reasons for Delay (>15mins ) ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Not at all Some of time Most of time

1 Had a feeling of general well-being

2 Had support from others (Doctors & nurses)

3 Been able to understand instructions and advice. Not being confused.

4 Been able to look after personal toilet and hygiene unaided

5 Been able to pass urine and having no trouble with bowel function.

6 Been able to breathe easily

7 Been free from headache, backache or muscle pains

8 Been free fromnausea, dry-retching or vomiting

9 Been free from experiencing severe pain or constant moderate pain

Total Score0 1 2

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

Results52 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

Recovery score following ambulatory surgery

5 min 10 min 15 min 20 min >20 min0

1

2

3

4

5

6

7

8

9

Series1Series2Series3

No of Patients

Minutes to recover from Anaesthesia

Recovery score

Blue- 11/12Red- 9/10Green-<8

Recovery score following in-patient surgery

5 min 10 min 15 min 20 min >20 min0

1

2

3

4

5

6

7

8

9

Series1Series2Series3No of

patients

Minutes to recover from anaesthesia

Recovery score

Blue-11/12Red-9-10Green<8

QOR9 –Audit Results from Upper Limb ambulatory

Surgery

Questions: Pt.-No

Q1

Had a feeling of general well-being 87% 45/52

Q2

Had support from staff (nurses and doctors) 98% 51/52

Q3

Been able to understand instructions and advice. Not being confused

98% 51/52

Q4

Been able to look after personal toilet and hygiene unaided

81% 42/52

Q5

Been able to pass urine and having no trouble with bowel function.

81% 42/52

QOR9 –Ambulatory surgery Results continued

Q6 Been able to breathe easily 92% 48/52

Q7 Been free from headache, backache or muscle pains

79% 41/52

Q8 Been free from nausea, dry-retching or vomiting

87% 45/52

Q9 Been free from experiencing severe pain or constant moderate pain

88% 46/52

QOR9 – In-patient surgeryQuestions: Pt.-No

Q1 Had a feeling of general well-being 70% 12/17

Q2 Had support from staff (nurses and doctors) 94% 16/17

Q3 Been able to understand instructions and advice Not being confused

82% 14/17

Q4 Been able to look after personal toilet and hygiene unaided

76% 13/17

Q5 Been able to pass urine and having no trouble with bowel function.

82% 14/17

QOR9 –In-patients result

Q6 Been able to breathe easily 100%

17/17

Q7 Been free from headache, backache or muscle pains

76% 13/17

Q8 Been free from nausea, dry-retching or vomiting

82% 14/17

Q9 Been free from experiencing severe pain or constant moderate pain

76% 13/17

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)

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

ANESTH ANALG,1999;89:652–8

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