Health Outcomes

The barriers and facilitators to routine outcome measurement by allied health professionals in practice: A structured review

by Jennifer Murray

(2012) Co-authored with Dr. Edward Duncan, Univerity of Stirling

Background: Allied Health Professionals today are required, more than ever before, to demonstrate the impact of their... more Background: Allied Health Professionals today are required, more than ever before, to demonstrate the impact of their practice. However, despite at least 20 years of expectation, many services fail to deliver routine outcome measurement in practice. This systematic review investigates what helps and hinders routine outcome measurement of allied health professionals practice.

Methods: A systematic review protocol was developed comprising: a defined search strategy for PsycINFO, MEDLINE and CINHAL databases and inclusion criteria and systematic procedures for data extraction and quality appraisal. Studies were included if they were published in English and investigated facilitators and/or barriers to routine outcome measurement by allied health professionals. No restrictions were placed on publication type, design, country, or year of publication. Reference lists of included publications were searched to identify additional papers. Descriptive methods were used to synthesise the findings.

Results: 960 papers were retrieved; 15 met the inclusion criteria. Professional groups represented were Physiotherapy, Occupational Therapy, and Speech and Language Therapy. The included literature varied in quality and design. Facilitators and barriers to routine outcome measurement exist at individual, managerial and organisational levels. Key factors affecting professionals' use of routine outcome measurement include: professionals' level of knowledge and confidence about using outcome measures, and the degree of organisational and peer-support professionals received with a view to promoting their work in practice.

Conclusions: Whilst the importance of routinely measuring outcomes within the allied health professions is well recognised, it has largely failed to be delivered in practice. Factors that influence clinicians' ability and desire to undertake routine outcome measurement are bi-directional: they can act as either facilitators or barriers. Routine outcome measurement may only be deliverable if appropriate action is taken at individual therapist, team, and organisational levels of an organisation.

Pain: a review of three commonly used pain rating scales

by Amelia Swift

Impact of clinical nurse specialists in multiple sclerosis: –synthesis of the evidence

by Peter Griffiths

Nursing‐led in‐patient units for intermediate care: a survey of multidisciplinary discharge planning practice

by Peter Griffiths

Referral pattern of patients with end-stage renal disease at a public sector hospital and its impact on outcome

by Vivekanand Jha

SREEJITH PARAMESWARAN, SARATH BABU GEDA, MANISH RATHI, HARBIR SINGH KOHLI, KRISHAN LAL GUPTA, VINAY SAKHUJA, VIVEKANAND JHA, National Medical Journal of India, 2011 24(4):208-11

Background. Late referral of patients with chronic kidney
disease (CKD) to a nephrologist has been shown to be... more Background. Late referral of patients with chronic kidney
disease (CKD) to a nephrologist has been shown to be associated
with greater morbidity and adverse clinical outcomes.
Methods. We did a prospective cross-sectional study of
2490 consecutive, newly diagnosed patients with end-stage
renal disease (ESRD) referred to the Postgraduate Institute of
Medical Education and Research (PGIMER), Chandigarh over
2 years. The referral pattern was classified on the basis of the
interval between first visit to a nephrologist and initiation of
renal replacement therapy (RRT). If the patient reported later
to a nephrologist, the disease would have progressed more, and
the time interval to initiation of RRT would thus be shorter. A
time interval of <3 months was classified as late referral (LR),
3–12 months as intermediate referral (IR) and >12 months as
early referral (ER). The demographic and clinical characteristics
and co-morbid conditions were compared, and factors associated
with LR and outcomes were evaluated.
Results. About 75% of patients were referred late. Poor
socioeconomic status, low level of education and reduced access
to reimbursement of treatment costs contributed to LR. The
aetiology of ESRD could not be established in a larger number
of LR patients as compared to the other groups. LR patients had
a higher prevalence of uraemic complications and required
emergency dialysis more frequently. A higher proportion of LR
patients were lost to follow up because they could not afford to
continue dialysis. Early mortality was higher in the ER group
than in the other groups. ER patients were older, more likely to
have diabetic nephropathy and a higher burden of co-morbid
conditions. They were also more likely to choose continuous
ambulatory peritoneal dialysis or undergo transplantation. Only
28% of all patients continued RRT beyond 3 months.
Conclusion. A large majority of patients with ESRD in
India seek medical attention late, usually in advanced stages of
CKD with uraemic complications. LR is more frequent in
younger patients and those with non-diabetic kidney disease,
and is associated with poor socioeconomic status, lack of
education and poor outcomes.

The kaupapa outcome rating scale

by Nick Drury

A brief client rating scale based on the whare tapa wha and correlated with the Outcome Rating Scale

Factors associated with changing patient needs in an assertive outreach team

by Nathan Gregory

The relationships between user, carer and staff perceptions of need in an assertive outreach team

by Nathan Gregory

Cochrane: spreading the message of research to students and juniors

by Zbys Fedorowicz

Sud V, Ejaz K, Fedorowicz Z, Mathew M, Sharma A.
SourceKasturba Medical College, Manipal, India

One of the Cochrane Collaboration's core principles is to "build on the enthusiasm of individuals", and this... more One of the Cochrane Collaboration's core principles is to "build on the enthusiasm of individuals", and this has been exemplified in what has been achieved to date. However, there is clearly scope to develop such activities and relationships further, engaging with students from other disciplines and from beyond South Asia. As the Collaboration prepares to conduct a strategic session on the subject of encouraging greater diversity, these pioneering activities provide much food for thought

Outcomes sensitive to nursing service quality in ambulatory cancer chemotherapy: systematic scoping review

by Peter Griffiths

Alison Richrdson
Rebecca Blackwell
Published in the European Journal of Oncology Nursing. Contains the main findings of the report into nurse sensitive outcomes and indicators for ambulatory chemotherapy.

Abstract
Background
There is long standing interest in identifying patient outcomes that are sensitive to... more Abstract
Background
There is long standing interest in identifying patient outcomes that are sensitive to nursing care and an increasing number of systems that include outcomes in order to demonstrate or monitor the quality of nursing care.

Objective
We undertook scoping reviews of the literature in order to identify patient outcomes sensitive to the quality of nursing services in ambulatory cancer chemotherapy settings to guide the development of an outcomes-based quality measurement system.

Methods
A 2-stage scoping review to identify potential outcome areas which were subsequently assessed for their sensitivity to nursing was carried out. Data sources included the Cochrane Library, Medline, Embase, the British Nursing Index, Google and Google scholar.

Results
We identified a broad range of outcomes potentially sensitive to nursing. Individual trials support many nursing interventions but we found relatively little clear evidence of effect on outcomes derived from systematic reviews and no evidence associating characteristics of nursing services with outcomes.

Conclusion
The purpose of identifying a set of outcomes as specifically nurse-sensitive for quality measurement is to give clear responsibility and create an expectation of strong clinical leadership by nurses in terms of monitoring and acting on results. It is important to select those outcomes that nurses have most impact upon. Patient experience, nausea, vomiting, mucositis and safe medication administration were outcome areas most likely to yield sensitive measures of nursing service quality in ambulatory cancer chemotherapy.

Keywords: Quality measurement; Outcomes; Chemotherapy; Nursing; Clinical nurse specialists; Ambulatory care

Clinical Information Systems in Oncology-Making a Difference to Patient Outcomes

by Andrew Miller

Journal Article

Clinical information systems in oncology have gradually been transferred from paper to electronic formats. This paper... more Clinical information systems in oncology have gradually been transferred from paper to electronic formats. This paper details the development of the Oncology Information System (OIS) from paper format to a modern unified electronic system, highlighting issues of choice, implementation and use. Various patient outcomes are discussed and the impact of electronic systems within oncology on these outcomes is highlighted.

The widespread implementations of computers within hospital and oncology departments means that all oncology departments will face the challenge of implementing modern electronic information systems. Indeed many departments already possess the software required.

As the changes implemented in one New Zealand centre demonstrate, the OIS is more than just a paper substitute. A clear advantage of the newer system is its capacity to re-use data and to quickly and repeatedly apply quality assurance to prospectively collected data.

Date 1 December 2003

Nurse Forecasting in Europe (RN4CAST): Rationale, design and methodology

by Peter Griffiths

Walter Sermeus
Linda H. Aiken
Koen Van den Heede
Anne Marie Rafferty
Peter Griffiths
Maria Teresa Moreno-Casbas
Reinhard Busse
Carol Tishelman
Anne Scott
Luk Bruyneel
Tomasz Brzostek
Juha Kinnunen
Maria Schubert
Lisette Schoonhoven
Dimitris Zikos
(For the RN4CAST Consortium)

Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore... more Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care. Methods/Design; A multi-country, multilevel cross sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences. This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce .

Progress In Measuring Nursing Outcomes

by Peter Griffiths

Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected dat

by Peter Griffiths

Published as: Griffiths, P., T. Murrells, J. Maben, S. Jones and M. Ashworth (2010). "Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data." British Journal of General Practice 60(1): e36-e48.

Background

In many UK general practices, nurses have been used to deliver results against the indicators... more Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a `pay for performance' scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.

"Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review." International Journal of Nursing Studies 2011

by Peter Griffiths

Goryakin, Y., P. Griffiths and J. Maben (2011). "Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review." International Journal of Nursing Studies 58, 501-512: doi: DOI: 10.1016/j.ijnurstu.2010.1007.1018.

Objective

Several systematic reviews have suggested that greater nurse staffing as well as a greater... more Objective

Several systematic reviews have suggested that greater nurse staffing as well as a greater proportion of registered nurses in the health workforce is associated with better patient outcomes. Others have found that nurses can substitute for doctors safely and effectively in a variety of settings. However, these reviews do not generally consider the effect of nurse staff on both patient outcomes and costs of care, and therefore say little about the cost-effectiveness of nurse-provided care. Therefore, we conducted a scoping literature review of economic evaluation studies which consider the link between nurse staffing, skill mix within the nursing team and between nurses and other medical staff to determine the nature of the available economic evidence.
Design

Scoping literature review.
Data sources

English-language manuscripts, published between 1989 and 2009, focussing on the relationship between costs and effects of care and the level of registered nurse staffing or nurse–physician substitution/nursing skill mix in the clinical team, using cost-effectiveness, cost-utility, or cost–benefit analysis. Articles selected for the review were identified through Medline, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Google Scholar database searches.
Review methods

After selecting 17 articles representing 16 unique studies for review, we summarized their main findings, and assessed their methodological quality using criteria derived from recommendations from the guidelines proposed by the Panel on Cost-Effectiveness in Health Care.
Results

In general, it was found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing was associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess.
Conclusions

Although considerable progress in economic evaluation studies has been reached in recent years, a number of methodological issues remain. In the future, nurse researchers should be more actively engaged in the design and implementation of economic evaluation studies of the services they provide.

Keywords: Workforce; Nurse staffing; Skill mix; Substitution; Economic evaluation; Cost-effectiveness; Nurse practitioners; Nurse-led care

Modeling subjective health outcomes: Top 10 reasons to use Thurstone's method.

by Alberto Maydeu-Olivares

Maydeu-Olivares, A. & Böckenholt, U. (2008). Modeling subjective health outcomes: Top 10 reasons to use Thurstone's method. Medical Care, 46, 346-348.

Clinically useful outcome measures for physiotherapy airway clearance techniques: a review

by Anne Bruton

This is a draft version of a paper published in Physical Therapy Reviews 2006;11(4): 299-307. A former PhD student (Alda Marques) is first author.

A lack of good outcome measures has been a barrier to the development of an evidence base for all areas of respiratory... more A lack of good outcome measures has been a barrier to the development of an evidence base for all areas of respiratory physiotherapy. Many of the clinically available outcome measures are not specifically related to the physiotherapy intervention employed and may be affected by other factors. In this paper, the outcome measures currently clinically available to UK NHS physiotherapists to assess the response to alveolar recruitment and airway clearance interventions have been reviewed. It is clear that there is an urgent need to increase the accuracy, reliability, and sensitivity of the outcome measures employed, or to develop new measures to assess the effectiveness of respiratory physiotherapy. Lung sounds provide useful, specific information, but standard auscultation is too subjective to allow them to be used as an outcome measure. Computer Aided Lung Sound Analysis (CALSA) is proposed as a new objective, non-invasive, bedside clinical measure with the potential to monitor and assess the effects of airway clearance therapy.

Keywords: Lung sounds, outcome measures, physiotherapy

Organisational quality, nurse staffing and the quality of chronic disease care in general practice: observational study using routinely collected data

by Peter Griffiths

to be published in the International Journal of Nursing Studies - this version has not been peer reviewed

Background: an association between quality of care and staffing levels, particularly registered nurses, has been... more Background: an association between quality of care and staffing levels, particularly registered nurses, has been established in acute hospitals. Recently an association between practice nurse staffing and quality of care for several chronic conditions has also been demonstrated in general practice. A smaller body of literature identifies organisational factors, in particular issues of human resource management, as being a dominant factor. However the literature has tended to consider staffing and organisational factors separately

Aims and objectives: we aim to determine whether relationships between the quality of clinical care and nurse staffing in general practice are attenuated or enhanced when organisational factors associated with quality of care are considered. We further aim to determine the relative contribution and interaction between these factors.

Method: we used routinely collected data on organisational factors and the quality of clinical care for a range of long term conditions: from 8409 English general practices. Regression models exploring the relationship of staffing and organisational factors with care quality were fitted using MPLUS

Results: higher levels of nurse staffing, clinical recording, education and reflection on the results of patient surveys were significantly associated with improved clinical care for COPD, CHD, Diabetes and Hypothyroidism after controlling for organisational factors. There was some evidence of attenuation of the estimated nurse staffing effect when organisational factors were considered, but this was small. The effect of staffing interacted significantly with the effect of organisational factors. Overall however, the characteristics that emerged as the strongest predictors of quality of clinical care were not staffing levels but the organisational factors of clinical recording, education and training and use of patient experience surveys.

Conclusions: organisational factors contribute significantly to observed variation in the quality of care in English general practices. Levels of nurse staffing have an independent association with quality but also interact with organisational factors. The observed relationships are not necessarily causal but a causal relationship is plausible. The benefits and importance of education, training and personal development of nursing and other practice staff was clearly indicated.

Substitution of a Nursing-Led Inpatient Unit for Acute Services: Randomized Controlled Trial of Outcomes and Cost of Nursing-Led Intermediate Care

by Peter Griffiths

Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data

by Peter Griffiths

Publised as: Griffiths, P., D. Dawoud, T. Murrells and S. Jones (2010). "Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data." BMC Health Sevices Research 10(276): doi:10.1186/1472-6963-1110-1276.

Background

Delivering good quality primary care for patients with chronic conditions has the potential to... more Background

Delivering good quality primary care for patients with chronic conditions has the potential to reduce non-elective hospital admissions. Practice nurse staffing levels in England have been linked to attainment of general practice performance targets for some chronic conditions. The aim of this study was to examine whether practice nurse staffing level is similarly associated with non-elective hospital admissions in three clinical areas: asthma, Chronic Obstructive Pulmonary Disease (COPD) and diabetes.
Methods

This observational study used cross sectional analysis of routinely collected data. Hospital admissions data for the period 2005-2006 (for asthma, COPD and diabetes) were linked with a database of practice characteristics, nurse staffing data and data on population characteristics for the same period. Statistical modelling explored the relationship between non-elective hospital admission rates for the three conditions and the list size per full time equivalent (FTE) practice nurse.
Results

Higher practice nurse staffing levels were significantly associated with lower rates of admission for asthma (p < 0.001) and COPD (p < 0.001). A similar association was seen for patients with two or more admissions (p < 0.05 for asthma and p < 0.001 for COPD). For diabetes, higher practice nurse staffing level was significantly associated with higher admission rates (p < 0.05), but this association was not significant in case of patients with two or more admissions. Across all models, increasing deprivation was associated with higher admission rates for all conditions.
Conclusions

The inconsistent relationship between nurse staffing and patient outcomes across the different conditions and the fact that for diabetes the relationship between staffing and outcomes was in a different direction from the association between staffing and care quality, highlights the need to avoid making a simple causal interpretation of these findings and reduces the possible confidence in such conclusions. There is a need for more research into the organisation and delivery of diabetes care services in general practice, preferably using patient level data; in order to better understand the impact of the different staffing configurations on patient outcomes.