Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation

To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks. A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised. Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians’ “belief about consequences”, “reinforcement”, and “environmental context and resources”. Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support. Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision. Implementation of patient reported outcome measures within multidiscipline rehabilitation settings are likely optimised by establishing infrastructure support e.g., information technology systems to automate the process and minimise manual aspects of data collection. Engaging site champions may be an important enabler for the routine collection of patient reported outcome measures Providing feedback to clinicians on aggregated results of patient reported outcome measures are likely to motivate and encourage routine collection.</p

Univariable and multivariable* logistic regression analyses of factors associated with chronic energy deficiency (body mass index &lt;18 kg/m²) in women and men aged ≥18 years.

<p>Govt, Government; RDA, Recommended Daily Allowance.*Multivariable analyses were adjusted for all other variables in the column. The multivariable analysis for women included 635 observations and the pseudo-<i>R</i>² was 0.0383 and for men there were 522 observations and the pseudo-<i>R²</i> was 0.0844. Value<i>s</i> in bold are significant at a <i>P</i>≤0.05. †Unemployed include students and retirees. ‡Low energy intake for women was defined as &lt;9330 kJ/day and &lt;11422 kJ/day for men.</p

Prevalence of Anaemia and CED in men and women aged 18 years and over.

<p>Panel 1A shows data for ‘not low’ income families (&gt;1,000 rupees per month) while panel 1B shows data for low income families (≤1,000 rupees per month). Anaemia was defined according to WHO individual haemoglobin (Hb) levels: Hb &lt;12 g/dL for non-pregnant women, Hb &lt;11 g/dL for pregnant women, and Hb &lt;13 g/dL for men. CED was defined in both genders as a BMI &lt;18 kg/m². (n = 524 men and 635 women). Error bars show 95% Confidence Intervals. Black bars show data for men and white bars show data for women. ** denotes significance at p&lt;0.001;* denotes significance at p&lt;0.05.</p

Prevalence of chronic energy deficiency according to socio demographic factors.

<p>BMI, Body Mass Index; Govt, Government. *A total of 269 women and 181 men had a BMI&lt;18 kg/m²</p

Demographic factors of the study population.

<p>BMI, Body Mass Index; RDA,Recommended Daily Allowance; Govt, Government. * Assessed in 642 women,527 men; † Assessed in 642 women, 528 men; ‡ Assessed in 640 women, 528 men;§ Assessed in 623 women,527 men;**Anaemia was defined as a blood haemoglobin concentration &lt;13 g/dL in men or &lt;12 g/dL in non-pregnant women and &lt;11 g/dL for pregnant women. RDA, Recommended Daily Allowance; Govt, Government</p

Prevalence of daily nutrient and energy intake deficiencies in men and women aged 18 years and over.

<p>Panel 2A shows data for ‘not low’ income families (&gt;1,000 rupees per month) while panel 2B shows data for low income families (≤1,000 rupees per month). (n = 524 men and 635 women). Error bars show 95% Confidence Intervals. Black bars show data for men and white bars show data for women.</p

Univariable and multivariable logistic regression analyses of factors associated with anaemia* in women and men aged ≥18 years.

<p>Govt, Government; RDA, Recommended Daily Allowance.*Anaemia was defined as a blood haemoglobin concentration &lt;13 g/dL in men or &lt;12 g/dL in non-pregnant women and &lt;11 g/dL for pregnant women. Multivariable analyses were adjusted for all other variables in the column. The multivariable analysis included 622 observations and the pseudo-<i>R</i>² was 0.0332 for women and for men there were 527 observations and the pseudo-<i>R</i>² was 0.0833. Values in bold are significant at <i>P</i>≤0.05. †Unemployed include students and retirees. ‡Low iron intake was defined as &lt;21 mg/day for women and &lt; 17 mg/day for men. §Low energy intake was defined as &lt;9330 kJ/day for women and &lt;11422 kJ/day for men.</p

Associations of type 2 diabetes mellitus (T2D), waist-hip ratio (WHR), body mass index (BMI), mean steps/day and cortical volumes (n = 560).

<p>β is unstandardized coefficient. CI–confidence interval. All regressions adjusted for age, sex and total intracranial volume.</p

Difference in Effect of Baseline Daily Steps (Per 1,000 Step Increase) on Mortality by Participant Characteristics.

<p>^a HR takes age and sex into account</p><p>^<b>b</b> Difference in effect of baseline daily steps on mortality across categories of the factor.</p><p>^c Any risk factors, refers to any of the diseases listed in this Table.</p><p>Difference in Effect of Baseline Daily Steps (Per 1,000 Step Increase) on Mortality by Participant Characteristics.</p

Abdominal Obesity and Brain Atrophy in Type 2 Diabetes Mellitus

<div><p>Aim</p><p>Type 2 diabetes mellitus (T2D) is associated with gray matter atrophy. Adiposity and physical inactivity are risk factors for T2D and brain atrophy. We studied whether the associations of T2D with total gray matter volume (GMV) and hippocampal volume (HV) are dependent on obesity and physical activity.</p><p>Materials and Methods</p><p>In this cross-sectional study, we measured waist-hip ratio (WHR), body mass index (BMI), mean steps/day and brain volumes in a community dwelling cohort of people with and without T2D. Using multivariable linear regression, we examined whether WHR, BMI and physical activity mediated or modified the association between T2D, GMV and HV.</p><p>Results</p><p>There were 258 participants with (mean age 67±7 years) and 302 without (mean age 72±7 years) T2D. Adjusting for age, sex and intracranial volume, T2D was independently associated with lower total GMV (p = 0.001) and HV (p<0.001), greater WHR (p<0.001) and BMI (p<0.001), and lower mean steps/day (p = 0.002). After adjusting for covariates, the inclusion of BMI and mean steps/day did not significantly affect the T2D-GMV association, but WHR attenuated it by 32% while remaining independently associated with lower GMV (p<0.01). The T2D-HV association was minimally changed by the addition of BMI, steps/day or WHR in the model. No statistical interactions were observed between T2D and measures of obesity and physical activity in explaining brain volumes.</p><p>Conclusions</p><p>Abdominal obesity or its downstream effects may partially mediate the adverse effect of T2D on brain atrophy. This requires confirmation in longitudinal studies.</p></div