The importance of qualitative methods for generating patient reported outcome measures and patient reported experience measures for pre-hospital and emergency care of stroke and heart attack
Context: The Patient Reported Outcomes for Vascular Emergencies: Interview Study (IS-PROVE) of patients and practitioners was conducted in a large regional ambulance service in the East Midlands region of the UK from 2010-2011. The aim of the study was to explore the experiences of patients and practitioners for emergency care of stroke or heart attack in the pre-hospital setting.
Problem: Current health policy emphasises patient experience, together with effectiveness and safety, as key components of quality of care. As a consequence, patient reported outcome measures (PROMs) and patient reported experience measures (PREMs) are increasingly being seen as important, whether by providers, commissioners, regulators or service users themselves for assessing quality of care, by researchers for evaluating the outcomes of specific interventions and also clinicians for assessment and decision support. Despite the introduction of PROMs into the NHS in 2009 there are few validated PROMs in use or under development in the field of urgent (or emergency) care.
Assessment of problem and analysis of its causes: We identified an important need to develop PROMs/PREMs for pre-hospital stroke and heart attack care and undertook the initial steps to develop appropriate item content for inclusion in such instruments. Patients that had suffered from these conditions and Practitioners that treated these conditions in the pre-hospital setting participated in qualitative interviews in order to obtain rich, in depth data.
Intervention: Data were analysed with the support of Nvivo software and coded before final items for inclusion in the PROM/PREM were agreed by the research team. The PROMs and PREMs have been refined following elaboration of individual items and the next stage will involve formal testing and modification of the (construct) validity, reliability and responsiveness of the instruments.
Study design: We used a qualitative design; individual interviews were conducted with patients or practitioners. Participants were also given the opportunity to take part in a focus group if they preferred. The benefits of focus groups are that they enable a range of experiences, beliefs, views and feelings to be explored in a setting of mutual understanding
Strategy for change: The PROM and PREM tools for stroke and heart attack that we have developed will be piloted by ambulance clinicians that routinely treat these conditions to assess their validity and feasibility in the setting. We envisage that the tool will enable us to quantify patient reported outcome measure scores and examine the effects of organisational changes on patient outcomes.
Measurement of improvement: The initial themes that emerged from the qualitative interviews and focus groups have included aspects such as reassurance, confidence in paramedic abilities, professional persona of clinicians and timeliness of service. These have allowed us to obtain a more informed understanding of the issues that patients attach greatest importance to in the pre-hospital setting.
Effects of changes: We will use the PROM and PREM tools to assess the quality of care for patients with stroke and heart attack presenting to ambulance services. This will enable the regular monitoring of care standards and identify areas for improvement.
Lessons learnt: We acquired new first hand knowledge from patients about their experiences of using the ambulance service for stroke and heart attack as well as learning about the issues that pre-hospital clinicians felt were important for improving care.
Message for others: Development of PROMs and PREMs will be important for evaluating health care services and improving the quality of care. The methods used in this study may be useful for the development of PROMs in other settings
