New Tools for Improving Patient-to-Physician Communication in Clinical Practice
The integration of computerized patient-reported outcomes data into your assessment tools offers a number of potential benefits for the clinical pain practice: promotion of patient-centered care, use as point-of-care screening and monitoring tools, aid for clinical decision-making, means for facilitating communication within multidisciplinary teams, and monitoring quality assurance of patient care.
The assessment of the functional status of a patient with pain holds the promise of improving patient-to-physician communication and patient-centered care. Unfortunately, the assessment of a patient’s current status and subsequent treatment is a complex task. Pain disorders are often a confluence of medical pathologies, psychiatric symptoms, and psychosocial issues.1-3 The presence of multiple medical conditions, in fact, has been found to significantly affect treatment outcomes and the general functionality of patients.2 For example, chronic pain may have a significant impact on the social, interpersonal, and occupational functioning of patients.
It is well established that all these factors play an integral role in the onset, maintenance, and/or exacerbation of chronic pain.4,5 Naturally, increased understanding of treatment-related factors allows for greater measurement precision of relevant treatment outcomes and related variables. Assessment of health-related outcomes has become increasingly “patient-centered,” with a focus on “health-related quality of life” (HRQL).2,6,7 Self-report measures of health status are increasingly referred to as “patient-reported outcomes” (PROs).8 PROs can take multiple forms in clinical practice: measures of HRQL, health status reports, symptom assessment, patient-reported function or disability, and patient satisfaction.9
While PRO measures have been well accepted in the realm of clinical research, they also have important implications in clinical practice.7,10 The integration of PRO data offers a number of potential benefits for clinical pain practice (eg, promotion of patient-centered care, use as point-of-care screening and monitoring tools, aid for clinical decision-making, means for facilitating communication within multidisciplinary teams, and monitoring quality assurance of patient care).8,9,11,12 This article will review PRO systems and how they may benefit both patients and clinicians.
Treatment Outcomes Tracking
Systematic tracking of health outcomes has gained increasing traction and attention.13-16 Traditional methods of assessment in pain management practice and other ambulatory care settings include face-to-face interviews and paper-and-pencil questionnaires. In recent years, computerized methodologies have been increasingly used for their abilities “to make assessment results immediately available for the clinical encounter.”9 This automated function is made possible by the “real-time” efficiency with which data are entered, administered, analyzed, and summarized in printout.9
Gwaltney and colleagues have argued that such computerized assessments have several advantages over paper-and-pencil assessments including reduction of missing data and patient selection of multiple answers to an item; ability to simplify more complex skip functions; and the reduction of data-entry burden.8 Multiple studies have also evaluated the measurement equivalence (ie, comparability of the psychometric properties of data) between measures by administration mode.8,17 Specifically, these studies have examined measurement equivalence for a variety of PRO measures and administration-mode comparisons (eg, computer-based [via the Internet at home, within the provider’s office], personal digital assistant, tablet-based, telephone-based or interactive voice recognition–based, and paper-based). In total, the majority of studies have found measurement equivalence by mode of administration.8,17
Computer Adaptive Testing (CAT)
Reeve argues that “we are on the brink of a new era for health outcomes measurement with the availability of CAT-based tools.”18 As an overview of the process of item response theory (IRT)–based CATs, the test begins with an “anchor” or starting item of average “difficulty.” Based upon response, the CAT’s predetermined algorithm will adjust the estimated level of the latent trait for the respondent. The algorithm selects subsequent questions based upon what will best discriminate theta (ie, term for latent trait being measured). This is repeated until a predetermined level of precision is achieved (ie, a termination criterion is reached [90%-95% CI]).19 This sophisticated approach minimizes the number of items administered, which leads to decreased patient burden and administration time associated with testing (Table 1).
Of course, computerized administration carries some concerns about the nature of the patient population being studied (in particular, literacy, reading level, visual ability, familiarity with touch-screen computers, and manual dexterity).9 However, these barriers may be partially overcome by having alternate administration modes available. Outside of these concerns, the development of CATs based upon IRT may provide a means of addressing the limitations of current questionnaires. Through their design, CATs are able to decrease respondent burden while increasing measurement precision.9
Barriers and Benefits
While there are clear benefits to the use of PRO data, significant barriers may exist with its integration into busy clinical practice settings. These barriers involve multiple “logistical complexities” inherent to medical care settings (eg, staff burden; need for immediate scoring, interpretation, and response summarization; patient burden when completing a set of measures; and overall time required for administration through results delivery).8,20 At the same time, there are significant barriers to the implementation of comprehensive outcome tracking and/or screening in outpatient medical care settings, namely time-related concerns (eg, general length of administration, patient burden, interruption/delays in flow of normal care); lack of staff support for scoring; lack of availability of a trained professional for interpretation; and the procedures for results feedback to patients and providers.6,7,21,22