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Monthly Archives: May 2018

The Primary Care Outcomes Questionnaire: a new generic instrument for measuring outcomes in primary care

By Mairead Murphy and Chris Salisbury
The majority of primary care consultations are by patients with multiple long-term conditions [1]. With ninety percent of all patient interaction with health services in the UK going through primary care, it’s not surprising that primary care clinicians and researchers try to figure out ways to improve services for their patients. Interventions are many and varied, and result in important questions about their effectiveness. Do electronic consultations offer a good service to patients? If GPs introduce advice on healthy lifestyles into the consultation, does it make patients healthier? What about increasing the duration of GP appointments to ten minutes – does this improve outcomes for patients? Or ensuring that patients always see the same named doctor? Or painting the waiting room green?
Questions like these are normally answered by administration of a generic patient-reported questionnaire. By comparing the responses of groups of patients (say those with eight-minute consultations and those with ten-minute consultations), researchers can see which group has the highest scores, and therefore whether one method of delivering care is better than the other.
Although this might sound a simple process, in practice it is not so easy. The problem is that primary care delivers a range of outcomes, some of which are more directly health-related than others. The recent blog on this site by Susan Smith (Identifying key outcomes for multimorbidity research April 19th) found that 17 core outcomes were important to measure in people with long-term conditions. These included outcomes related to mortality, health-related quality of life, patient behaviours, shared decision making and quality of health services. When we explored this issue in 2015, we similarly found that primary care patients, both those with and without long term conditions want broad range of outcomes [2]. Some of these, such as reduction in pain or depression, are captured on most generic patient-reported questionnaires. But others, such as reduction in concern, a sense of confidence in health plan, or an understanding of illnesses/problems and an ability to manage symptoms, are less well-captured.
This is why we have designed a new questionnaire, called the Primary Care Outcomes Questionnaire, or the PCOQ. The PCOQ was designed in consultation with patients [3] specifically to measure outcomes which many primary care patients seek, and which GPs seek to deliver. It contains 24 questions in four areas: health and well-being; health knowledge and understanding; confidence in health plan; and confidence in health provision. We quantitatively tested the PCOQ in a sample of primary care patients and found that it was easy for patients to complete, had construct validity, and able to show change in each of the four areas. We published these findings in March in the BJGP [4]. We have made the PCOQ available free of charge for non-commercial use and hope that researchers will find it useful for assessing the effectiveness of interventions in primary care. In the future, we plan to test the PCOQ for use in routine clinical practice.
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1. Salisbury, C., et al., Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. British Journal of General Practice, 2011. 61(582): p. e12-21.
2. Murphy M, Hollinghurst S, Turner K, Salisbury C. Patient and practitioners’ views on the most important outcomes arising from primary care consultations: a qualitative study. BMC Fam Practice 2015;16:108. Doi: 10.1186/s12875-015-0323-9
3. Murphy M, Hollinghurst S, Salisbury C. Qualitative assessment of the primary care outcomes questionnaire: a cognitive interview study, BMC Health Services Research 2018 10.1186/s12913-018-2867-6
4. Murphy M, Hollinghurst S, Cowlishaw S, Salisbury C. Psychometric Testing of the Primary Care Outcomes Questionnaire, British Journal of General Practice, 26th March 2018,10.3399/bjgp18X695765

‘Multimorbidity Treatment Burden Questionnaire’ (MTBQ) – a new measure of treatment burden

By Polly Duncan and Chris Salisbury
A group of researchers from the University of Bristol, UK, have developed a new simply worded, concise questionnaire, named the ‘Multimorbidity Treatment Burden Questionnaire’ (MTBQ) to measure treatment burden (the perceived effort of looking after one’s health and the impact that this has on day to day life) in patients with multimorbidity (multiple long-term conditions).  The study has been published in the BMJ Open [1].
Treatment burden includes everything that the patient has to do to look after their health – from ordering, collecting and taking medicines; to co-ordinating, arranging transport for and attending health appointments with multiple different health professionals; to monitoring blood sugar or blood pressure levels; to learning about your health conditions; and taking on lifestyle advice.
To understand how new health care interventions impact on treatment burden, we need to be able to measure it, and a recent study published in the Annals of Family Medicine highlighted treatment burden as one of the core outcome measures for research studies involving patients with multimorbidity [2].
The MTBQ was developed as part of a large research study called the 3D Study [3].  The research team identified and reviewed three existing measures of treatment burden that were not specific to a medical condition.  A further measure has since been published.  We found that the existing measures had limitations (e.g. they did not cover all of the areas of treatment burden or they required good literacy levels and so were not suitable for our study population of mainly older people) and so we decided to develop and validate a new measure.
We discussed the concept of treatment burden and an existing framework of treatment burden that had been developed in the United States with members of a patient and public involvement group.  Using this framework as a guide, we developed a questionnaire to include all the important areas of treatment burden.  We interviewed patients with multimorbidity and asked them to comment on the layout and wording of questions, how easy the questions were to understand and to ‘think aloud’ as they answered the questionnaire – what did the questions mean to them and what answer would they give if they were completing the questionnaire?
The MTBQ was then completed by over 1500 mostly elderly patients (average age 71 years) with three or more long-term conditions who took part in the 3D Study.  The research team assessed the questionnaire against the ISOQOL international standards for developing and validating questionnaires and found that it performed well, demonstrating good face validity (e.g. it measured what it set out to measure), construct validity (e.g. patients with high disease burden and poor quality of life reported higher treatment burden), reliability and responsiveness to change  (e.g. as expected, patients who reported reduce quality of life over time also reported higher treatment burden over time) [1].
Strengths of the MTBQ include:
- simple wording
- a concise measure with ten questions
- all the important aspects of treatment burden are included
- it was tested in patients for whom it was intended – elderly patients (means age 71 years) with three or more long-term conditions
Further information about the MTBQ can be found here:
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References:
1. Duncan P, Murphy M, Man MS, et al. Development and validation of the Multimorbidity Treatment Burden Questionnaire (MTBQ). BMJ Open 2018;8(4):e019413. doi: 10.1136/bmjopen-2017-019413 [published Online First: 2018/04/12]
2. Smith SM, Wallace E, Salisbury C, et al. A Core Outcome Set for Multimorbidity Research (COSmm). Ann Fam Med 2018;16(2):132-38.
3. Man MS, Chaplin K, Mann C, et al. Improving the management of multimorbidity in general practice: protocol of a cluster randomised controlled trial (The 3D Study). BMJ Open 2016;6(4):e011261. doi: 10.1136/bmjopen-2016-011261